Screening for Mental Illness in Nursing Facility Applicants:
Understanding Federal Requirements

VII. Frequently Asked Questions

1. Under PASRR, can an applicant with only mental illness be admitted to a nursing facility?

Yes. An applicant with mental illness may be admitted to a nursing facility if the State Mental Health Authority determines that the applicant requires the level of services provided by the facility. Regulations require that the SMHA, when making the determination of whether NF services are needed, assess whether the total needs of an applicant with mental illness can be met in a community setting or must be met on an inpatient basis. If inpatient care is appropriate, the SMHA must assess whether a nursing facility is an appropriate setting. NF placement may be considered appropriate if the applicant meets the minimum standards of admission and if the applicant's treatment needs do not exceed the level of services that can be delivered by the NF--combined with any required specialized services provided or arranged for by the State.

2. Can nursing facilities conduct any part of the Level I or II screens?

Nothing in Federal law or regulations precludes NF involvement in Level I screens to identify applicants or residents suspected of having a mental illness. However, nursing facilities may not conduct Level II evaluations or determinations, although they may ascertain whether existing data are sufficient to determine that an applicant fits a category established by the State for an advance group determination. Evaluations for mental illness must be conducted by an independent entity (other than the State Mental Health Authority) with no direct or indirect relationship with any nursing facility. Determinations are the responsibility of State Mental Health Authorities, but SMHAs may delegate or contract that responsibility to any entity without direct or indirect ties to any nursing facility.

3. Under what circumstances can an applicant be admitted to a nursing facility before the Level I or II screens are completed?

None. Regulations require a Level I screen prior to admission for every nursing facility applicant, including private pay. The Level I screen identifies applicants who may have mental illness and thus will require the Level II evaluation. Federal law bars nursing facilities from admitting new applicants with mental illness unless the State Mental Health Authority has determined, on the basis of a PASRR Level II evaluation, that the person needs NF services. States cannot seek Federal Medicaid reimbursement for eligible NF services provided to residents with mental illness who were not determined by a PASRR program to require such services. CMS is prohibited from providing Federal financial participation until a PASRR screen is conducted.

However, regulations allow States to expedite certain nursing facility admissions through advance group determinations--Level II determinations based on categories for which NF services are normally needed. Some examples in regulation include provisional admissions pending further assessment in cases of delirium and emergency protective services. States must specify an appropriate time limit for provisional admissions. Further, a person later determined to need a longer stay must be given an individualized Level II resident review before continuation of the stay is permitted and payment made for care beyond the State's time limit. In cases of delirium in which an accurate diagnosis cannot be made until the delirium resolves and in emergency situations requiring protective services, patients may be admitted provisionally pending further assessment. An emergency admission must not exceed 7 days. Most persons who meet the criteria for a categorical NF determination must still have an individualized evaluation for the need for specialized services. In only two circumstances are specialized services categorical determinations permitted: in the provisional admissions categories for emergencies requiring protection and respite.

4. Can the state mental health authority delegate determinations?

Yes. Federal statute and regulations anticipate that State Mental Health Authorities may delegate or contract determination decisions to others by prohibiting delegation to entities related to nursing facilities. SMHAs may delegate admission and continued stay determinations to any entity without direct or indirect ties to a nursing facility. However, SMHAs retain ultimate control and responsibility for the determinations.

5. Are nursing facilities obligated to provide services recommended by the State Mental Health Authority on the basis of Level II screens?

Yes, but only those services of lesser intensity than specialized services. State Mental Health Authorities are required to determine whether nursing facility applicants and residents with mental illness need specialized services, and the State must provide or arrange for those services. The Medicaid statute mandates that nursing facilities provide treatment and services required by residents with SMI that are not otherwise provided or arranged for (or required to be provided or arranged for) by the State. Regulations interpret the statutory language to require provision of mental health services of lesser intensity than specialized services to all residents who need such services. However, if the treatment needs of an applicant or resident with SMI cannot be met by the nursing facility or through specialized services provided by the State, placement is not considered appropriate and the individual may not stay in the nursing facility.

6. What constitutes specialized services? Can they be defined any way a state chooses?

Congress authorized HHS to define specialized services in regulation. The resulting HHS regulations define specialized services as those "specified by the State" that, combined with services provided by the nursing facility, result in the continuous and aggressive implementation of an individualized plan of care. The plan of care must be developed and supervised by an interdisciplinary team, which includes a physician, qualified mental health professional, and other professionals as appropriate. It must prescribe specific therapies and activities for the treatment of acute episodes of serious mental illness. The plan must also be directed toward diagnosing and reducing the resident's behavioral symptoms that necessitated institutionalization, improving independent functioning, and achieving a level of function that enables the elimination of specialized services at the earliest possible time. Within the definition of specialized services articulated in Federal regulations, States maintain considerable flexibility in the definition of specific services and treatment.

7. Can specialized services be defined as those services provided in a psychiatric hospital or psychiatric unit of a general hospital?

Yes. PASRR's purpose is to determine whether NF care for persons with SMI is appropriate and whether specialized services are needed. In States that define specialized services as intensive mental health services provided in an inpatient psychiatric hospital or general hospital, PASRR determinations that specialized services are needed mean that NF services are not needed. The State then becomes involved in the person's placement in an appropriate alternative setting (e.g., an inpatient psychiatric hospital, an IMD, or a psychiatric wing of a general hospital).

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Screening for Mental Illness in Nursing Facility Applicants: Understanding Federal Requirements