Revision 20-0; Effective August 25, 2020

Preadmission Screening and Resident Review (PASRR) is a federal requirement as documented in the Code of Federal Regulations, Title 42, Part 483, Subpart C, §483.100 through 138. PASRR is a process to identify people with a mental illness (MI), intellectual disability (ID) or developmental disability (DD), which is also known as a related condition (RC), who apply to, or reside in, a Medicaid-certified nursing facility (NF) to ensure the appropriateness of NF admission. PASRR is also intended to ensure that people with MI, ID or DD are receiving all the agreed upon specialized services.

In Texas, local intellectual and developmental disability authorities (LIDDAs), local mental health authorities (LMHAs) and local behavioral health authorities (LBHAs) play key roles in the PASRR process.

Texas Health and Human Services Commission (HHSC) rules governing PASRR are contained in:

• 26 Texas Administrative Code (TAC), Chapter 303, Preadmission Screening and Resident Review (for LIDDAs, LMHAs and LBHAs);
• 25 TAC, Chapter 412, Local Mental Health Authority Responsibilities (for LMHAs and LMHAs); and
• 40 TAC, Chapter 19, Subchapter BB, Nursing Facility Requirements for Licensure and Medicaid Certification (for NFs).

This handbook provides additional instructions and procedures for LMHAs and LBHAs in implementing PASRR requirements.

1100 Definitions

Revision 20-0; Effective August 25, 2020 

The following words and terms, when used in this handbook, have the following meanings unless the context clearly indicates otherwise.

Acute care hospital — A facility in which a person receives short-term treatment for a severe physical injury or episode of physical illness, an urgent medical condition or recovery from surgery and: 

• may include a long-term acute care hospital, an emergency room within an acute care hospital or an inpatient rehabilitation hospital. 
• does not include a stand-alone psychiatric hospital or a psychiatric hospital within an acute care hospital. 

Adult Needs and Strengths Assessment (ANSA) Tool — The Texas uniform assessment tool developed for adult behavioral health services. It is intended to prevent duplicate assessments by multiple parties, decrease unnecessary psychological testing, aid in identifying placement and treatment needs, and inform case planning decisions. Its assessments help support decision making, including level of care and service planning, to facilitate quality improvement initiatives and to allow for outcomes monitoring. 

Community living options — A process by which the LIDDA provides information to a person and their legally authorized representative (LAR) about the range of community living services, supports and programs the person may be eligible for, and discusses services and supports the person will need to live in the community, as well as individual preferences and barriers to community living.  The Community Living Options (CLO) apply only if the person has a dual diagnosis of mental illness (MI) and intellectual disability or developmental disability (ID/DD). 

Collateral contact — An individual such as family member, previous provider or caregiver, who is knowledgeable about the person seeking admission to a nursing facility (NF) or the resident, and who may support or corroborate information provided by the person or resident. 

Comprehensive care plan — A service plan developed by an NF to meet the person’s medical, nursing, mental and psychological needs. 

Exempted hospital discharge — A category of NF admission that occurs when a physician has certified that a person who is being discharged from an acute care hospital is likely to require less than 30 days of NF services for the condition for which the person was hospitalized. 

Expedited admission — A category of NF admission that occurs when a person is coming from an acute care hospital or another NF and meets the criteria for one of the following categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite or coma. 

Habilitative Service Plan (HSP) — Used by LIDDAs to: 

• describe the desired outcomes of an individual with ID or DD residing in an NF and identify specialized services provided. 
• document community living educational and exploration activities. 
• document barriers to transitioning to community living and the solutions to those barriers. 

Intellectual and Developmental Disability (IDD) Habilitative Specialized Services — Helps people learn, keep or improve skills for everyday life activities. It is different from rehabilitation because IDD habilitative specialized services teaches a new skill that a person has not learned before and rehabilitation teaches people to recover a previously learned skill. People are learning how to do something for the first time. It can include learning how to walk, bathe, speak and more. 

The following specialized services are available to an individual with ID or DD: 

• Habilitation coordination; 
• Day habilitation; 
• Independent living skills training; 
• Behavioral support; 
• Employment assistance; and 
• Supported employment. 

Interdisciplinary Team (IDT) — Consists of these required members (Note: Mandatory participants of the IDT are bolded below. An IDT without all mandatory participants is invalid and must be reconvened.):    

• a person with MI, ID or DD; 
• the person's LAR, if any; 
• a registered nurse from the NF with responsibility for the person; 
• a representative of the: 
  • LIDDA, if the person has ID or DD; 
  • LMHA or LBHA, if the person has MI; or 
  • LIDDA and the LMHA or LBHA, if the person has MI and DD, or MI and ID. 
• others as follows: 
  • a concerned person whose inclusion is requested by the resident or LAR; 
  • a person specified by the resident, LAR, NF, LIDDA, LMHA or LBHA, as applicable, who is professionally qualified, certified or licensed with special training and experience in the diagnosis, management, needs and treatment of people with MI, ID or DD; or 
  • a representative of the appropriate school district if the person is school age and inclusion of the district representative is requested by the person or LAR. 

Individual — A person whose active PASRR evaluation (PE) or resident review is positive for MI and who is age 21 or older. 

Local authority (LA) — In this handbook, LA means a local intellectual and developmental disability authority (LIDDA) and/or a local behavioral health authority (LBHA) or local mental health authority (LMHA). 

Local authority update meeting — Meetings held at any time by the LA after the initial meeting to add, change or remove services, or to discuss transfers, transitions or discharges. The results of these meetings are recorded on the PASRR Comprehensive Service Plan (PCSP) form as an LA update. Attendees for LA updates are determined by the reason for the update meeting as stated in the PCSP Item by Item Guide.   

Legally Authorized Representative (LAR) — A person authorized by law to act on behalf of a person seeking admission to an NF or currently an NF resident, and is the parent of a minor child, the legal guardian or the surrogate decision maker. (See limitations on authority of surrogate decision maker in the definition of “surrogate decision maker.” Also, see the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook, Appendix III, Legal Authority to Make Decisions.) 

Local Behavioral Health Authority (LBHA) — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code, §533.0356.  

Local Intellectual and Developmental Disability Authority (LIDDA) — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code, §533A.035. LIDDAs serve as the point of entry for publicly funded intellectual and developmental disability (IDD) programs. 

Local Mental Health Authority (LMHA) — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code, §533.035. The LMHA is the state contracted agency that serves as the point of entry for publicly funded MI programs.  

Licensed Practitioner of the Healing Arts — A staff member who is a: 

• physician; 
• registered nurse (RN); 
• licensed professional counselor (LPC); 
• licensed clinical social worker (LCSW); 
• psychologist; 
• advanced practice registered nurse (APRN); 
• physician assistant (PA); or 
• licensed marriage and family therapist (LMFT). 

Long Term Care Online Portal — A web-based application used by Medicaid providers to submit forms, screenings, evaluations and other information. 

Medicaid managed care organization (MCO) service coordinator — The staff person assigned by a resident’s Medicaid MCO to ensure access to, and coordination of, additional Medicaid services that are needed. 

Minimum Data Set assessment — A standardized collection of demographic and clinical information that describes a person's overall condition, which a licensed NF in Texas is required to submit into the Long Term Care Online Portal (LTCOP) for people admitted into the facility and each quarter thereafter. 

Mental Health Services — The delivery system for providing adult mental health services in Texas designed to meet people’s needs and strengths to achieve the best possible results. This service delivery system is based on the Texas Resiliency and Recovery (TRR) model.   

Mental Illness (MI) — Serious MI, as defined in the Code of Federal Regulations, 42 CFR §483.102(b)(1). 

Mental Illness/Dementia Resident Review (Form 1012) — Form 1012 assists NFs in determining if a previously negative PASRR Level 1 (PL1) form, that has already been submitted to the LTCOP, needs to be changed to a positive PL1 for MI.   

MI specialized services — Available to people who are PASRR positive for MI, as described in the Texas Resilience and Recovery Utilization Management Guidelines, including: 

• Skills training and development (individual and/or group); 
• Routine case management (21 years of age or older); 
• Medication training and support services (individual and group); 
• Pharmacological management; 
• Psychosocial rehabilitation services (individual and/or group);  
• Psychiatric diagnostic evaluation; and  
• Supportive housing, which includes alternate placement assistance and transitioning to the community. 

Nursing facility (NF) — A Medicaid-certified facility that is licensed in accordance with the Texas Health and Safety Code, Chapter 242. 

NF PASRR support activities — Consistent with 40 TAC §19.2703, actions an NF coordinates with a LIDDA, LMHA or LBHA to facilitate the successful provision of IDD habilitative specialized services or MI specialized services, including: 

• arranging transportation for a person to participate in an IDD habilitative specialized service or an MI specialized service outside the facility; 
• sending a person to a scheduled IDD habilitative specialized service or MI specialized service with food and medications required by the resident; and 
• stating in the comprehensive care plan an agreement to avoid, when possible, scheduling NF services at times that conflict with IDD habilitative specialized services or MI specialized services. 

NF specialized services — The following specialized services available to a person with ID or DD: 

• Habilitative therapy services; 
• Customized manual wheelchair (CMWC); and 
• Durable medical equipment (DME). 

PASRR Comprehensive Service Plan (PCSP) form — The form completed to record the results of the initial IDT meeting. The PCSP form is also completed when there is an LA update meeting, a quarterly meeting or an annual IDT meeting.  

PASRR evaluation (PE) — A face-to-face evaluation: 

• of a person seeking admission to an NF who is suspected of having MI, ID or DD; 
• performed by a LIDDA, LHMA or LBHA to determine if the person has an MI, ID or DD diagnosis and, if so, to: 
  •   assess the person's need for care in an NF; 
  •   assess the person's need for specialized services; and 
  •   identify alternate placement options. 

PASRR Level I (PL1) screening — The process of screening a person seeking admission to an NF to identify whether the person is suspected of having MI, ID or DD. 

Peer provider — A staff member who: 

• has received a high school diploma or a high school equivalency certificate issued in accordance with the law or the issuing state; and 
• has at least one cumulative year of receiving mental health services for a disorder that is treated in the target population for Texas. 

Person-Centered Recovery Plan (PCRP) — Uses a recovery orientation and team approach that includes the individual, formal supports and natural supports to best support the individual’s recovery and goals. 

Pharmacological management — The in-depth management of psychopharmacological agents to treat a person’s mental health symptoms. 

Preadmission process — A category of NF admission: 

• from a community setting, such as a private home, an assisted living facility, a group home, a psychiatric hospital or jail, but not an acute care hospital or another NF; and 
• that is not an expedited admission or an exempted hospital discharge. 

Pre-Admission Screening and Resident Review (PASRR) Evaluation Summary Report (Form 1014) —  A summary of the results of a person’s positive PASRR evaluation.   

Qualified Mental Health Professional-Community Services (QMHP-CS) — A staff member who is credentialed as a QMHP-CS who has demonstrated and documented competency in the work to be performed and: 

• has a bachelor's degree from an accredited college or university with a minimum number of hours that is equivalent to a major (as determined by the LMHA or MCO in accordance with TAC §412.316(d) of this title, relating to Competency and Credentialing) in psychology, social work, medicine, nursing, rehabilitation, counseling, sociology, human growth and development, physician assistant, gerontology, special education, educational psychology, early childhood education or early childhood intervention. 
• is a registered nurse. 
• completes an alternative credentialing process as determined by the LMHA or MCO in accordance with TAC §412.316(c) and (d) of this title relating to (Competency and Credentialing). 

Referring entity — The entity that refers a person to an NF, such as a hospital, attending physician, LAR or other personal representative selected by the person, a family member of the person or a representative from an emergency placement source, such as law enforcement. 

Resident — A person who resides in an NF and receives services provided by professional nursing personnel of the facility. 

Resident review — A face-to-face evaluation of a person performed by a LIDDA, LMHA or LBHA: 

• for a person with MI, ID or DD who experienced a significant change in status to: 
  • assess the person's need for continued care in an NF; 
  • assess the person's need for specialized services; and 
  • identify alternate placement options. 
• for a person suspected of having MI, ID or DD, to determine whether the person has MI, ID or DD and if so to: 
  • assess the person's need for continued care in an NF; 
  • assess the person's need for specialized services; and 
  • identify alternate placement options. 

Registered nurse (RN) — A person licensed to practice professional nursing as an RN in accordance with Texas Occupations Code, Chapter 301. 

Service coordination — Assistance in accessing medical, social, educational and other appropriate services and supports, including alternate placement assistance, that will help a person achieve a quality of life and community participation acceptable to the person and LAR on the person's behalf. 

Service coordinator — An employee of a LIDDA who provides service coordination to persons with IDD. If a person is dually PASRR positive (MI and IDD), the service coordinator takes the lead in coordinating specialized services and SPT meetings. 

Specialized services — The following support services, other than NF services, that are identified through the PE or resident review and may be provided to a person who has a PE or resident review that is positive for MI, ID or DD:  

• NF specialized services;  
• IDD habilitative specialized services; and 
• MI specialized services. 

Service Planning Team (SPT) — A team convened by a LIDDA staff person who develops, reviews and revises the HSP and the transition plan for a person who is PASRR positive for IDD or IDD and MI. the team must include: 

• The person; 
• Person’s LAR, if any; 
• Habilitation coordinator for discussions and service planning related to specialized services or the service coordinator for discussions related to transition planning if the person is transitioning to the community; 
• MCO service coordinator, if the person does not object; 
• While the person is in an NF: 
  • An NF staff person familiar with the person’s needs; and 
  • A person providing a specialized service to the person or a representative of a provider agency that is providing specialized services for the person. 
• If the person is transitioning to the community: 
  • A representative from the community program provider, if one has been selected; and  
  • A relocation specialist. 
  • A representative from the LMHA or LBHA, if the person has MI; and 
• Other participants on the SPT may include: 
  • A concerned person whose inclusion is requested by the person or the LAR; and 
  • At the discretion of the LIDDA, a person who is directly involved in the delivery of services to people with ID or DD. 

Surrogate decision maker — An actively involved family member of a person who has been identified by an IDT, in accordance with Texas Health and Safety Code §313.004, and who is available and willing to consent to medical treatment on behalf of the person. 

Texas Resiliency and Recovery (TRR) — The term that describes the service delivery system in Texas for community mental health services. The system’s mission is to foster resilience and recovery with respect to MI. A primary aim of HHSC’s service delivery system is to ensure the provision of interventions and evidence-based practices with empirical support to promote recovery and resilience from mental health disorders.  

Transition plan — A plan developed by the SPT that describes the activities, timetable, responsibilities, services and essential supports involved in assisting a person to transition from residing in an NF to living in the community. The transition plan is developed for people who are PASRR positive for IDD only or dual IDD/MI only.

Revision 20-0; Effective August 25, 2020

2100 Referring Entity

Revision 20-0; Effective August 25, 2020

The Preadmission Screening and Resident Review (PASRR) process begins with the referring entity (RE). An RE is a person or entity who refers someone to a nursing facility (NF) for admission. The most common REs are hospital discharge planners. Other REs can be, but are not limited to:

PASRR requires that all people seeking admission to an NF have a PASRR Level 1 Screening (PL1) form completed prior to admission, and the referring entity is responsible for completing the paper version of the form.

The PL1 documents the suspicion of a mental illness (MI), intellectual disability (ID) or developmental disability (DD) based on information available to the RE. The RE responds to the questions regarding a diagnosis provided within Section C of the PL1 form.

2110 PASRR Level 1 Screening

Revision 20-0; Effective August 25, 2020

This section provides an overview of the PL1 Screening and its role in the PASRR process. The PL1 Screening form may be downloaded from the Texas Medicaid and Healthcare Partnership (TMHP) website at https://www.tmhp.com/programs/ltc/forms.

2120 PL1 Screening Form Purpose

Revision 20-0; Effective August 25, 2020

The PL1 Screening form is designed to identify people seeking admission to an NF who are suspected of having an MI, ID or DD.

2130 PL1 Screening Form Sections

Revision 20-0; Effective August 25, 2020

The PL1 Screening form contains the following sections:

• Section A:
  • Submitter Information identifies contact information for the person from the local behavioral health authority (LBHA)/local mental health authority (LMHA) submitting the PL1 into the TMHP Long Term Care Online Portal (LTCOP).
  • Referring Entity Information contains information about the person who performed the PL1 screening.
• Section B:
  • Personal Information contains information about the person who is being screened. This section also contains fields used later, if necessary, to update the PL1 due to a death or discharge. It is essential the LMHA/LBHA enter and verify the person's demographic information correctly prior to submitting the PL1. The demographic information can be found in the medical chart, including the person's Social Security number, Medicaid and Medicare information, birth date, proper name and other information that may be needed.
• Section C:
  • PASRR Screen Section C documents answers to the questions related to whether the person completing the form believes there is evidence or indicators of mental illness (C0100), intellectual disability (C0200) or developmental disability (C0300). The person will document either yes or no to each of the three questions.
  • Local Authority (LA) Information documents the LMHA/LBHA/LIDDA information associated with the PL1 submission. This section will auto-populate based on the LMHA/LBHA/LIDDA vendor number.
• Section D:
  • Nursing Facility Choices documents the person's or LAR's choice(s) of NFs for admission.
• Section E:
  • This section is only available for data entry to the LA after the PL1 has been submitted on the LTCOP.
  • Alternative Placement (Preferences) documents the person's or LAR's alternate placement preferences and should be completed by the referring entity (RE).
  • Alternative Placement (Disposition) documents to which alternate placement program the person was admitted. For a person transitioning out of the NF, the LA must complete this section before the person is discharged on the PL1 (B0650 and B0655) and within seven business days after the person enrolls in a community program.
  • For diversions, the LA completes this section after Medical Necessity (MN) is approved and will also discharge the person on the PL1 (B0650 and B0655).
• Section F:
  • Documents the person's PASRR Admission Category and must be completed by the RE. There are four types of NF admissions:
    • Exempted hospital discharge
    • Expedited admission
    • Preadmission
    • Negative

TMHP determines admission type (or category) by responses in Section F of the PL1. If the response in F0100 is "0" (meaning No) and the response in F0200 is "0" (meaning not expedited admission), then the admission category is considered "preadmission" by default.

2140 Exempted Hospital Discharge

Revision 20-0; Effective August 25, 2020

Exempted hospital discharge occurs when a physician has certified that a person being discharged from an acute care hospital is likely to require less than 30 days of nursing facility (NF) services for the condition for which the person was hospitalized. An example of this type of admission would be for a person who falls, breaks a hip and goes into the NF for rehabilitation services.

The referring entity (RE) [acute care hospital] provides the NF with a copy of the PL1. The NF enters the PL1 into the TMHP Long Term Care Online Portal (LTCOP) immediately upon the person's admission.

A person in this category with a positive PL1 will only require a PASRR evaluation (PE) if a stay in the NF exceeds 30 days. If the person's stay exceeds 30 days, the LTCOP will send an alert to the LMHA/LBHA/LIDDA to conduct the PE. 

2141 Expedited Admission

Revision 20-0; Effective August 25, 2020

Expedited admission occurs when a person meets the criteria for any of the following seven categories:

• Convalescent Care: Person is admitted from an acute care hospital to an NF for convalescent care with an acute physical illness or injury which required hospitalization and is expected to remain in the NF for greater than 30 days.
• Terminal Illness: Person has a medical prognosis that his or her life expectancy is six months or less if the illness runs its normal course. A person's medical prognosis is documented by a physician's certification, which is kept in the person's medical record maintained by the NF.
• Severe Physical Illness: An illness resulting in ventilator dependence or diagnosis, such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis or congestive heart failure, which result in a level of impairment so severe that the person could not be expected to benefit from specialized services.
• Delirium: Provisional admission pending further assessment in case of delirium where an accurate diagnosis cannot be made until the delirium clears.
• Emergency Protective Services: Provisional admission pending further assessment in emergency situations requiring protective services, with placement in the NF not to exceed seven days.
• Respite: Very brief and finite stay of up to a fixed number of days to provide respite to in-home caregivers to whom the person with MI or ID is expected to return following the brief NF stay.
• Coma: Severe illness or injury resulting in the inability to respond to external communication or stimuli, such as coma or functioning at brain stem level.

The RE provides the NF with a copy of the PL1. The NF enters the PL1 into the LTCOP immediately upon a person's admission.

The length of stay or the type of expedited admission will determine when the PE is completed for a person. For example, a person admitted who is in a coma will not receive a PE until they regain consciousness.

2142 Preadmission

Revision 20-0; Effective August 25, 2020

The preadmission process starts when an NF admission is from an RE in the community (such as the person's home, group home, psychiatric hospital, assisted living or jail) but not an acute care hospital or another NF. When the RE is a family member, the RE may request assistance from the NF to complete the PL1. The NF is not allowed to submit preadmission PL1s. If the PL1 is negative, the negative admission process is followed (see Section 2233, Documentation Review for PE Completion).

If the PL1 is positive:

• The RE faxes the PL1 Screening form to the LMHA/LBHA/LIDDA (this serves as the notification to complete the PE).
• The LMHA/LBHA/LIDDA submits the PL1 Screening form on the LTCOP.
• The LMHA/LBHA/LIDDA initiates face-to-face contact for the PE within 72 hours of notification by the RE.
• The LMHA/LBHA/LIDDA submits the PE on the LTCOP within seven calendar days of notification by the RE.

Texas Medicaid & Healthcare Partnership (TMHP) is responsible for reviewing successfully submitted preadmission PEs to determine medical necessity (MN) for people who are PASRR positive. The initial Minimum Data Set (MDS) assessment will inherit the MN determination from the PE, if the MDS assessment effective date is within 30 days (plus or minus) of the date of assessment of the PE.

The NF reviews the PE, including recommended specialized services, and certifies on the PL1 Screening form, Section D, if able or unable to serve the person, and MN must be established before the person can be admitted to the NF.

2143 Negative Admission

Revision 20-0; Effective August 25, 2020

If the RE determines the answer is "No" to all three questions within Section C, PASRR Screen, then the PL1 screening status is considered negative for suspicion of an MI, ID or DD. The RE sends the PL1 to the admitting NF with the person. The NF enters the negative PL1 into the LTCOP upon the person's admission. The PASRR process ends for the person after admission.

2150 PL1 Submission

Revision 20-0; Effective August 25, 2020

The PL1 Screening form can only be submitted in the LTCOP by an LA or NF depending on the admission type.

After completing the PL1, the RE has the final responsibility of sending the completed paper PL1 Screening form to the appropriate party for submission to the LTCOP.

The table below summarizes who completes the PL1 and to which party the PL1 is sent based on the admission type in Section F, and positive or negative status in Section C, of the PL1 Screening form.

Admission Type:	PL1 Completed By:	PL1 Submitted By:
Positive Preadmission	Referring Entity (RE)	LMHA/LBHA if positive for MI; LIDDA if positive for ID/DD
Negative Preadmission	RE	NF
Expedited Admission	RE	NF
Exempted Hospital Discharge	RE	NF
Change of Ownership (CHOW)	NF with the old contract/vendor number becomes the RE to the new contract number	NF with the new contract number
NF to NF Transfers	Discharging NF becomes the RE to the admitting NF	Admitting NF

2200 PASRR Level II Evaluation (PE)

Revision 20-0; Effective August 25, 2020

This section provides an overview of the PE form and its purpose in the PASRR process. For detailed information on how to complete a PE and steps for submitting a PE into the LTCOP, refer to the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook, Appendix I, Resources, "Detailed Item by Item Guide for Completing the PASRR Evaluation (PDF)".

2210 PE Purpose

Revision 20-0; Effective August 25, 2020

A PE is a face-to-face evaluation of the person and/or interview with the LAR and is performed by the LMHA, LBHA or LIDDA. If the PL1 is positive, a PE is completed to confirm the suspicion of MI, ID or DD. Medical records, interviews with the person and/or LAR, school records and any statewide historical records that are available are used to complete the PE. The PE is administered to identify:

• whether a person has an MI, ID or DD diagnosis;
• an appropriate service setting for a person; and
• meeting a person's need for specialized services.

To complete a PE for a person suspected of having both an MI and ID/DD diagnosis, refer to Section 2320, NF Enters Initial IDT/SPT Meeting Information.

2211 PASRR Positive

Revision 20-0; Effective August 25, 2020

When the PE confirms a person has an MI, ID or DD, the PASRR status for the person is PASRR positive. For guidance on determining whether a person is PASRR positive for MI, refer to Section 2234, Determining the MI PASRR Condition.

2212 PASRR Negative Status

Revision 20-0; Effective August 25, 2020

When the PE does not confirm a person has an MI, ID or DD, the PASRR status for the person is PASRR negative, even when the PL1 is positive. This ends the PASRR process for a person whose PE determines if the person is PASRR negative.

2213 Staff Qualifications for Completing a PE

Revision 20-0; Effective August 25, 2020

The qualifications for staff completing a PE are contained in 26 Texas Administrative Code, Chapter 303, §303.303 (relating to Qualifications and Requirements for Staff Person Conducting a PE or Resident Review). For more information on resident reviews, see Section 2237, PE for Resident Review.

An LMHA/LBHA must ensure a PE or resident review is conducted by a person who is a:

• Qualified Mental Health Professional – Community Service;
• Registered Nurse (RN);
• Licensed Clinical Social Worker;
• Licensed Professional Counselor;
• Licensed Marriage and Family Therapist;
• Licensed Psychologist;
• Advanced Practice Registered Nurse;
• Physician; or
• Physician Assistant.

Before a staff person conducts a PE or resident review, an LMHA/LBHA must ensure the staff person receives HHSC-developed training about how to conduct a PE and resident review and demonstrates competency in completing a PE and resident review. Additionally, the LMHA/LBHA must maintain documentation of the training received by a staff person who conducts a PE or resident review.

2220 LTCOP Notification

Revision 20-0; Effective August 25, 2020

The LA will receive an automatic alert notification to complete a PE in the LTCOP generated by an NF's submission of a positive PL1 into the LTCOP for an expedited admission or an exempted hospital discharge.

For preadmissions, the receipt of the faxed PL1 serves as notification for the LA to complete a PE.

2221 Notifications for Dually Diagnosed Individuals

Revision 20-0; Effective August 25, 2020

Dually diagnosed individuals are people who show signs of both MI and IDD, MI and ID, or MI and DD. There are two sections on one PASRR evaluation (PE) and two payments for the PE if performed by separate local authorities (LAs) [a LIDDA side and an LMHA/LBHA side].

When two LAs are involved, the LA that initiates submitting a PE is responsible for completing common sections of the PE. All sections of the PE are common except Section B, which is specific to IDD and Section C, which is specific to MI.

The PE is not considered complete until both sections (MI and IDD) are completed when the person is dually diagnosed. If only one part of the PE is completed, a system-generated alert is sent to the LA responsible for completion.

2222 Timing of Alert is Based on Admission Type

Revision 20-0; Effective August 25, 2020

The type of admission from the PL1 determines when an alert will be sent to the LA to conduct a PE. The timing for alerts are explained in Section 2330, Confirmation of IDT/SPT Meeting Information.

The LA must:

• check the LTCOP daily for PE alerts;
• have a single, identified fax line to receive PL1 forms from Res; and
• check the fax line daily to ensure all requests to conduct a preadmission PE are promptly acted on.

2223 Change of Ownership Extensions

Revision 20-0; Effective August 25, 2020

A Change of Ownership (CHOW) occurs when an NF is purchased by another facility, entity or corporation. When a CHOW happens, a new contract number is assigned to the NF. Once the new contract number is assigned, the NF being purchased must enter a new PL1 for every person in the NF within 90 calendar days after the new contract number's effective date.

Depending on the number of persons that are PASRR positive and need a new PE completed, extensions may be granted when an LA receives eight or more alerts from the same NF to complete a PE. The due date for the extension is calculated based upon the total number of alerts and calculating the LA completing four PEs per week. The LA may request an extension to the seven-day time frame to complete the PE. To request an extension, the LA must contact the HHSC PASRR Unit at PASRR.support@hhsc.state.tx.us.

2230 Completing and Submitting the PE

Revision 20-0; Effective August 25, 2020

LMHAs or LBHAs are responsible for completing a PE for people suspected of having MI.

Both the LMHA/LBHA and the LIDDA are responsible for completing their respective part of a PE for people suspected of having a dual diagnosis (MI and ID/DD).

Note: While an LMHA and LBHA will generally have the same responsibilities as a LIDDA for completing and submitting a PE, this handbook is intended to provide instructions and procedures for LMHAs/LBHAs in implementing PASRR requirements. From this point forward, this handbook will no longer reference LIDDAs unless it is within the context of a person with dual diagnoses, meaning MI and ID/DD.

The Qualified Mental Health Professional-Community Services (QMHP-CS) must meet face to face with the person within 72 hours of receiving the PL1 to begin the process of completing the PE.

The LMHA/LBHA uses documentation reviews, family interviews, interviews with others who know or have known the person, and NF staff interviews to complete the PE. The LMHA/LBHA has the following responsibilities when completing a PE:

1. Conducting a historical record review. See Section 2233, Documentation Review for PE Completion.
2. Contacting the RE or NF to make sure the person is still in the RE location or the NF before traveling to the RE location or NF to complete the PE and confirming the person is available and alert for the evaluation. It is advisable at this point to determine if the person needs translator services. See Section 2231, Interpreter Services.
3. Meeting face to face with the person within 72 hours after notification from the LTCOP online portal or receiving a copy of the PL1 from the RE.
4. Traveling to the NF to conduct the PE for exempted hospital discharge admissions and expedited admissions or, for preadmissions, to the location of the person in the community to conduct the PE, and carrying proper identification provided by the LMHA/LBHA.
5. Bringing a release of confidential information to obtain the person's/LAR's consent to obtain additional information, as needed, from collateral contacts.
6. Notifying HHS Complaint and Incident Intake at 800-458-9858 immediately if they are prevented from seeing a person or reviewing the person's medical record.
7. Using the medical information or documentation in the person's NF record to confirm whether the person has a diagnosis for MI and meets the criteria for MI specialized services. The LMHA/LBHA should seek assistance and clarification of documentation from available medical staff, as needed, and record only what is documented in the medical record.
8. The LMHA/LBHA must document on the PE what information and documentation were used to complete the evaluation. In the event the LMHA/LBHA is not satisfied with the diagnostic information available, it may be more appropriate to schedule a diagnostic interview with the LMHA's/LBHA's psychiatrist. This can be done either in person or via telemedicine.
9. Submitting the PE into the LTCOP within seven calendar days after notification.

The PE can be completed on paper or electronic versions, but ultimately the information collected must be submitted on the LTCOP by the LA within the seven-day time frame.

2231 Interpreter Services

Revision 20-0; Effective August 25, 2020

To complete the PE, the person/LAR should be given the opportunity for interpreter services, if needed. The LMHA/LBHA must arrange or work in cooperation with the RE, NF and person/LAR for interpreter services, if needed.

2232 Person/LAR Refuses to Participate in PE

Revision 20-0; Effective August 25, 2020

If a person or LAR refuses participation in the PE, the LMHA/LBHA should request assistance from NF staff who have the greatest knowledge and rapport with the person/LAR in explaining the process to the person/LAR. If the person or LAR continues to refuse, the LMHA/LBHA will complete the PE solely from chart review and will document the person's/LAR's refusal in a comment field located within Section F1000 of the PE.

2233 Documentation Review for PE Completion

Revision 20-0; Effective August 25, 2020

When investigating a person's history for a PE, the LMHA/LBHA should search all applicable service and medical records, including those available in online databases, such as the Client Assignment and Registration (CARE) system, Clinical Management for Behavioral Health Services (CMBHS) and if available, LTCOP.

Investigating these systems can provide the LMHA/LBHA with insight on where to look for records and can yield valuable information, such as previous placement in settings of:

• State psychiatric hospitals;
• Private psychiatric hospitals;
• Other state facilities;
• Criminal justice facilities;
• Waiver programs, Home and Community Based Services (HCBS), STAR+PLUS;
• State supported living centers; and
• Intermediate care facilities (ICFs).

Documentation gathering, and record review should include, but not be limited to:

• Diagnostic records;
• Medical records;
• Previous PEs, service plans and assessments; and
• All relevant records from other LMHAs/LBHAs.

2234 Determining the MI PASRR Condition

Revision 20-0; Effective August 25, 2020

To determine whether a person is PASRR positive for MI, there are several things the evaluator must take into consideration when responding to the following questions in Section C of the PE.

Section C0100 Primary Diagnosis of Dementia – Does this person have a primary diagnosis of dementia? The primary diagnosis is the most serious and/or resource-intensive diagnosis. Secondary diagnoses are other diagnosis that require attention.

To determine if the person has a primary diagnosis of dementia, review the NF's medical record for documentation by the physician that dementia is the primary diagnosis with a secondary diagnosis of MI (if MI diagnosis as per Section C0300 of the PE).

If a person has a primary diagnosis of dementia and no MI diagnosis, the PASRR evaluator would respond "Yes" to the question in this section. If there is no documentation in the medical record that states the person has a primary diagnosis of dementia, then the correct response for this question would be "No."

Some of the most common types of dementia diagnoses to look for are:

• Alzheimer's disease;
• Vascular dementia;
• Frontotemporal dementia;
• Lewy body dementia; and
• Dementia from Parkinson's disease and similar disorders.

Once "Yes" is checked in C0100, the rest of Section C will automatically be disabled within the form, but the evaluator must still complete Sections D, E and F of the PE. If the PASRR evaluator responds "Yes" in this section, the evaluator must ensure a diagnosis of dementia is recorded in Section D under Diagnosis.

If the evaluator responds "No" to this question, the evaluator will complete the remainder of Section C.

C0200 Severe Dementia Symptoms – Are the individual's dementia symptoms so severe that they cannot be expected to benefit from PASRR specialized services?

This determination must be based on documentation in the medical record that the person's symptoms are resulting from the dementia diagnosis and not for any other reason. The PASRR evaluator may also talk with NF staff to find out more about the person's dementia symptoms and the evaluator can take into consideration how the person responded or engaged during the PASRR evaluation.

If the person does not have a dementia diagnosis, then the response to this question should be "No."

Persons with a diagnosis of dementia, that is not their primary diagnosis and the response to C0200 is "Yes," may potentially be determined PASRR positive for MI once Section C is completed.

Note: If this section is checked "Yes," there must be a diagnosis of dementia (not primary) in Section D for this response to be legitimate.

For persons whose dementia symptoms are so severe that they cannot be expected to benefit from PASRR specialized services and are determined to be PASRR positive for MI, it is important to discuss whether this person would benefit from MI PASRR services during the interdisciplinary team (IDT) meeting.

If the IDT (including the person and/or their LAR, NF RN and the LMHA/LBHA) agrees that "at this time" the person would not benefit from specialized services because of their current medical condition, this decision must be documented as specialized services "not needed." A note must be added to the comment section of the PASRR Comprehensive Service Plan (PCSP) explaining why the person will not be receiving services.

C0300 Mental Illness – In this section, the LMHA/LBHA documents whether a person has an MI diagnosis. If something other than "None of the Above Apply" is selected, the LMHA/LBHA needs to make sure an MI diagnosis is documented in Section D.

The LMHA/LBHA must review the medical record for a diagnosis of MI. Examples of MI are: 

• Schizophrenia;
• Mood disorder (Bipolar disorder, major depression or other mood disorder);
• Paranoid disorder;
• Panic or other severe anxiety disorder;
• Somatoform disorder;
• Schizoaffective disorder; and
• Panic or other disorder that may lead to a chronic disability diagnosable under the current Diagnostic and Statistical Manual of Mental Disorders.

Documenting "None of the Above Apply" in this section, indicates that the PASRR evaluator's medical record review resulted in the person not having an MI diagnosis and is therefore PASRR negative for MI.

2235 Determining When Diagnosis is MI or Symptom Co-occurring with Dementia

Revision 20-0; Effective August 25, 2020

Many common signs and symptoms caused by dementia (i.e., Alzheimer's disease, vascular dementia, Lewy body dementia and frontotemporal dementia) may be confused with a mental illness (MI) diagnosis.  

Dementia symptoms vary depending on the cause but are not an MI. Examples of common signs and symptoms of dementia include:

• Cognitive changes:
  • Memory loss, which is usually noticed by a spouse or someone else;
  • Difficulty communicating or finding words;
  • Difficulty with visual and spatial abilities, such as getting lost while driving;
  • Difficulty reasoning or problem-solving;
  • Difficulty handling complex tasks;
  • Difficulty with planning and organizing;
  • Difficulty with coordination and motor functions; and
  • Confusion and disorientation; and
• Psychological changes:
  • Personality changes;
  • Depression;
  • Anxiety;
  • Inappropriate behavior;
  • Paranoia;
  • Agitation;
  • Hallucinations; and
  • Psychosis.

Unless the individual had an MI prior to their dementia diagnosis, these changes/symptoms are caused by their dementia. Therefore, the individual does not have MI. 

Examples of medical conditions not considered MI are: 

• Huntington's disease;
• Traumatic brain injury; and
• Parkinson's disease.

Depression, unless diagnosed as a major depressive disorder in the medical record by the physician, is not considered an MI.  

C0400 Functional Limitation – It is important to thoroughly research the responses to this section. Refer to the Intellectual and Developmental Disability Preadmission Screening and Resident Review (IDD-PASRR) Handbook, Appendix I, Resources, "Detailed Item by Item Guide for Completing the PASRR Evaluation (PDF)," for more information on each choice in this section.

Documenting "None of the Above Apply" in this section indicates that the PASRR evaluator's medical record review resulted in the person not having any functional limitations and is, therefore, PASRR negative for MI even if they have selected "Yes" as a response in Sections C0500 – C0700.

C0500 – C0700 Recent Occurrences – For a person to meet the federal PASRR definition of MI, they must have an MI diagnosis listed under C0300, a functional limitation documented in C0400 and had at least one of the following experiences listed in C0500, C0600 and C0700.

After a thorough record review, if the response to any of these three questions is "Yes," then C0800 is auto-populated to show that this person is PASRR positive for MI. If all selected are "No," then C0800 auto-populates to show that this person is PASRR negative for MI even if this person has a diagnosis of MI.

C0500 Inpatient Psychiatric Treatment – Has this individual experienced a psychiatric treatment more intensive than outpatient care more than once in the past two years?

This means that a person must have had more than one inpatient stay in a psychiatric hospital or more than one partial psychiatric hospitalization (when a person resides at home, but commutes to a treatment center up to seven days a week). This includes the Intensive Outpatient Program (IOP) where the person goes daily to the psychiatric hospital or crisis treatment center.

C0600 Disruption to Normal Living Situation – Has this individual experienced a significant disruption to their normal living situation requiring supportive services (e.g., residential or respite services) in the last two years due to MI?

Were supportive services required to maintain functioning at home or in a residential treatment environment (i.e., psychiatric home health nurse or the LMHA/LBHA provide in-home psychiatric services to assist the person in staying in their own home). If so, then the PASRR evaluator would respond "Yes."

If a person has only had one inpatient or partial psychiatric hospitalization (C0500), the response would be "No." But, disruption to normal living situations (C0600) would be "Yes" as they had a disruption to their normal living situation due to their MI.

C0700 Intervention by Law Enforcement – Has this individual experienced intervention by law enforcement, protective services agencies or other housing officials in the last two years due to MI?

Has law enforcement, protective agencies or a housing official's person been contacted due to behaviors caused by their MI or because this person was a danger to themselves or others due to their MI? This also includes any interventions by an LMHA/LBHA crisis team.

C0800 Based on the QMHP-CS assessment, does this individual meet the PASRR definition of mental illness? – There must be at least one "Yes" response to the questions in C0500 – C0700 for a PE to determine if the person is PASRR positive for MI. On the LTCOP, this question on the PE is auto-populated based on the responses in Sections C0500 – C0700.

Section C, Specialized Services and Recommendations – The purpose of this section is to determine what types of specialized services, provided by the LMHA/LBHA, a person may benefit from receiving.

When completing this section, consideration must be given to any additional support this person may need, not only while they are residing in the NF, but to help prepare persons whose goal is to transition out of the NF.

A person who is PASRR positive for MI is not only eligible for the specialized services listed on the PE, but all Texas Resilience and Recovery (TRR) services their LMHA/LBHA offers.

C0900 Does the individual need assistance in any of the following areas? – This section lists areas that a person may need assistance with and how these needs correspond with the services listed in C1000. But, as stated above, the person is eligible for all TRR services; not just those listed on the PE.

If Section C0900 does not list all the needs a person being evaluated may require assistance with, it is important for the PASRR evaluator to list these needs in C0900M, Other Areas, along with the TRR services that would address these needs.

Examples:

• Relief of post-traumatic stress disorder (PTSD) symptoms – Cognitive processing therapy;
• Relief of symptoms of persistent serious MI – Counseling services (CBT – individual or group);
• Suspected of, or are using, alcohol or other substances – Screening, brief intervention and referral to treatment (SBIRT) – Brief intervention provided; and
• Transitioning to the community – Supported housing.

C01000 Recommended Services Provided/Coordinated by the LMHA/LBHA – The LMHA/LBHA must take into consideration when deciding which services to recommend for a person who is PASRR positive for MI, that the services are not limited to those listed on the PE. The person is eligible for all TRR services offered by a center.

2236 PE Section F, Certain Community Programs Information

Revision 20-0; Effective August 25, 2020

All the community programs listed in Section F0700 of the PE may not apply to the person. The staff conducting the PE should determine which program the person may be eligible for and use the following information to describe these two programs to the person and LAR.

• F0700O STAR+PLUS is a Medicaid managed care program. Generally, all eligible people are automatically enrolled in STAR+PLUS. For the STAR+PLUS Home and Community Based Services (HCBS) Program or STAR+PLUS Waiver, use F0700D.
• F0700V Other community-based services is an example of the various housing programs offered at the LMHAs/LBHAs. 

2237 PE for Resident Review

Revision 20-0; Effective August 25, 2020

When a person with MI and/or IDD who has been residing in an NF experiences a significant change in medical status, the NF will submit an updated MDS assessment referred to as a Significant Change in Status Assessment (SCSA) into the LTCOP. When an SCSA is submitted, the LTCOP will issue an alert to the LA to conduct a resident review within seven calendar days after receiving the alert.

Before initiating a new PE, the LA should contact the NF to confirm what the change of condition is, and will it affect their current PASRR status (i.e., is the change of condition medical only, placed on hospice or hospital stay?). If it is determined that the change of condition will not affect the current PASRR status, then the LA should note this on the PE in the history section documenting who they spoke with, date, time and results of conversation.

If it is determined that a new PE is warranted, the LMHA/LBHA/LIDDA will initiate a new PE from the current PL1 and submit the resident review in the same manner as the PE on the LTCOP. The resident review is conducted to:

• assess the person's need for continued care in an NF;
• assess the person's need for specialized services as the need may have changed due to the significant change in mental or medical condition; and
• identify alternate placement options.

Form 1012, Mental Illness/Dementia Resident Review, is used by the NF for a person who has been residing in an NF and has a negative PL1 for MI. Form 1012 assists the NF in determining whether the person may meet the Code of Federal Regulations definition of MI, if there is a dementia diagnosis and whether the person's dementia is the primary diagnosis. After completing the form, the NF may submit another PL1 for the person, only this time the PL1 will be positive. Submitting a new positive PL1 will alert the LA to complete a resident review (new PE).

Form 1012 also provides NFs the documentation for medical records as to why a new positive PL1 was not needed.

The NF must convene the IDT meeting within 14 calendar days after the LTCOP generates an automated notification to the LA to conduct a resident review. The LA must attend the IDT in person or by phone.

When a person who is a resident in an NF who has a negative PL1 for MI and has a significant change of condition that could indicate the person may be PASRR positive for MI, 26 Texas Administrative Code §303.102 requires that a resident review be conducted. When this occurs, Form 1012 is used by the NF for a person who has a negative PL1 for MI. This form assists the NF in determining whether the person may meet the Code of Federal Regulations definition of MI, if there is a dementia diagnosis and whether the person's dementia diagnosis is the primary diagnosis. After completing Form 1012, the NF must submit a positive PL1 for the resident. The positive PL1, once entered by the NF into the LTCOP, will trigger the process to conduct a PE by the LMHA/LBHA.

Form 1012 also provides NFs the documentation for medical records as to why a new positive PL1 was not needed.

2238 PE Submission 

Revision 20-0; Effective August 25, 2020

The LMHA/LBHA will:

• enter the data recorded from the electronic or paper copy PE into the LTCOP;
• retain the original paper copy PE in the person's record; and
• reference the Texas Medicaid & Healthcare Partnership (TMHP) PASRR User Guide.

2239 Specialized Services Recommendation

Revision 20-0; Effective August 25, 2020

Form 1014, Pre-Admission Screening and Resident Review (PASRR) Evaluation Summary Report, is used to summarize the recommended specialized services for a person who is eligible for specialized services following the completion of a PE, but prior to the IDT meeting. The entity that completes the PE will complete Form 1014.

Only one Form 1014 should be completed per person. For a person whose PE is positive for:

• MI only, an LMHA/LBHA must complete Form 1014.
• MI and ID/DD (dual diagnosis), the LIDDA should take the lead on completing Form 1014.

Form 1014 is a summary of the results of a person's positive PE listing the recommended specialized services. The LA completes and provides a copy of the form to the person or LAR after completing a PE, but before the IDT meeting. The form must be signed by the person or LAR to indicate receipt of the form. The LA must keep a signed copy in the person's LMHA/LBHA record.

Detailed step-by-step instructions on how to complete the form are found on the HHS website with Form 1014.

2240 Fair Hearing Related to Negative PE

Revision 20-0; Effective August 25, 2020

Based on the PE determination, a negative PE will result in the person not being eligible for PASRR specialized services which are funded through Medicaid. A negative PE does not affect the person's eligibility for nursing facility services.

An LMHA/LBHA must notify the person and their LAR about the negative PASRR determination using Form 2360, Negative PASRR Evaluation Letter. This form informs the person or their LAR of their PASRR determination and their right to request a Medicaid fair hearing to contest the denial of the specialized services.

If a person or LAR requests a fair hearing, HHSC will notify the LMHA/LBHA, which must provide information or material supporting a negative PE determination. The LMHA/LBHA must submit all requested material or information related to the fair hearing by the date established by HHSC staff assembling the PE fair hearing packet. The LMHA/LBHA must also attend the fair hearing in person or by phone as a representative of HHSC to defend the negative PE determination.

After the PE fair hearing, the person or LAR will receive a letter from the hearing officer informing them of the hearing results. LMHAs/LBHAs will also receive a copy of the letter with the hearing outcome.

2250 PE Retention Period

Revision 20-0; Effective August 25, 2020

HHSC currently requires an LMHA/LBHA/LIDDA to keep all handwritten PE documentation indefinitely in the person's record. The electronic version of the PE will be retained in the LTCOP system.

2300 PASRR Initial IDT/SPT Meeting

Revision 20-0; Effective August 25, 2020

For any person with a positive PE for MI, ID or DD, the NF will convene an interdisciplinary team (IDT) meeting within 14 calendar days of the person's NF admission, or for a resident review, within 14 calendar days after the LTCOP generated an alert to the LMHA/LBHA to complete a PE. The NF is responsible for scheduling, conducting and documenting the IDT meeting on the LTCOP. By participating in the IDT meeting, the LMHA/LBHA staff assists IDT members in accomplishing the goals of the IDT meeting, which are to:

• identify which of the MI specialized services recommended for the resident, or LAR on the resident's behalf, wants to receive by:
  • ensuring the person, regardless of whether he or she has an LAR, participates in the IDT to the extent possible and receives the support necessary to do so;
  • reviewing all available assessments, prior to the IDT meeting;
  • explaining the Uniform Assessment (UA) and how it will determine a Level of Care (LOC); and
  • explaining the need to schedule an LA update meeting once the UA is completed; and
• determine whether the resident is best served in a facility or community setting.

The IDT will review and discuss which of the PE's recommended specialized services the person wants and the LAR consents to being provided.

PASRR specialized services and the funding source should be discussed during the meeting. For example, if the person is under the age of 21, specialized services could be accessed through Texas Health Steps. Funding sources other than Medicaid for persons age 21 and older should be discussed and recorded in the IDT meeting.

If barriers are identified that would limit the provision of specialized services, the IDT members should determine whether provision of any specialized service could help eliminate barriers. If so, those specialized services should also be recommended and must be identified as such on the PASRR Comprehensive Service Plan (PCSP) form. It is important to remember a person has the right to accept or refuse any or all recommended specialized services and the acceptance or refusal of services must be documented in the PCSP form.

Excluding a person's/LAR's refusal of specialized services, if there is not consensus among all IDT members regarding whether a person should receive an NF specialized service, obtaining an assessment for the NF specialized service is strongly encouraged. The assessment will indicate whether the person can benefit from the specific NF specialized service.

Note: Persons who are PASRR positive for MI only do not have quarterly service planning team (SPT) meetings, but an LA update meeting may be held anytime there is a need for acceptance of services after refusing in the IDT meeting, changes in services, etc. This LA update is documented on the PCSP form in the LTCOP.

2310 Attendance at Initial IDT/SPT Meeting

Revision 20-0; Effective August 25, 2020

At the initial IDT meeting for a person, LMHA/LBHA staff are required to be in attendance either in person or by phone.

If the LMHA/LBHA staff, as an IDT member participates by phone, the LMHA/LBHA staff must ensure their name is included on the meeting sign-in sheet.

The Qualified Mental Health Professional-Community Services (QMHP-CS) must review any other available supporting documentation prior to the IDT meeting. This could include diagnostic information and previous uniform assessments (UAs) in Clinical Management for Behavioral Health Services (CMBHS), previous LMHA/LBHA services in the Mental and Behavioral Health Outpatient Warehouse (MBOW) and previous recovery plans in the LMHA/LBHA medical record.

The LMHA/LBHA strongly encourages the LMHA/LBHA QMHP-CS, who completed the PE, to attend the person's initial IDT meeting. The QMHP-CS must be prepared to discuss the person's needed MI specialized services and make those recommendations, as well as ensure the recommended services are entered in the PASRR Comprehensive Service Plan (PCSP) form.

For a person with a positive PE for MI and ID/DD, the LIDDA representative is also required at the IDT meeting and the LIDDA takes the lead for coordinating all specialized services discussed during the initial IDT meeting. If the person is eligible for habilitation coordination, a habilitation coordinator attends as well.

Attendance at the initial IDT meeting as a required IDT member is an activity that is included in the PE reimbursement rate regardless of whether the person accepts or refuses services.

2320 NF Enters Initial IDT/SPT Meeting Information

Revision 20-0; Effective August 25, 2020

Following the IDT meeting, the NF enters the following information from the IDT meeting in the LTCOP on the PASRR Comprehensive Service Plan (PCSP) form:

• Date of the IDT meeting;
• Names and titles of the required IDT members in attendance;
• All specialized services agreed upon during the IDT meeting, if any; and
• Determination of whether the person is best served in a facility or community setting.

2321 Specialized Services Funding Considerations

Revision 20-0; Effective August 25, 2020

The specialized services agreed upon during the IDT meeting for a person with a positive PE for MI and/or IDD who:

• has Medicaid and is age 21 or older, are documented on the PCSP form in the Specialized Services Information section, Field A3100, MI Specialized Services, and in Fields A2800, NF Specialized Services, A2900, Durable Medical Equipment (DME), and A3000, IDD Specialized Services, if the person also has ID/DD.
• does not have Medicaid or is age 20 or younger, are documented on the PCSP form in the Comments section, Field A3200, Nursing Facility Comments.

If the person will be receiving the service through other funding sources:

• The LMHA/LBHA is responsible for identifying the funding source for MI specialized services;
• The LIDDA is responsible for identifying the funding source for IDD specialized services; and
• The NF is responsible for identifying the funding source for NF specialized services.

2330 Confirmation of IDT/SPT Meeting Information

Revision 20-0; Effective August 25, 2020

Within five business days after receiving notification from the LTCOP that the NF entered information from an initial or annual IDT meeting into the PCSP form, an LMHA/LBHA must log into the LTCOP and take one of the following three actions in the chart below, as appropriate:

1. If an LMHA/LBHA representative participated in the IDT and agrees with the information the NF entered in the LTC online portal related to the specialized services at the IDT, the LMHA/LBHA must confirm in the LTCOP in Section A3400 agreement with the:

• specialized services listed in the LTCOP; and
• LMHA/LBHA representative's attendance at the IDT.

For instructions on confirming the IDT form, refer to the LTC User Guide for Preadmission Screening and Resident Review (PASRR) (PDF).

2. If an LMHA/LBHA representative participated in the IDT but determines the information the NF entered in the PCSP form related to the specialized services agreed to at the IDT is incorrect, the LMHA/LBHA must contact the NF and ask the NF to address the discrepancy. The LMHA/LBHA will allow seven calendar days for the NF to correct the information in the PCSP form.

• If the NF corrects the information in the LTCOP within seven days, the LMHA/LBHA must confirm in the LTCOP in Section A3400 agreement with the:
  • specialized services listed in the LTCOP; and
  • LMHA/LBHA representative's attendance at the IDT.
• If the NF does not correct the information in the LTCOP within seven days, the LMHA/LBHA must document in the LTCOP in Section A3400 disagreement with whichever of the following that continues to be incorrect:
  • specialized services listed in the LTCOP; and
  • LMHA/LBHA representative's attendance at the IDT.

3. If an LMHA/LBHA representative did not participate in the IDT, the LMHA/LBHA must:

• contact the NF and request that the NF conduct another IDT that includes an LMHA/LBHA representative; and
• document in the LTCOP in Section A3500 disagreement with the LMHA/LBHA representative's attendance at the IDT.

Revision 20-0; Effective August 25, 2020

3100 Refusal of MI Specialized Services

Revision 20-0; Effective August 25, 2020

During the initial Interdisciplinary Team (IDT) meeting, if a person who is Preadmission Screening and Resident Review (PASRR) positive for mental illness (MI)/legally authorized representative (LAR) refuses MI specialized services, the Qualified Mental Health Professional-Community Services (QMHP-CS) must: 

• complete Form 1041, Refusal of PASRR Mental Illness Specialized Services;
• obtain the necessary signatures on Form 1041; 
• provide the person/LAR a copy of the completed Form 1041; 
• maintain a copy of Form 1041 and the PASRR Comprehensive Service Plan (PCSP) form in the person's local mental health authority (LMHA)/local behavioral health authority (LBHA) record; and
• confirm the nursing facility (NF) documented the refusal in Section A3100 of the PCSP.

The LMHA/LBHA must also inform the person/LAR of the need to conduct follow-up visits every 30 days for 90 days after the initial IDT meeting regarding their refusal of specialized services. During these visits, the LMHA/LBHA must attempt to engage them and discuss their need for MI specialized services. These visits must be documented on the PCSP as a Local Authority (LA) update meeting and in the person's LMHA/LBHA record. 

For persons dually diagnosed with MI and intellectual disability (ID)/developmental disability (DD), since the required 90-day follow up is due at the same time as the quarterly Service Planning Team (SPT) meeting, it must be conducted as part of the quarterly SPT meeting. When the local intellectual and developmental disability authority (LIDDA) completes the quarterly meeting on the PCSP, these results will be included as part of their documentation. The refusal of MI specialized services does not impact the need for, and provision of, habilitation coordination or intellectual and developmental disability (IDD) services. However, the person may also refuse all IDD services if they so choose. The LIDDA's habilitation coordinator will follow up with the person for habilitation coordination needs.

Annual IDT Meetings

If the person/LAR continue to refuse MI specialized services during subsequent annual IDT meetings, LMHAs/LBHAs are not required to complete the 30-, 60-, 90-day follow ups nor is a new Form 1041 needed. The NF must continue to document the refusal of MI specialized services in Section A3100 of the PCSP.   

3110 Assignment of Qualified Provider of MI Specialized Services

Revision 20-0; Effective August 25, 2020

An LMHA/LBHA must assign a qualified provider who is at least a QMHP-CS to every person who is PASRR positive for mental illness (MI). The QMHP-CS must complete a face-to-face interview within three days of receiving the alert and complete the PASRR evaluation within seven days of receiving the alert.

The QMHP-CS will ensure there is a current MI diagnosis, a current psychosocial assessment, administer the uniform assessment (UA) and complete a person-centered recovery plan (PCRP) with the person. A diagnostic and psychosocial assessment may be conducted via telemedicine/telehealth, if necessary, when conducted in accordance with 15 Texas Administrative Code (TAC) §354.1432 and 22 TAC §174.9.

3200 Required Uniform Assessment and Person-Centered Recovery Plan

Revision 20-0; Effective August 25, 2020

The MI specialized services provided to a person who is PASRR positive are determined by the LMHA/LBHA staff conducting a uniform assessment (UA), Adult Needs and Strengths Assessment (ANSA) and the person-centered recovery plan (PCRP), which are requirements for admission to a Texas Resilience and Recovery (TRR) Level of Care.

Based on ANSA results, the LMHA/LBHA staff will develop a PCRP with the person and/or their LAR.  

The PCRP will include core services, adjunct services and other supports needed, as determined by the UA. 

In most cases, the clinician who conducts the UA and PCRP will also be the person who provides the specialized services. In the unlikely event the clinician who conducts the UA, the PCRP and provides the specialized services is not the same person, a clinical staffing, which includes the person who is PASRR positive and/or their LAR, must be conducted to make the new clinician fully aware of all pertinent information needed to step into the role of provider of the MI specialized services.

3210 Texas Resiliency and Recovery (TRR) Model

Revision 20-0; Effective August 25, 2020

This philosophy approaches people in need to foster resilience and recovery with respect to MI and severe emotional disturbances. A primary aim of the service delivery system is to ensure the provision of interventions and evidence-based practices with empirical support to promote recovery from psychiatric disorders and resilience from severe emotional disturbances.  

The TRR model, or public mental health service design in Texas, includes the following components:

• Establishes who is eligible to receive services through a uniform assessment Adult Needs and Strengths Assessment (ANSA), which determines a Level of Care Recommended (LOC-R);
• Establishes a plan to manage the use of services, as outlined in the Utilization Management Guidelines, which determines a Level of Care Authorized (LOC-A);
• Measures clinical outcomes or the impact of services; and
• Determines how much these services should cost.

The Utilization Management Guidelines is an integral part of the program to ensure the delivery of mental health services are properly tailored to the person's needs and strengths to achieve the best possible results.

All mental health services must be provided in accordance with 25 TAC, Chapter 412, Subchapter G, MH Community Services Standards: "All staff must demonstrate required competencies before contact with individuals and periodically throughout the staff's tenure of employment or association with the local authority provider system, MCO, or provider."

• Pharmacological Management: Doctor of Medicine (MD), Registered Nurse (RN), Physician Assistant (PA), Doctor of Pharmacy (Pharm D), Advanced Practice Registered Nurse (APRN), Licensed Vocational Nurse (LVN)
• Psychiatric Diagnostic Interview: Licensed Practitioner of Healing Arts (LPHA)
• Counseling: LPHA or LPHA Intern (See Add-On definitions for CPT Provider Requirements)
• Routine Case Management: Qualified Mental Health Professional-Community Services (QMHP-CS) or Community Services Specialist (CSSP)
• Rehabilitative Services: QMHP-CS, Licensed Medical Personnel, CSSP or Peer Provider
• Supported Employment: QMHP-CS or CSSP or Peer Provider
• Supportive Housing: QMHP-CS or CSSP or Peer Provider
• Crisis Intervention Services: QMHP-CS

3220 Adult Needs and Strength Assessment (ANSA) Tool

Revision 20-0; Effective August 25, 2020

ANSA is a multipurpose tool developed for adult behavioral health services. It is intended to:

• Prevent duplicate assessments by multiple parties; 
• Decrease unnecessary psychological testing; 
• Aid in identifying placement and treatment needs; and
• Inform case planning decisions.

Assessments help support decision making, including level of care and service planning, to facilitate quality improvement initiatives, and to allow for outcomes monitoring. The ANSA manual, assessment forms and training information can be reviewed at: https://hhs.texas.gov/doing-business-hhs/provider-portals/behavioral-health-services-providers/comprehensive-providers/adult-needs-strengths-assessment. 

3221 Six Key Principles of the ANSA Tool

Revision 20-0; Effective August 25, 2020

The six key principles of the Adult Needs and Strength Assessment (ANSA) tool are:

1. Items were selected because each one is relevant to service and recovery planning. An item exists because it might lead the clinician down a different pathway in terms of planning actions.
2. Each item uses a four-level rating system. Those levels are designed to translate immediately into action levels. Different action levels exist for needs and strengths.
3. Rating should describe the person, not the individual in services. The assessment should identify what is important to the person, and what is important for the person.
4. The ratings are generally collaborative. This is a descriptive tool including the person's assessed input. It is the "what," not the "why." Only two items, "Adjustment to Trauma" and "Social Behavior," have any cause-effect conclusions.
5. A 30-day window is used for ratings to ensure assessments stay fresh and relevant to the individual present circumstances. However, the action levels can be used to override the 30-day rating period. There is an expectation that success is possible – it's a "chance to get past your past."
6. Consider culture and development before establishing an action level. Cultural sensitivity involves considering whether cultural factors are influencing the expression of needs and strengths. Developmental age is part of cultural consideration.

3222 Reason for ANSA Tool

Revision 20-0; Effective August 25, 2020

The ANSA tool has received positive feedback by recipients, family members, providers and other partners in the services system because it is a collaborative process and doesn't necessarily require scoring to be meaningful to a person and their family. The way ANSA works is that each item suggests different pathways for recovery service provision. There are four levels of each item with anchored definitions; however, these definitions are designed to translate into the following action levels and be scored accordingly (separate for needs and strengths):

For needs

0 = No evidence
1 = Watchful waiting/prevention
2 = Action
3 = Immediate/Intensive Action

For strengths

0 = Centerpiece strength
1 = Strength that you can use in planning
2 = Identified-strength-must be built
3 = No strength identified

3223 Administering the ANSA Tool

Revision 20-0; Effective August 25, 2020

To administer the Texas ANSA tool, the clinician must be, at a minimum, a QMHP-CS. The clinician must have completed the ANSA training and then passed the ANSA certification exam. The certification exam must be renewed annually to retain certification to administer the ANSA tool.  The LMHA/LBHA must conduct at least two annual trainings facilitated by an ANSA "superuser."  The twice annual trainings must be documented. The clinician conducting the ANSA tool must attend at least one of these trainings.

In Texas, the ANSA tool must be updated at least every 180 days. It can be updated at any time and must be updated when there is a change in the person's condition or a change in services.  The ANSA tool should always be current and based on the current condition of the person served.

One of the benefits is the ANSA tool will recommend a level of care (LOC) to which the person can be admitted. The clinician can then make the recommendation to the authority department to authorize the recommended LOC. If the clinician believes a different LOC is more suitable, they can make the case to deviate from the ANSA recommended LOC and ask for a different LOC to be authorized.

Each LOC provides a "package" of services based on the results of the ANSA tool. This means there are specific services designed to meet the needs of the person based on the ANSA's LOC recommendation. This prepares the clinician and the person to move forward with development of the PCRP.

3300 Discovery Process

Revision 20-0; Effective August 25, 2020

Discovery is the process of meeting with the person face to face and listening and learning about what people want from their life. It is getting to know people so that their personal outcomes, preferences, choices and abilities are understood and documented to form the foundation for planning services and supports. 

Discovery is the basis for person-centered planning and service delivery, an ongoing process that occurs each time the LMHA/LBHA provider talks to the person or those who know the person best. 

Recording the information is necessary so it can be used when developing or updating the PCRP. The LMHA/LBHA leads the discovery process, advocating on behalf of the person whose services and supports are being planned.

3400 Developing the Person-Centered Recovery Plan (PCRP) 

Revision 20-0; Effective August 25, 2020

An LMHA/LBHA must develop and revise, as needed, a person's PCRP. Each person's PCRP is developed through a person-centered process using ongoing discovery and input from all the people involved. Changes in the PCRP may or may not include changes in MI specialized services.  In the event there are changes in MI specialized services, the LMHA/LBHA must initiate an LA update meeting. 

The PCRP identifies a person's goals, strengths, preferences and clinical needs, as well as other support needs and desired outcomes. This information is gathered through discovery and information from other sources, such as:

• PASRR evaluation;
• Records from the NF and previous providers;
• Clinical Management for Behavioral Health Services (CMBHS) data warehouse;
• Mental and Behavioral Health Outpatient Warehouse (MBOW), CARE (e.g., diagnostic data, previous LMHA/LBHA services); and
• Previous individual recovery plans.

The PCRP identifies the services and supports that are needed to meet the person's needs, achieve the desired outcomes and maximize the person's ability to live successfully in the most integrated setting possible. The PCRP must include all specialized services agreed upon during an IDT or LA update meeting, including the person's desired outcomes.

At a minimum, for each MI specialized service agreed upon during the IDT or LA update meeting, the PCRP must indicate the amount, frequency and duration of the specialized service to be provided.

Information and training for person-centered recovery planning can be found at: https://centralizedtraining.com/. 

3410 Sharing the PCRP

Revision 20-0; Effective August 25, 2020

An LMHA/LBHA is responsible for providing a copy of the current PCRP to the person being served, or their LAR, and to the NF for placement in the person's medical record. A copy can also be given upon request to the LIDDA for people who are PASRR positive for both MI and IDD.

3500 Initiation of Specialized Services

Revision 20-0; Effective August 25, 2020

The LMHA/LBHA will begin providing needed MI specialized services following the IDT meeting.  TAC 26, Chapter 303, Section 303.301, allows the LMHA/LBHA 20 business days after the IDT meeting to begin initiation of specialized services.  

Before providing PASRR MI specialized services, completion of the UA and PCRP are required.  Therefore, the PCSP form for the IDT should document a UA and PCRP is agreed to by the team. Once the UA and PCRP are completed, an LA update meeting convened by the LMHA/LBHA will be held to discuss recommended specialized services. The LMHA/LBHA will document the LA update meeting on the PCSP form.

For people with dual diagnosis only, if funding for NF specialized services is available (i.e., Medicaid), the NF is responsible for the successful submission of a complete and accurate prior authorization request for NF specialized services in the Long Term Care Online Portal (LTCOP) within 20 business days after the date of the IDT meeting and must start providing a habilitative therapy service within three business days after receiving approval from HHSC in the LTCOP. Additionally, the NF must:

• order all durable medical equipment devices and customized manual wheelchairs in accordance with NF rules in 40 TAC §19.2754(e);
• provide ongoing habilitative therapy services, as approved by HHSC; and
• document annually on the PCSP form in the LTCOP all NF specialized services, IDD habilitative specialized services and MI specialized services being provided to a person.

When a person who is dually diagnosed PASRR positive for MI and ID/DD, the habilitation coordinator will be the lead in coordination of all specialized services. This requires the habilitation coordinator to work with the mental health case manager to coordinate MI specialized services and activities with the LIDDA specialized services.

3510 Eligibility for MI Specialized Services 

Revision 20-0; Effective August 25, 2020

A person who is determined to be PASRR positive for MI (has a serious mental illness, as defined in 42 Code of Federal Regulations §483.102(b)(1)) with Medicaid is eligible for MI specialized services. A list of MI services is found in Section 3530, Providing MI Specialized Services.

PASRR specialized services funded through Medicaid and other funding sources (if the person is not Medicaid-eligible at the time of the IDT meeting) should be discussed during the IDT meeting. Funding sources other than Medicaid for persons over 21 years of age should be recorded in the comment section of the PCSP form (field A3200).

3520 Authorization of MI Specialized Services

Revision 20-0; Effective August 25, 2020

All specialized services agreed upon during the LA update meeting will be authorized by the LMHA's/LBHA's Utilization Management department. Any changes in needed services after authorization is complete requires an updated uniform assessment, as well as an updated PCRP, to include the additional specialized services. In the event there is a change in specialized services, the QMHP-CS must convene an LA update meeting as soon as possible with all required team members in accordance with Section 3600, Local Authority (LA) Update Meetings.

See the Texas Resilience and Recovery Utilization Management (UM) Guidelines and the Utilization Management Program Manual at: https://hhs.texas.gov/doing-business-hhs/provider-portals/behavioral-health-services-providers/behavioral-health-provider-resources/utilization-management-guidelines-manual.

3530 Providing MI Specialized Services

Revision 20-0; Effective August 25, 2020

MI specialized services funded through Medicaid include:

• Group Skills Training;
• Individual Skills Training;
• Intensive Case Management;
• Medication Training (Group);
• Medication Training (Individual);
• Medication Training and Support Services (Group);
• Medication Training and Support Services (Individual);
• Psychiatric Diagnostic Interview Examination;
• Psychosocial Rehabilitative Services (Group);
• Psychosocial Rehabilitative Services (Individual);
• Routine Case Management;
• Skills Training and Development (Group); and
• Skills Training and Development (Individual).

Additional MI specialized services include:

• Cognitive Processing Therapy;
• Counseling Services (CBT – Individual or Group);
• Crisis Intervention Services;
• Peer Support; 
• Pharmacological Management;
• Screening Brief Intervention and Referral to Treatment (SBIRT) Screening – Brief Intervention Not Provided; and
• SBIRT Screening – Brief Intervention Provided.

The LMHA's/LBHA's QMHP-CS provides ongoing MI specialized services in accordance with the TRR Adult Utilization Management Guidelines. The services provided may change as the person's needs change or goals are more fully realized.

3540 Frequency and Duration of MI Specialized Services

Revision 20-0; Effective August 25, 2020

The eligibility for MI specialized services is "while the person is residing in the nursing facility." The frequency and duration of MI specialized services is determined by the PCRP in accordance with Adult Utilization Management Guidelines and the person's needs. Should the needs change, the LMHA/LBHA must conduct an updated uniform assessment and revise the PCRP. Following that, the LMHA/LBHA must initiate a PASRR LA update meeting with the appropriate attendees.

3550 Required Face-to-Face Encounters

Revision 20-0; Effective August 25, 2020

The LMHA/LBHA staff, who must be at least a QMHP-CS, meets face-to-face with a person as often as indicated in the PCRP to meet the person's needs. Based on personal need and the services provided, the frequency of face-to-face encounters will be one of the recommendations the QMHP-CS will make to the IDT. 

Face-to-face meetings with the person must include the provision of the services and supports described in this section.

3560 Accessing Other Needed Programs

Revision 20-0; Effective August 25, 2020

The LMHA/LBHA must assist a person to access needed specialized services and other needed programs and services that can provide supports and services to address the person's needs and achieve outcomes identified in the PCRP.

3570 Assess and Reassess Service Needs

Revision 20-0; Effective August 25, 2020

The LMHA/LBHA staff must continually assess and reassess a person's service needs by gathering information from the person and other appropriate sources, such as the LAR, family members, social workers, NF and other service providers, to determine the person's service needs and the specialized services that will address those needs.

• People admitted to a TRR level of care (LOC) must be reassessed periodically regardless of the LOC they have been admitted to.  
• A person who is PASRR positive and meets admission criteria to the LMHA/LBHA may be admitted to an LOC once the ANSA tool is completed and indicates a recommended LOC.  
• A person receiving MI specialized services must be reassessed every 180 days, although they can be reassessed at any time based on need.  

3600 Local Authority (LA) Update Meetings

Revision 20-0; Effective August 25, 2020

LMHA/LBHA staff must convene an LA update meeting when:

• the UA and PCRP are completed after the IDT meeting. This allows the person and/or their LAR to review results of the UA and PCRP with the LMHA/LBHA staff and a representative from the NF and the LIDDA in the case of a person who is PASSR positive and dually diagnosed;
• the person has become eligible for Medicaid-funded specialized services; 
• a change in condition affects the services being provided;
• there is a need, an outcome or goal that was not previously identified;
• an updated or new uniform assessment is completed;
• the person decides they no longer want MI services;
• the person transitions to the community; or 
• the person is discharged or deceased.

Within three days after an LA update meeting, the LMHA/LBHA must enter into the LTC online portal all required information on the PCSP form, as well as maintain a paper copy in the LMHA's/LBHA's permanent medical record.

3610 Required Members for LA Update Meetings

Revision 20-0; Effective August 25, 2020

The required members for LA update meetings depends on the reason for the meeting. Reasons for updates include a change in the person's medical condition or specialized services.

LA Update Meetings with Reason Code 1 or 2 

1. Change in the person's medical condition.
2. Change in specialized services.

Required members include the person or LAR, LIDDA and/or LMHA/LBHA depending on PASRR condition, habilitation coordinator (if assigned), an NF staff member who knows the person best (may be an RN) and providers of specialized services (except for durable medical equipment (DME) providers).

LA Update Meetings with Reason Code 3, 4, 5, 6, 7 or 8.

These meetings are held when the person:

1. Is deceased.
2. Is discharged from the NF.
3. Refuses habilitation coordination.
4. Transfers to another NF.
5. Transitions to the community.
6. Refuses MI specializes services.

Because these reason codes are used to document events that took place and affect a person's specialized services, convening the entire team is not always necessary. 

3700 Convening a Team Meeting When a Person/LAR Refuses to Attend

Revision 20-0; Effective August 25, 2020

When an LMHA/LBHA receives information that the person or LAR will not attend a scheduled IDT or LA update meeting:

• Offer to reschedule the IDT or LA update meeting. Ask the person or LAR for a date and time that is preferable for them and work with them to reschedule.
• Provide adequate notice of the meeting. Adequate notice may mean something different to each person/LAR. An LAR may need several weeks' notice. For a person who is anxious about the IDT or LA update meeting preparations, one hour may be adequate notice.
• Offer to change the location of the IDT or LA update meeting. A person may prefer the meeting in their room instead of a conference room.
• Offer the person or LAR the opportunity to participate by phone.
• Offer to have other IDT members participate by phone if the meeting is too crowded for the person or LAR. 
• If a person or LAR states that the IDT or LA update meeting should proceed without him or her, the LMHA/LBHA must find out what topics he or she wants discussed at the meeting and afterward share with the person or LAR a summary of the discussion and the results of meeting.
• If a person absolutely refuses to attend or participate in IDT meetings, the NF must initiate a discussion about why the person refuses to attend or participate. The IDT members must attempt to identify and resolve barriers.

Revision 20-0; Effective August 25, 2020

The nursing facility (NF) must convene an annual Interdisciplinary Team (IDT) or Service Planning Team (SPT) meeting for a person who is Preadmission Screening and Resident Review (PASRR) positive for mental illness (MI), regardless of whether the person is receiving MI specialized services. The NF is responsible for inviting all IDT members to the annual IDT/SPT meeting.

If the person has refused MI specialized services, the local mental health authority (LMHA)/local behavioral health authority (LBHA) still must attend the annual IDT meeting.

The IDT/SPT members will discuss the specialized services provided by the LMHA/LBHA and review:

• specialized services the person (or legally authorized representative (LAR) on the person's behalf) is receiving and/or wants to receive;
• whether the person is best served in the NF or the community; and
• whether the person wants to transition to the community. If the person desires an alternative placement, refer to Section 5000, Alternative Placement Considerations.

If the IDT/SPT agrees to the provision of MI specialized services for the person and the person accepts the recommendations, the LMHA/LBHA will review the current authorization for services and make any needed changes. The LMHA/LBHA must then initiate services within 20 days of the IDT meeting.

Within five days upon receiving notification, the LMHA/LBHA must confirm the annual IDT/SPT meeting information in the Long Term Care Online Portal (LTCOP) on the PASRR Comprehensive Service Plan (PCSP) form.

The LMHA/LBHA is confirming the following:

• Their attendance (in person or by phone) at the IDT/SPT meeting; and
• Their agreement with all specialized services listed on the PCSP form and agreed to during the IDT/SPT meeting.

4100 QMHP-CS Preparation for Annual IDT/SPT Meeting

Revision 20-0; Effective August 25, 2020

An LMHA/LBHA Qualified Mental Health Professional-Community Services (QMHP-CS) must prepare to present the IDT/SPT with an update including services provided, the person's progress or lack thereof, the most current version of the Person-Centered Recovery Plan (PCRP) and changes in the recovery plan that have been made since the last IDT/SPT meeting. The LMHA/LBHA must be prepared to discuss the plan with the team, including what services are planned and what the goals are for the next 180 days or through the end of the current authorization period. The LMHA/LBHA must record an outline of the discussion and provide a copy of the recovery plan in the NF permanent medical record.

4200 Refusal of Mental Illness (MI) Specialized Services

Revision 20-0; Effective August 25, 2020

If an eligible person/LAR does not want MI specialized services at the annual IDT/SPT meeting, the LMHA/LBHA documents the refusal of MI specialized services on the PCSP form and obtains necessary signatures, provides the person/LAR a copy of the completed form provided by HHSC and maintains the original completed form in the person's record. See Section 3100, Refusal of MI Specialized Services, for additional information on refusal of services.

4300 PASRR Evaluation and IDT Meeting Billable Activities

Revision 20-0; Effective August 25, 2020

Throughout the MI PASRR process, there are various activities that are billable as PASRR activities. The billable activities begin with the completion of the PASRR Evaluation (PE) and are covered through participation in the IDT meeting.

The completion of the PE is a billable activity. For claim submissions, the approved rate for PE completion and related activities will be paid at the rate of $12.73 per 15-minute increments, or $50.92 per hour, with a maximum of six hours. PASRR billable activities are defined below.

PASRR Activity

• Preliminary scheduling call with the facility to arrange assessment;
• Meeting/coordination with nursing facility (NF) staff;
• Review of the person's medical records;
• Face-to-face communication with the person;
• Communication/coordination with the guardian and collateral contacts;
• PE results letter to the person. PE evaluators must complete Form 2360, Negative PASRR Evaluation Letter, for a negative PE (which includes Form 2361, PASRR Specialized Services Fair Hearing Request) and when positive, Form 1014, Pre-Admission Screening and Resident Review (PASRR) Evaluation Summary Report, which must be presented to the person/LAR and a signature must be obtained to indicate receipt
• Documentation and entry of evaluation data into the LTC online portal;
• Participation in the NF IDT for a PASRR-positive person; and
• Completion of LTC online portal input following the NF IDT meeting.

Revision 20-0; Effective August 25, 2020

If the person has expressed an interest in alternative placement, other than the nursing facility (NF), the local mental health authority (LMHA)/local behavioral health authority (LBHA) is responsible for providing information related to the alternative placement. This would include availability, waiting list, accessibility, cost and other pertinent information relative to the requested alternative placement.

If after receiving information the person wishes to pursue alternative placement, the LMHA/LBHA is responsible for providing the supports necessary to coordinate and assist with the transition. Once the transition is completed, the LMHA/LBHA shall update the uniform assessment (UA) and Person-Centered Recovery Plan (PCRP) to indicate that the person has transferred to alternate placement in the community.

5100 LMHA/LBHA Role in Alternative Placement

Revision 20-0; Effective August 25, 2020

Throughout the Preadmission Screening and Resident Review (PASRR) process, the Qualified Mental Health Professional-Community Services (QMHP-CS) shall serve as an advocate for the person’s desires related to community relocation. During completion of the PASRR Level 1 (PL1), the person is given the opportunity to discuss alternatives to an NF placement and the person’s preferences shall be recorded on the PL1.

During the PASRR Evaluation (PE) process, the person is again given the opportunity to discuss alternatives to NF placement. When the person indicates living somewhere other than an NF, the LMHA/LBHA must complete Section F of the PE.

Section F of the PE records the individual’s previous community living experiences, alternate placement preferences, alternate placement options, barriers to community living, supports needed for successful community living and referrals made for alternate placement.

To complete Section F of the PE, the LMHA/LBHA must select the program of interest to the person for which they are eligible.

Following completion of Section F of the PE, the LMHA/LBHA shall make a referral to the program of interest to the person. The LMHA/LBHA must add the date the referral was made, the phone number of the person the referral was made to, and any additional comments relating to the referral. Once these steps are completed, the LMHA/LBHA may submit the PE.

If a person has indicated that they would like to live somewhere other than an NF, and the referral field in Section F is left blank or not fully completed, PASRR staff will contact the LMHA/LBHA to ensure that Section F is completed.

Alternate placement shall also be discussed during the Interdisciplinary Team (IDT) meeting. The results of the discussion shall be recorded on the PASRR Comprehensive Service Plan (PCSP) form.

The QMHP-CS shall keep the alternative placement option part of ongoing discussions with the person and during all meetings. When a person is ready to begin to pursue alternate placement, the QMHP-CS shall revise the Person-Centered Recovery Plan (PCRP) to include the transition process. The QMHP-CS must also engage the LMHA/LBHA housing resources, if needed, at the point seeking and/or securing alternative housing become part of the PCRP to ensure all potential resources are made available.

5110 Completion of PASRR Level 1, Section E, Prior to Transition

Revision 20-0; Effective August 25, 2020

Section E of the PASRR Level 1 (PL1) records the disposition of the location where the person went after leaving the NF.

When an NF informs an LMHA/LBHA a person is leaving the NF, the LMHA/LBHA must complete Section E of the PL1 before the person has been discharged on the PL1.

When a person left the NF and the LMHA/LBHA was not notified, Section E cannot be completed if the person has been discharged on the PL1. The LMHA/LBHA must add a note to the Form History to record the disposition of the location where the person went.

If there is no documentation on the PL1 regarding the disposition, PASRR staff will contact the LMHA/LBHA and request this be completed.

5120 Transition and Relocation to Community Living

Revision 20-0; Effective August 25, 2020

The transition process must include the person, the Legally Authorized Representative (LAR) and others involved in the person’s life who may assist in the transition.

At the time the person is discharged from the NF, the QMHP-CS must conduct an updated UA. During the process of completing an updated UA, the person’s place of residence must be changed on the PL1 in Section 4, Community Data, from Nursing Home to the correct new residence type.

It is encouraged to admit the person in a high enough level of care (LOC) to ensure adequate support during the first 90 to 180 days. This may require the QMHP-CS to deviate from the recommended LOC to an LOC that will be intense enough to better meet the person’s transition needs. Services must be provided in accordance with Texas Administrative Code 25, Part 1, Chapter 416, Mental Health Community-based Services.

At the point when a person is no longer a resident of the NF, the services provided are no longer PASRR specialized services. They are now community-based Texas Resiliency and Recovery services based on their LOC and the updated PCRP. The transition process will most likely require a transfer to a different QMHP-CS provider. The transition to a new QMHP-CS provider must be completed with minimal confusion or instability.

ES = Spanish version available.

Form	Title
1012	Mental Illness/Dementia Resident Review
1014	Pre-Admission Screening and Resident Review (PASRR) Evaluation Summary Report	ES
1041	Refusal of PASRR Mental Illness Specialized Services	ES
2360	Negative PASRR Evaluation Letter	ES
2361	PASRR Specialized Services Fair Hearing Request

For questions about the Preadmission Screening and Resident Review Mental Illness Handbook, email: PASRR.support@hhsc.state.tx.us. 

For technical or accessibility issues with this handbook, email: form.handbook.request@hhs.texas.gov