Understanding PASRR: Part 2 - How to complete a Level 1 in the Qualitrac system and a brief overview of the Level 2 process - HCPF
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Understanding PASRR: Part 2
How to complete a Level 1 in the Qualitrac system
and a brief overview of the Level 2 process
February 2021
2017, Telligen, Inc.
© 2018,
Objectives
Provide background and overview and on PASRR Process
– Purpose and Intent – the What, How and Why
– History of PASRR – Federal and CO State
– General Process Flow – Level I to Level II
Discuss requirements and process steps for PASRR Level I
– Requirements
Federal vs Colorado
Outcomes
Opportunities and Take Aways
– Process Steps
Process Steps
Process Flow
Key Take Aways
Discuss requirements and process steps for PASRR Level II
– Brief overview
2
Background and Overview
Understanding PASRR
© 2017, Telligen, Inc.
Background and Overview
History of PASRR: Why was PASRR created?
Administered by Centers for Medicare and Medicaid Services (CMS) –Created in 1987
Before the Preadmission Screening & Resident Review (PASRR) Rule:
Institutionalization of individuals with disability
Inappropriate Placements (Restrictive environments)
Inadequate Assessments and Care Plan
Inadequate Provision of Services
Discrimination based on disability
Now, because of the PASRR Rule:
All applicants to Medicaid-certified nursing facilities must be screened for: Mental Illness (MI),
Intellectual/Developmental Disability (ID/DD) or Related Condition (RC), regardless of funding
Known or suspected condition must trigger evaluation
To ensure appropriateness of NF placement
To ensure receipt of needed services
For more on the detailed history or PASRR over the years please visit
https://www.pasrrassist.org/
4
Background and Overview
Purpose and Intent: What is PASRR?
PASRR is made up of a two-part process: Level 1 Screen and Level 2 Evaluation, which together have the
three goals we have mentioned…
1. Detection through screens and evaluations for potential diagnoses of mental illness, intellectual disabilities
or related conditions;
2. Verification of appropriateness of nursing home placement level of care and opportunities for community
transition;
3. Determination of need for specialized services as additions to treatment plan.
Person-Centered and Strengths-Based!
Objective
Supportive of self-actualization, self-efficacy and self-empowerment
Promote a continuity of care
Support long term goals of recovery and community engagement wherever possible
5
Background and Overview
Purpose and Intent: How is PASRR operationalized?
SNAP = Strengths, Needs, Abilities and Preferences
How is person-centered planning different?
Traditional Person-Centered
Approach Approach
Person Patient/Client Person/Individual
“In Charge” The professional The individual
Focus Impairment Life Satisfaction
Solution Professional intervention Removal of barriers
Results Defined by the professional Defined by the individual
6Background and Overview
Definitions in CO rule 10 CCR 2505-10 8.401.182 (1 of 3)
Intellectual or Developmental Disability or Related Condition - Intellectual or
developmental disability refers to significantly sub-average general intellectual functioning existing
concurrently with deficits in adaptive behavior and manifested during the developmental years.
– Manifested before age 22
– Likely to continue indefinitely
– Results in substantial functional limitations in 3 or more of the following:
Self-care;
Understanding and use of language;
Learning;
Mobility;
Self-Direction; or
Capacity for independent living
– “Persons with related conditions” means individuals who have a severe, chronic disability attributable
to:
Cerebral palsy or epilepsy
Any other condition, other than mental illness, found closely related to intellectual or developmental disability. These related conditions result in
impairment of general intellectual functioning or adaptive behavior similar to individuals with intellectual or developmental disability, and require
treatment or services similar to those required for these individuals.
7Background and Overview
Definitions in CO rule 10 CCR 2505-10 8.401.182 (2 of 3)
Mental Illness - A major mental disorder is defined as: A primary diagnosis of schizophrenic, paranoid, major affective,
schizoaffective disorders or other psychosis.
– Exclusions:
a primary diagnosis of dementia (including Alzheimer's disease or a related disorder);
a non-primary diagnosis of dementia (including Alzheimer's disease or a related disorder) without a primary
diagnosis of serious mental illness, or intellectual or developmental disability or a related condition
Helpful to think of the 3 Ds when determining the PASRR definition of
mental illness.
– 1) Duration of illness
– 2) Deficits of functioning and independent ADLs
– 3) Dementia exclusion
8Background and Overview
Definitions cont. (3 of 3)
Specialized Services - Specified services combined with the services provided by the nursing facility, resulting in a
person-centered program designed for the specific needs of eligible individuals who require the services.
– Including but not limited to:
Enhanced staffing in social services and activities
Specialized training for staff on behavior management
Creating resident specific written guidelines with positive reinforcement
Crisis intervention and/or crisis planning
Psychotropic medication education
Daily therapeutic groups such as anger management, conflict resolution, effective communication skills, hygiene, art therapy, goal
setting, problem solving
Individual psychotherapy
Sober supports like Alcoholics Anonymous and Narcotics Anonymous
Stress management/relaxation groups such as Yoga, Tai Chi, drumming and medication
Therapeutic work programming
Community safety training
Life skills training that includes budgeting and learning how to navigate public transportation and shopping
9Background and Overview
General Process Flow (1 of 2)
Level 1 Screen = Doorway to PASRR
– The Level I screening is the process that determines which individuals will receive the more in-depth
Level II evaluation, thus the initial screening serves as the gatekeeper for state PASRR system
– Required for each person admitting to a Medicaid licensed NH, regardless of their individual payer
source
– No professional requirements for the person completing the screen
Level 2 Evaluation = Looking under the hood
– The Level II evaluates and confirms, or disconfirms the diagnosis and PASRR applicability, based on a
more comprehensive evaluation and related documentation, but this only occurs based on the
decision made at the Level I stage
– Required to be completed by a trained and appropriately experienced and credentialed behavioral
health professional or qualified intellectual/development disability professional who is an objective 3rd
party
10Level 1 Requirements
Understanding PASRR
© 2017, Telligen, Inc.Level 1 Requirements
Federal vs CO vs Best Practices
Federal CO Best Practices
– CFR provides little – The purpose of the – Questions should be
guidance on what a PASRR Level I included that seek to
Level I screening tool Identification identify possible PASRR
or process looks like, screening is to conditions that have not
it is clear about the identify for further been reported
goals of the Level I review all those previously
screening clients seeking – Questions should seek to
– The Level I should nursing facility look beyond reported
capture all persons admission, for diagnosis of MI/ID/RC
with suspected or whom it appears a – When dementia and
known, serious diagnosis of mental mental illness are both
mental illness, illness or intellectual present, the Level 1
intellectual / or developmental should gather sufficient
developmental disability is likely. information to help the
disability or related Level II evaluator
condition determine which
condition is primary
12Level 1 Requirements
Outcomes (1 of 2)
Reduce “False Reality
Negatives” and “False PASRR Condition PASRR Condition
Positives” Present NOT Present
PASRR
Condition Likely Correct False Positive
Level 1 Present (+)
Outcome PASRR
Condition Likely False Negative Correct
NOT Present (-)
13Level 1 Requirements
Level 1 Outcomes (2 of 2)
No Level 2 Needed = Level 1 Indicators for PASRR condition NOT found (- Screen) are automatically
closed out and…
– PASRR process ends
– Retrospective QA for representative sample of automated negative screen outcomes
Provisional Admission = Level 1 Indicators for PASRR condition found (+ Screen) with indicators of
qualifying Provisional Admission are automatically closed out and…
– PASRR process ends
– Retrospective QA for representative sample of automated Categorical Determination outcomes
Level 2 Required = Level 1 Indicators for PASRR condition found (+ Screen) without a Provisional
Admission are reviewed manually by appropriate staff to determine if…
– Determine if…
Referral to Level 2 Evaluation is warranted or,
A false positive for a PASRR Condition or,
A missed categorical determination
– If Level 2 is warranted, then a referral is made to the scheduling team
14Level 1 Requirements
More on Provisional Admissions
Provisional Admissions include:
1. Is the need for NH service regarding convalescent care due to discharge from an acute care hospital
and likely will require fewer than 30 days of nursing services? (Or Exempted Hospital Discharge)
2. Emergency stays due to emergency evacuations or protective services placements not to exceed 14
days.
3. Individuals with delirium where the delirium prevents an accurate diagnosis at the time of entry into the
nursing home but is expected to clear within 14 days.
4. Respite stays of up to 30 days to provide respite to in-home caregivers.
15Level 1 Requirements
Opportunities and Take Aways
Data on outcomes is tracked and automated Level 1 screen determinations are consistently
reviewed retroactively to determine quality (keep false + and – low).
Questions raised by the Level 1 screen are meant to raise critical thinking for the professional
completing the form.
Level 1 is not meant to be a “one and done” check list item prior to NH admission, rather it is an
opportunity to evaluate needs specific to a PASRR condition from an outside objective
professional perspective.
A lot relies on how the form is initially filled out so good training on the intention of this process is
paramount – when in doubt, fill it out!
Submitting a current H&P from within 3-6 months is crucial to avoid potential requests for
additional information that could delay the process.
16Level 1 Process Steps
Understanding PASRR
© 2017, Telligen, Inc.Level 1 Process Steps
Process Steps
For CO Medicaid recipients, when Medicaid is the primary payor, The Single Point Entry shall
complete the Level 1 screen
For non-Medicaid individuals admitted from the community, the NH staff shall complete the
Level 1 Screen
For non-Medicaid individuals admitted from the hospital, the hospital staff shall complete the
Level 1 Screen
Screen results are entered into the Qualitrac portal, which we will demo
Staff manually review all positive screens with no provisional admission indicators and render an
outcome within 6 business hours of receipt of complete information
– If more information is determined to be necessary to complete the Level 1 screen review, information is requested and if
returned within 3 BD, the review will continue immediately
18Level 1 Process Steps
Process Flow for 3 Outcomes of PASRR Level 1
1
Automatically Filtered QA’d at Random
- Results
Out Sample
Level 1 Screen 2
completed in Automatically Filtered
Qualitrac + Provisional Admission QA’d at Random Sample
Out
+ Results 3
+ Level 2
- Provisional Admission Manually Reviewed
False + Results or False –
Provisional Admission
19Level 1 Process Steps
Key Take Away of Level 1
– If the answers to the questions trigger an automated review, you will receive an immediate
outcome
– If the answers to the questions trigger a manual review, you will be contacted through
Qualitrac to either present additional information or be informed of the review outcome
20Level 1 Process Steps
Vendor Transition Timeline
February 16th 2021 February 25th 2021 March 1st 2021
• Known Triggered PALs emailed via • All PALs emailed to • Qualitrac Portal opens
secure email to Coloradoreviews@telligen.com • Create user accounts
Coloradoreviews@telligen.com • Begin processing all Level 1 screens via
• All other PALs submitted via current Qualitrac
process
21Level 1 Form
Understanding PASRR
© 2017, Telligen, Inc.Level 1 Form
Form Fields
PASRR Level 1 form in Qualitrac – Yes or No Questions
– Section A = PASRR Condition indicators – MI
Does the individual have a known or suspected diagnosis of a major mental illness?
Does the individual have any indications of a major mental illness?
Is the individual on antipsychotic or antidepressant medication?
– Section B = PASRR Condition indicators – ID/D or RC
Does the individual have a known or suspected diagnosis of intellectual or developmental disability?
Does the individual have a diagnosis of a related condition such as Cerebral Palsy, autism, or seizures?
Has the individual ever received services from, or been referred to, an agency serving persons with an intellectual or development
disability?
Does the individual have any indicators of intellectual or development disability or a related condition?
Does the individual have a brain injury?
– Section C = Provisional Admission Indicators
Is the need for NH service regarding convalescent care due to discharge from an acute care hospital and likely will require fewer
than 30 days of nursing services?
Emergency stays due to emergency evacuations or protective services placements not to exceed 14 days.
Individuals with delirium where the delirium prevents an accurate diagnosis at the time of entry into the nursing home but is expected
to clear within 14 days.
Respite stays of up to 30 consecutive days to provide respite to in-home caregivers.
Manual Review triggered by a (+) in either Section A or B, and all (-) in C
23Level 1 Form
Form Demo
Supporting documentation for this process with screen shots will be available as a PDF file
following this online presentation and demo.
First a few brief points…
– There is skip logic built in so that for every Yes/No question, if you select the Yes option, more fields will appear.
– You will also have the ability to upload additional documentation necessary directly to the Level 1 screen, at a
minimum we require the most recent, not to exceed 6-months old, H&P and a current medication list.
24Level 1 Form
Supporting Documentation
Step-by-step handouts
Summary Cheat Sheets
A recording of this training
Support staff and resources through Telligen, HCPF, OBH and SIDA
25Level 2 Overview
Understanding PASRR
© 2017, Telligen, Inc.Level 2 Requirements
Purpose and Intent
As noted by PTAC, the PASRR Level II evaluation must not merely rubber stamp the outcome of the Level I.
Rather it must “look behind” the diagnosis of record to identify the “true” diagnosis.
The Level II must include the following elements:
A history and physical (H&P), performed by a physician;
A functional assessment, including activities of daily living (ADLs) and instrumental activities of living (IADLs);
A history of medication and drug use;
An assessment of psychiatric history performed by a qualified assessor (e.g., a psychiatrist, a licensed social
worker or BHP, or a nurse with substantial psychiatric experience).
27Level 2 Requirements
Outcomes and NOD letters
Outcomes are focused on
– Is there a PASRR Condition?
– Is the Nursing Home the Most Appropriate Level of Care?
– Is there a need for Specialized Services?
Once the outcomes are recommended by Telligen (within 1 BD of completed evaluations),
then the applicable state authority (SMHA or SIDA) will turn the above recommendations into
determinations through a Notice of Determination (NOD) letter which will be added to the
case in Qualitrac.
– The goal is to complete the entire PASRR process within 5-7 business days from start to finish
This NOD letter should be made available to:
– The Individual or representative
– To the Nursing Home
– And the referral source, if different from the nursing home itself
28Level 2 Requirements
Outcomes and NOD letters
A word on Contingent NOD letters,
– If the I/DD determination has not yet been formally made by the appropriate CCB, the PASRR process will
result in a contingent NOD which means any recommendations resulting from the PASRR II evaluation should
be implemented to the extent possible, knowing that the sub set of services specifically supported by I/DD
funding streams will not be accessible until the I/DD determination can be confirmed.
– NH staff are responsible for continuing to advocate for an I/DD determination with the relevant CCB, and if the
I/DD determination is completely more than 30 days from the Contingent NOD letter, a 2nd Level 1 screen
should be completed to initiate the resident review process.
29Level 2 Requirements
PAS vs RR
New – Preadmission:
A Level II evaluation is a comprehensive and individualized evaluation of an applicant to a
Medicaid certified NF.
The Level II evaluation is the function of evaluating and determining whether NF services and
specialized services are needed.
The exception would be for admissions to a dually certified NF under an Exempted Hospital
Discharge (EHD).
A Resident Review is similar to the Level II, but is conducted for a current NF resident and
triggered by:
An EHD stay that is exceeding 30 days
The conclusion of a time limited Advanced Group Determination admission
Notification to a State Authority of a resident having a significant change in condition
30Level 2 Requirements
Opportunities and Take Aways
It is the responsibility and expectation of the one submitting the Level I screen into Qualitrac to
provide supplemental clinical documentation that will be crucial to an effective and timely
Level 2 evaluation such as:
– The most recent H&P within the last 6 months,
– A current medication list,
– Any other relevant clinical to support any Yes answers indicated on the screen
It is the expectation that the one submitting the Level I screen will share the Level I Outcome
letter and the Level 2 NOD letter (if applicable) with the individual, and/or the individuals
representative
– In particular, the notice of recommendation for the Level 2 evaluation
31Level II Form
Form Fields
PASRR II Evaluation Sections:
Information about PASRR II
Patient Demographics
Narrative HPI
Biology
Free Text Discrete Data Diagnosis History
Fields Medication List
Medical Treatment History
Behavioral Health and Support
Services Treatment History
Substance Use History
Social Systems
Social and
Communication and Comprehension
Environmental Psychology
MSE
Factors
Current Behaviors
ADLs
Diagnostic Results of Evaluation
Case Formulation
Bio-Psycho-Social Evaluation
32Summary
BH Program: Understanding PASRR
© 2017, Telligen, Inc.Summary
Putting it All Together
PASRR is a person-centered process to provide an objective clinical assessment for folks that
could potentially benefit from additional services at the nursing home level of care, specific to
addressing an intellectual or mental health disability.
PASRR has been around for over 3 decades and continues to maintain relevance and provide
benefit for individuals, as evidence by continued resources through PTAC and a new notice of
proposed rule making.
PASRR is a clinical opportunity and not paperwork compliance requirement.
Turnaround times and utility of output documentation matters and is key to the success of a
PASRR program
Telligen is committed to hearing directly from all stakeholders and evolving the process as
needed to maintain the best efficacy and satisfaction for all involved.
34Closing
1. What was a key take-away
for you from this training?
2. What, if anything, will you
do differently as a result?
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