Revision 19-0; Effective July 7, 2019

 

Preadmission screening and resident review (PASRR) is a federal requirement as documented in the Code of Federal Regulations, Title 42, Part 483, Subpart C. 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 necessary 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, for LIDDAs, LMHAs and LBHAs; and
  • 40 TAC, Chapter 19, Subchapter BB, for NFs. This handbook provides additional instructions and procedures for LIDDAs in implementing PASRR requirements.

 

1100 Definitions

Revision 19-0; Effective July 7, 2019

 

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

  1. 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:
    1. a. may include a long-term acute care hospital, an emergency room within an acute care hospital or an inpatient rehabilitation hospital; and
    2. b. does not include a stand-alone psychiatric hospital or a psychiatric hospital within an acute care hospital.
  2. Behavioral support — Specialized interventions by a qualified service provider to assist a person to increase adaptive behaviors and to replace or modify maladaptive behaviors that prevent or interfere with the person's inclusion in home and family life or community life.
    1. Behavioral support includes:
      1. assessing and analyzing assessment findings so that an appropriate behavior support plan may be designed;
      2. developing an individualized behavior support plan consistent with the outcomes identified in the Habilitation Service Plan (HSP);
      3. training and consulting with family members or other providers and, as appropriate, the person; and
      4. monitoring and evaluating the success of the behavior support plan and modifying the plan as necessary.
    2. A qualified service provider of behavioral support:
      1. is a licensed psychologist;
      2. is licensed as a psychological associate in accordance with Texas Occupations Code, Chapter 501;
      3. has been issued a provisional license to practice psychology in accordance with Texas Occupations Code, Chapter 501;
      4. is a certified authorized provider as described in 40 TAC §5.161 (relating to Certified Authorized Provider);
      5. is a Licensed Clinical Social Worker (LCSW);
      6. is a Licensed Professional Counselor (LPC); or
      7. is licensed as a behavior analyst in accordance with Texas Occupations Code, Chapter 506.
  3. CLO or Community living options — A process by which the LIDDA provides information to an individual and legally authorized representative (LAR) about the range of community living services, supports and programs the individual may be eligible for, and discusses services and supports the individual will need to live in the community, as well as individual preferences and barriers to community living.
  4. CMWC or customized manual wheelchair — In accordance with 40 TAC §19.2703, a wheelchair that consists of a manual mobility base and customized seating system and is adapted and fabricated to meet the individualized needs of an individual.
  5. Collateral contact — A person who is knowledgeable about the individual seeking admission to an NF or the resident, such as family members, previous providers or caregivers, and who may support or corroborate information provided by the individual or resident.
  6. Comprehensive care plan — A plan developed by an NF for a resident.
  7. Day habilitation — Assistance to a person to acquire, retain or improve self-help, socialization, and adaptive skills necessary to live successfully in the community and participate in home and community life. Day habilitation provides:
    1. individualized activities consistent with achieving the outcomes identified in the person's service plan;
    2. activities necessary to reinforce therapeutic outcomes targeted by other support providers and other specialized services;
    3. services in a group setting, other than the person's residence, for typically up to five days a week, six hours per day on a regularly scheduled basis;
    4. personal assistance for a person who cannot manage personal care needs during the day habilitation activities; and
    5. transportation during the day habilitation activity necessary for a person's participation in the day habilitation activities.
  8. DD or developmental disability — A disability that meets the criteria described in the definition of "persons with related conditions" in 42 Code of Federal Regulations (CFR) §435.1010.
  9. DID or determination of intellectual disability — An assessment conducted in accordance with 40 TAC §5.155 by an authorized provider to determine if an individual meets the criteria for a diagnosis of intellectual disability.
  10. DME or durable medical equipment — In accordance with 40 TAC §19.2703, the following items, including any accessories and adaptations needed to operate or access the item:
    1. a gait trainer;
    2. a standing board;
    3. a special needs car seat or travel restraint;
    4. a specialized or treated pressure-reducing support surface mattress;
    5. a positioning wedge;
    6. a prosthetic device; and
    7. an orthotic device.
  11. ECC or enhanced community coordinator — A LIDDA staff who meets the qualifications and other requirements described in the performance contract.
  12. Employment assistance — Assistance provided to a person to help the person locate competitive employment in the community, consisting of a service provider performing the following activities:
    1. identifying a person's employment preferences, job skills and requirements for a work setting and work conditions;
    2. locating prospective employers offering employment compatible with a person's identified preferences, skills and requirements;
    3. contacting a prospective employer on behalf of a person and negotiating the person's employment;
    4. transporting the person to help the person locate competitive employment in the community; and
    5. participating in SPT meetings.
  13. Enhanced community coordination — Funding available to LIDDAs pursuant to the performance contract for assisting individuals in transitioning from an NF to the community or in diverting from NF admission.
  14. Essential supports — Those supports identified in a transition plan that are critical to an individual’s health and safety and that are directly related to the individual’s successful transition to living in the community from residing in an NF.
  15. Exempted hospital discharge — A category of NF admission that occurs when a physician has certified that an individual 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 individual was hospitalized.
  16. Expedited admission — A category of NF admission that occurs when an individual meets the criteria for one of the following categories: convalescent care, terminal illness, severe physical illness, delirium, emergency protective services, respite or coma.
  17. Habilitation coordination — Assistance for an individual residing in an NF to access appropriate specialized services necessary to achieve a quality of life and level of community participation acceptable to the individual and LAR on the individual’s behalf.
  18. Habilitation coordinator — An employee of a LIDDA who provides habilitation coordination.
  19. Habilitative therapy services — In accordance with 40 TAC §19.2703, assessment and treatment to help an individual learn, keep or improve skills and functioning of daily living affected by a disabling condition. Habilitative therapy services are limited to:
    1. physical therapy;
    2. occupational therapy; and
    3. speech therapy.
  20. HHSC — Texas Health and Human Services Commission.
  21. HSP or habilitation service plan — A plan developed by the service planning team (SPT) while an individual is residing in an NF that:
    1. is individualized and developed through a person-centered approach;
    2. identifies the individual’s:
      1. strengths;
      2. preferences;
      3. desired outcomes; and
      4. psychiatric, behavioral, nutritional management, and support needs as described in the comprehensive care plan or MDS assessment; and
    3. identifies the specialized services that will accomplish the desired outcomes of the individual, or the LAR’s on behalf of the individual, including amount, frequency and duration of each service.
  22. HSP year or habilitation service plan year — An approximate 12-month period starting on the date of the initial or annual interdisciplinary team (IDT)/SPT meeting.
  23. ID or intellectual disability — As defined in 42 CFR §483.102(b)(3)(i).
  24. IDD habilitative specialized services — The following specialized services available to an individual with ID or DD:
    1. habilitation coordination;
    2. day habilitation;
    3. independent living skills training;
    4. behavioral support;
    5. employment assistance; and
    6. supported employment.
  25. IDT or interdisciplinary team — A team consisting of:
    1. a resident with MI, ID or DD;
    2. the resident's LAR, if any;
    3. a registered nurse from the NF with responsibility for the resident;
    4. a representative of:
      1. the LIDDA, if the resident has ID or DD;
      2. the LMHA or LBHA, if the resident has MI; or
      3. the LIDDA and the LMHA or LBHA, if the resident has MI and DD, or MI and ID; and
    5. others as follows:
      1. a concerned person whose inclusion is requested by the resident or LAR;
      2. 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; and
      3. a representative of the appropriate school district if the resident is school age and inclusion of the district representative is requested by the resident or LAR.
  26. Individual — A person:
    1. whose active PASRR evaluation (PE) or resident review is positive for ID or DD;
    2. who is 21 or older; and
    3. who is a Medicaid recipient.
  27. Independent living skills training — Individualized activities that are consistent with the HSP and provided in a person's residence and at community locations, such as libraries and stores. These activities include:
    1. habilitation and support activities that foster or facilitate improvement or maintenance of the person's ability to perform functional living skills and other daily living activities;
    2. activities for the person's family that help preserve the family unit and prevent or limit out-of-home placement of the person; and
    3. transportation to facilitate the person's employment opportunities and participation in community activities, and between the person's residence and day habilitation site.
  28. LA or local authority — 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).
  29. LAR or legally authorized representative — A person authorized by law to act on behalf of an individual seeking admission to an NF or resident about a matter described by this chapter, and who may be 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 Appendix III, Legal Authority to Make Decisions.)
  30. LBHA or local behavioral health authority — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code, §533.0356.
  31. LIDDA or local intellectual and developmental disability authority — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code, §533A.035.
  32. LMHA or local mental health authority — An entity designated by the executive commissioner of HHSC, in accordance with Texas Health and Safety Code, §533.035.
  33. LTC online portal or long term care online portal — A web-based application used by Medicaid providers to submit forms, screenings, evaluations and other information.
  34. MCO SC or Medicaid managed care organization service coordinator — The staff person assigned by a resident’s Medicaid MCO to ensure access to, and coordination of, needed services.
  35. MDS assessment or Minimum Data Set assessment — A standardized collection of demographic and clinical information that describes a resident's overall condition, which a licensed NF in Texas is required to submit for a resident admitted into the facility.
  36. MI or mental illness — Serious mental illness, as defined in 42 CFR §483.102(b)(1).
  37. MI specialized services — Specialized services available to a resident with MI, as described in the Texas Resilience and Recovery Utilization Management Guidelines, including:
    1. skills training;
    2. medication training;
    3. psychosocial rehabilitation;
    4. case management;
    5. psychiatric diagnostic interview exam; and
    6. supported housing, which includes alternate placement assistance and transitioning to the community.
  38. NF or nursing facility — A Medicaid-certified facility that is licensed in accordance with the Texas Health and Safety Code, Chapter 242.
  39. NF PASRR support activities — Consistent with 40 TAC §19.2703, actions an NF takes in coordination with a LIDDA, LMHA or LBHA to facilitate the successful provision of IDD habilitative specialized services or MI specialized services, including:
    1. arranging transportation for a resident to participate in an IDD habilitative specialized service or an MI specialized service outside the facility;
    2. sending a resident to a scheduled IDD habilitative specialized service or MI specialized service with food and medications required by the resident; and
    3. 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.
  40. NF specialized services — The following specialized services available to a resident with ID or DD:
    1. habilitative therapy services;
    2. CMWC; and
    3. DME.
  41. PASRR — Preadmission Screening and Resident Review. Required by 42 CFR 483.100-138.
  42. PE or PASRR level II evaluation — A face-to-face evaluation:
    1. of an individual seeking admission to an NF who is suspected of having MI, ID or DD; and
    2. performed by a LIDDA, LHMA or LBHA to determine if the individual has MI, ID or DD and, if so, to:
      1. assess the individual's need for care in an NF;
      2. assess the individual's need for specialized services; and
      3. identify alternate placement options.
  43. PL1 or PASRR level I screening — The process of screening an individual seeking admission to an NF to identify whether the individual is suspected of having MI, ID or DD.
  44. Preadmission process — A category of NF admission:
    1. 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
    2. that is not an expedited admission or an exempted hospital discharge.
  45. Referring entity — The entity that refers an individual to an NF, such as a hospital, attending physician, LAR or other personal representative selected by the individual, a family member of the individual, or a representative from an emergency placement source, such as law enforcement.
  46. Relocation specialist — An employee or contractor of an MCO who provides outreach and relocation activities to individuals in NFs who express a desire to transition to the community.
  47. Resident — A person who resides in an NF and receives services provided by professional nursing personnel of the facility.
  48. Resident review — A face-to-face evaluation of a resident performed by a LIDDA, LMHA or LBHA:
    1. for a resident with MI, ID or DD who experienced a significant change in status, to:
      1. assess the resident's need for continued care in an NF;
      2. assess the resident's need for specialized services; and
      3. identify alternate placement options; and
    2. for a resident suspected of having MI, ID or DD, to determine whether the resident has MI, ID or DD and, if so:
      1. assess the resident's need for continued care in an NF;
      2. assess the resident's need for specialized services; and
      3. identify alternate placement options.
  49. RN or registered nurse — A person licensed to practice professional nursing as an RN in accordance with Texas Occupations Code, Chapter 301.
  50. 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.
  51. Service coordinator — An employee of a LIDDA who provides service coordination.
  52. 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 resident who has a PE or resident review that is positive for MI, ID or DD: a. NF specialized services; b. IDD habilitative specialized services; and c. MI specialized services.
  53. SPT or service planning team — A team convened by a LIDDA staff person that develops, reviews and revises the HSP and the transition plan for an individual.
    1. The team must include:
      1. the individual;
      2. the individual’s LAR, if any;
      3. the habilitation coordinator for discussions and service planning related to specialized services or the service coordinator for discussions related to transition planning if the individual is transitioning to the community;
      4. the MCO service coordinator, if the individual does not object;
      5. while the individual is in an NF:
        1. an NF staff person familiar with the individual’s needs; and
        2. a person providing a specialized service to the individual or a representative of a provider agency that is providing specialized services for the individual;
      6. if the individual is transitioning to the community:
        1. a representative from the community program provider, if one has been selected; and
        2. a relocation specialist; and
      7. a representative from the LMHA or LBHA, if the individual has MI.
    2. Other participants on the SPT may include:
      1. a concerned person whose inclusion is requested by the individual or the LAR; and
      2. at the discretion of the LIDDA, a person who is directly involved in the delivery of services to people with ID or DD.
  54. Supported employment — Assistance to sustain competitive employment for a person who, because of a disability, requires intensive, ongoing support to be self-employed, work from the person's residence or perform in a work setting at which people without disabilities are employed. Assistance consists of the following activities:
    1. making employment adaptations, supervising and providing training related to the person's assessed needs;
    2. transporting the person to support the person to be self-employed, work from the person's residence or perform in a work setting; and
    3. participating in SPT meetings.
  55. Surrogate decision maker — An actively involved family member of a resident 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 resident. Note: A surrogate decision maker is authorized to make decisions related to NF specialized services. A surrogate decision maker is not authorized to make decisions related to IDD habilitative specialized services or decisions related to community programs or where the individual lives or will live.
  56. Transition plan — A plan developed by the SPT that describes the activities, timetable, responsibilities, services and essential supports involved in assisting an individual to transition from residing in an NF to living in the community.