F646
(Rev. 173, Issued: 11-22-17, Effective: 11-28-17, Implementation: 11-28-17)
§483.20(k)(4) A nursing facility must notify the state mental health authority or state intellectual disability authority, as applicable, promptly after a significant change in the mental or physical condition of a resident who has mental illness or intellectual disability for resident review.
INTENT §483.20(k)(4)
To ensure that individuals with a mental disorder or intellectual disabilities continue to receive the care and services they need in the most appropriate setting, when a significant change in their status occurs.
DEFINITIONS §483.20(k)(4)
“Preadmission Screening and Resident Review (PASARR)” is a federal requirement to help ensure that individuals who have a mental disorder or intellectual disabilities are not inappropriately placed in nursing homes for long term care. PASARR requires that 1) all applicants to a Medicaid-certified nursing facility be evaluated for a serious mental disorder and/or intellectual disability; 2) be offered the most appropriate setting for their needs (in the community, a nursing facility, or acute care setting); and 3) receive the services they need in those settings. Regulations governing PASARR are found at 42 CFR §483.100-138.
“Significant Change” is a major decline or improvement in a resident’s status that 1) will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions; the decline is not considered “self-limiting” (NOTE: Self-limiting is when the condition will normally resolve itself without further intervention or by staff implementing standard clinical interventions to resolve the condition.); 2) impacts more than one area of the resident’s health status; and 3) requires interdisciplinary review and/or revision of the care plan. This does not change the facility’s requirement to immediately consult with a resident’s physician of changes as required under 42 CFR §483.10(i)(14), F580.
“Significant Change in Status Assessment (SCSA)” is a comprehensive assessment for a resident that must be completed when the Interdisciplinary Team (IDT) has determined that a resident meets the significant change guidelines for either improvement or decline.
GUIDANCE §483.20(k)(4)
As part of the Pre-Admission Screening and Resident Review (PASARR) process, the facility is required to notify the appropriate state mental health authority or state intellectual disability authority when a resident with a mental disorder (MD) or intellectual disability (ID) has a significant change in their physical or mental condition.
The nursing facility must notify the state mental health (SMH)/ID authority of significant changes in residents with MD or ID independent of the findings of the SCSA. PASARR Level II is to function as an independent assessment process for this population with special needs, in parallel with the facility’s assessment process. Nursing facilities should know their State’s PASARR policy on referral to the SMH/ID authority, so that these authorities may exercise their expert judgment about when a Level II evaluation is needed.
Referral to the SMH/ID authority should be made as soon as the criteria indicative of a significant change are evident — the facility should not wait until the SCSA is complete.
Facilities should look to their state PASARR program requirements for specific procedures. PASARR contact information for the SMH/ID authorities and the State Medicaid Agency is available at http://www.pasrrassist.org/resources/personnel/pasrr-state-lead-contact-information.
Referral for Level II resident review evaluation is required for individuals previously identified by PASARR to have a mental disorder, intellectual disability, or a related condition who experience a significant change. Examples of such changes include, but are not limited to:
- A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms.
- A resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment.
- A resident who experiences an improved medical condition—such that the residents’ plan of care or placement recommendations may require modifications.
- A resident whose significant change is physical, but has behavioral, psychiatric, or mood- related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living.
- A resident whose condition or treatment is or will be significantly different than described in the resident’s most recent PASARR Level II evaluation and determination. (NOTE that a referral for a possible new Level II PASARR evaluation is required whenever such a disparity is discovered, whether or not associated with a SCSA.)
Requirements for the completing a SCSA are found at §483.20(b)(2)(ii), F637, comprehensive assessment after significant change.
PROBES §483.20(k)(4)
- When a significant change in status was identified in a resident with a mental disorder or intellectual disability, was the appropriate state mental health or intellectual disability authority promptly notified?
- Does the facility have a process in place to notify the appropriate state mental health or intellectual disability authority when a resident with a Level II PASARR has a significant change in his or her mental or physical status?
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