Ch. 19, § 6. Level II Screening

(a) A nursing facility must not admit an individual whom the level I screening determined a Level II screening was required until the Level II screening is completed and the determination is that a nursing facility is an appropriate placement. (b) If there has been a previous Level II screening and the residents physical or mental functioning has significantly changed, the nursing facility must request a new Level II screening promptly by completing and submitting a new Level I form. The nursing facility must indicate on the Level I form that a new Level II screening is being requested because of a significant change in the person's physical or mental functioning. (c) Nursing facilities must timely comply with the PASRR requirements. (i) The Department will not pay for nursing facility services furnished to an individual before the Level II screening is completed and the proper authority determines placement of the individual in a nursing facility is appropriate. (ii) The Department may impose any of the remedies in Chapter 5 for failure to timely comply with PASRR requirements for non-Medicaid eligible individuals. (d) A categorical determination takes into account that certain diagnoses, levels of severity of illness, or need for a particular service clearly indicate that admission to or residence in a nursing facility is appropriate without a Level II screening. An individual with a mental illness or an intellectual disability who meets the criteria for any category in this section is deemed appropriate for nursing facility placement. The individual must still be evaluated for a specialized services determination. (i) Terminal illness. A diagnosis of terminal illness constitutes a Level II determination of appropriate placement and specialized services are not required. (ii) Severe medical condition. A diagnosis of a severe medical condition constitutes a Level II determination of appropriate placement if an individual who has a mental illness or has an intellectual disability meets the criteria for severe medical condition if the individual or resident is comatose, ventilator dependent, or functioning at the brain stem level or has chronic obstructive pulmonary disease, severe Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, congestive heart failure, severe cardiovascular accident, quadriplegia, advanced multiple sclerosis, end stage renal disease, severe diabetic neuropathy, or refractory anemia that is so severe that the individual could not be expected to benefit from specialized services for a mental illness or an intellectual disability. (iii) Convalescent care. An individual who has a mental illness or an intellectual disability and requires nursing facility services of no more than 120 days constitutes a Level II determination of appropriate placement. Thirty days before the end of the 120 days, the nursing facility must refer the individual for a Level II screening to determine if the individual has a mental illness or an intellectual disability and has an acute physical illness which: (A) Requires hospitalization; and (B) Does not meet the criteria for an exempt hospital discharge as defined in 42 C.F.R. § 483.106. (iv) Provisional placement. An individual who requires a nursing facility stay of no more than fourteen days. Before the end of the fourteen days, the nursing facility must refer the individual for a Level II screening to determine if the individual has a mental illness or intellectual disability and requires admission for: (A) Delirium, where an accurate diagnosis cannot be made until the delirium clears; or (B) Respite care. (v) Emergency admissions. The individual has a mental illness, or an intellectual disability and requires a nursing facility stay of no more than seven days for his or her protection. Before the end of the seven days, the nursing facility must refer the individual for a Level II screening. (e) Criteria for Level II screening. (i) Each individual referred for a Level II screening, regardless of payment source, must be evaluated for medical necessity pursuant to Chapter 22. (ii) Level II screening must be performed using the minimum criteria specified by CMS in §§ 4251 through 4253 of the State Medicaid Manual appropriate for the specific individual. The State Medicaid Manual is published by CMS and is available from CMS or the Department. (iii) SMHA and SIDA must review the mental and physical evaluations and the determinations of medical necessity and determine whether, based on the individual's physical and mental condition, he or she requires the level of services provided by a nursing facility. (iv) Determination of need for specialized services. (A) The need for specialized services for an individual with a mental illness must be determined using the procedures and protocols of the SMHA. The procedures and protocols of the SMHA are available from the SMHA or the Department. (B) The need for specialized services for persons with an intellectual disability must be determined using the procedures and protocols of the SIDA. The procedures and protocols are available from SIDA or the Department. (f) Level II screening determines the appropriateness of nursing facility placement and the need for specialized services. Following are the possible determinations. (i) Individual requires nursing facility services but does not require specialized services: (A) Nursing facility placement is appropriate; and (B) Mental health services of a lesser intensity than specialized services may be recommended. (ii) Individual requires nursing facility services and specialized services: (A) Nursing facility placement is appropriate; and (B) Specialized services are appropriate. (iii) Individual does not require nursing facility services but requires specialized services and chooses to remain in the nursing facility under the thirty month rule, defined in 42 C.F.R. § 483.130: (A) Nursing facility services are deemed appropriate; and (B) Specialized services are appropriate. (iv) Individual does not require nursing facility services or specialized services: (A) Nursing facility placement is not appropriate and admission is denied; or (B) If the individual is already admitted, the nursing facility must arrange an orderly discharge including preparation and orientation for discharge. (v) Individual does not require nursing facility services but does require specialized services that cannot be provided in the nursing facility: (A) Nursing facility placement is not appropriate and admission is denied; or (B) If the individual is already admitted, the nursing facility must arrange an orderly discharge including preparation and orientation for discharge. (vi) There is no evidence of a serious mental illness or of an intellectual disability: (A) Nursing facility placement is appropriate; but (B) Specialized services are not appropriate. (vii) Individual has a primary or secondary diagnosis of dementia without a diagnosis of an intellectual disability: (A) Nursing facility placement is appropriate; but (B) Specialized services are not appropriate. (viii) Evaluation not completed due to death or discharge: (A) PASRR not complete; and (B) Medicaid payment for nursing facility services will not be authorized. (g) Notice of Level II determination. (i) The Department must notify the nursing facility in writing of the results of each Level II determination; and (ii) The Department must notify the individual in writing of the Level II determination.