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Screening for Mental Illness in Nursing Facility Applicants:
Understanding Federal Requirements
VI. Responsibilities of Nursing Facilities, State Medicaid Agencies, and Mental Health Authorities
In general, the Medicaid statute can be described as a series of State Medicaid plan requirements. States must designate a single State agency to administer and manage the State Medicaid program. Thus, State Medicaid agencies bear the ultimate responsibility for fulfilling all Medicaid requirements, including those associated with PASRR.
Regulations specifically require State Medicaid agencies to include a PASRR program in their State plan and to develop a written agreement with the State Mental Health Authority detailing the operation of the PASRR program. State Medicaid agencies also bear the final responsibility for providing or arranging for specialized services to NF residents with mental illness or residents discharged from nursing facilities because of PASRR. Medicaid agencies may delegate the function of providing or arranging for specialized services to the SMHA or another agency, but the ultimate responsibility remains with the Medicaid agency. State Medicaid agencies may not claim any nursing facility services provided to individuals with mental illness not screened by PASRR as Medicaid expenditures eligible for Federal financial participation. In addition, State Medicaid agencies must protect patients' rights by establishing an appeals system, providing culturally/linguistically/ethnically appropriate notices to persons with SMI and their families, retaining records, and tracking persons to ensure that appeals are heard and that future reviews are performed.
Federal regulations articulate the required elements of written agreements between State Medicaid agencies and State Mental Health Authorities. The agreement must specify the respective responsibilities of the State Medicaid agency and the Mental Health Authority for
- conducting joint planning;
- providing access by the Medicaid agency to SMHA records;
- recording, reporting, and exchanging medical and social information about individuals subject to PASRR;
- ensuring that preadmission screenings and resident reviews are performed in a timely manner;
- ensuring that if the SMHA delegates its determination responsibility, this delegation complies with regulations;
- ensuring that PASRR determinations made by the SMHA are not countermanded by the Medicaid agency;
- designating the independent person or entity that performs Level II PASRR evaluations for individuals with mental illness; and
- ensuring that all requirements of PASRR are met.
Nothing prohibits States from addressing other issues such as the provision of specialized services in these written agreements; nor do Federal law and regulations spell out the division of functions between State Medicaid agencies and SMHAs. Thus, States are granted considerable flexibility to design the operations of their PASRR program.
Federal law and regulations require State Mental Health Authorities to perform certain PASRR duties. SMHAs must determine whether persons with mental illness need nursing facility services and whether they need specialized services. SMHAs must base their determinations on independent evaluations that are in no way connected to a nursing facility. Determinations must be made on an annual average of 7 to 9 working days after an applicant is referred for a Level II screening. Anticipating that State Mental Health Authorities may delegate or contract determination decisions to others, the statute and regulations prohibit delegation to entities related to nursing facilities.
| PASRR Screens |
Responsibility for Oversight |
Eligible to Conduct Screen |
| Level I |
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All involved parties, including nursing facilities, State Mental Health Authority, or an independent entity |
| Level II |
- State Mental Health Authority for mental illness
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Independent entity (other than the State Mental Health Authority) without ties to a nursing facility |
| Change in condition assessment |
- State Mental Health Authority, after NF identifies change
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Independent entity (other than the State Mental Health Authority) without ties to a nursing facility |
Nursing facilities are obligated to perform certain duties under PASRR as well. The Medicaid statute bars nursing facilities from admitting any new resident who has a mental illness unless the State Mental Health Authority has conducted a Level II (PASRR) assessment and determined that NF services are needed. The law also requires that nursing facilities notify the SMHA promptly after a significant change in the physical or mental condition of a resident. Forthcoming regulations will elaborate further on NF duties with regard to resident review and changes in a resident's condition. The statute also requires nursing facilities to provide services of lesser intensity than specialized services to their residents with mental illness. The scope of this requirement is not articulated fully by Federal law and regulations, and depends on the definitions and policies adopted at the State level regarding specialized services. Regulations also require that nursing facilities transfer PASRR reports when residents with mental illness are transferred to a hospital or another nursing facility. Because States have great flexibility in designing their PASRR programs, they may place additional responsibilities on nursing facilities.
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