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Tennessee Bureau of TennCare

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Presentation on theme: "Tennessee Bureau of TennCare"— Presentation transcript:

1 Tennessee Bureau of TennCare
PASRR PRESENTATION Tennessee Bureau of TennCare

2 Level I Pre-Admission Screening Resident Review (PASRR)
Requirement of the Federal Nursing Home Reform law of 1987, nursing homes must complete a screening process BEFORE admitting any person known or suspected to have a diagnosis of mental retardation or mental illness to ensure that placement in a nursing home is in fact appropriate.

3 Current Level I PASRR Process
■ Tennessee nursing homes have been allowed to submit their PASRR screenings up to 30 days AFTER admission, as the PASRR is a part of the Pre-Admission Evaluation (PAE) level of care application Nursing homes have been given up to 30 days after admission to submit the PAE applications

4 Effective July 1, 2009 Tennessee will eliminate the 30 day PAE retro eligibility. However, discussions are being held with nursing home industry to possibly allow a lesser period of time for completing Level of Care criteria, ONLY if PASRR is FULLY completed. Tennessee NFs must comply with federal PASRR requirements and complete the screening prior to admission. If a Level I PASRR screen is positive, Medicaid payment will not begin until Level II evaluation is completed and the recipient is found to be appropriate for nursing facility placement.

5 Level I PASRR Requirements
If individual meets certain MEDICAL EXEMPTIONS or has a negative response to Level One Screen, they may be admitted to or continue to reside in a Medicaid-certified Nursing Facility without being determined appropriate for nursing facility placement thorough the Level II PASRR process.

6 Level I PASRR Requirements
Any individual for whom there is a positive response for any of the criteria for Mental Retardation or Mental Illness may not be admitted to or continue to reside in a Medicaid-Certified nursing facility without being determined appropriate for nursing facility placement through the Level II PASRR process. Code of Federal Regulations (CFR) (b)….”FFP is available only for services furnished after the screening or review has been performed,..”

7 Level II Screen On site, face to face evaluation with the individual that has a positive Level I PASRR Purpose: To determine if an individual’s special needs must be addressed in a NF or if those needs are so significant that they cannot be met in a NF.

8 Key Points for PASRR Level I Screening required on individuals regardless of their payment source for Medicaid Certified NF If Level I positive, and no exemptions are met, the applicant should not be admitted to nursing home until completion of Level II evaluation.

9 Exemptions for Positive Level I Screens
When Level I screen indicates a positive response, review to see if exemption is applicable Dementia (not for known or suspected MR) Terminal Illness-less than 6 months to live Short Term Convalescence (after hospitalization, needed care that can not be >120 days from admit date to NF) Severity of Illness-provide documentation Physician must certify the exemption with signature and date

10 PASARR Status Changes Resident not discovered on Pre-Admission Screening to have MI, MR, or RC Residents, previous identified through a Level II PASRR evaluation, experiences a significant increase in symptoms and/or behavior problems Resident that experiences a significant improvement in their health status that could possible then benefit from community services

11 For MI/RC Status changes
Complete the DMHDD Report Form for Change in Mental Status Fax completed form to DMHDD (615) For MR Status changes Complete the DMRS Report Form for Change in Mental/Health Status Fax to DMRS (615) or mail to address on procedure

12 Division of Long Term Care Executive Staff TennCare
Pattie Killingsworth – Assistant Commissioner; Chief of Long Term Care (LTC) Richard Strecker - Deputy of LTC Operations Mollie Mennell – Deputy LTC Quality & Administration Nita Mangum – Deputy LTC Eligibility/Enrollment Pat Santel – Director Institutional & PACE Brooke Boswell – Director Home & Community Based Services Waivers Matt Keppler – LTC Government Relations Liaison

13 TennCare LTC Unit Staff Telephone Numbers
Patty Killingsworth (Chief of LTC) (615) Pat Santel (Director of LTC) (615) Debbie Coleman, RN (PAE Mgr.) (615) Reba Hitchock, RN (PAE Supervisor) (615) Kaye Swindell, RN (PAE Supervisor) (615) Laurie Gibbs, RN (PAE Nurse) (615) Carol Harrison, RN (PAE Nurse) (615) Joy Foster, RN (PAE Nurse) (615) Harriet Cummings, RN (PAE Nurse-ICF, HCBS/MR) (615) Kim Carroll (Billing & Claims Unit) (615) Glenda Davidson (Billing & Claims Unit) (615)

14 What if a PAE/PASRR is denied?
The Notice of Denial is issued when it is determined that resident requires Specialized Services for MI/MR The PAE with additional information can be resubmitted within 30 calendar days of the receipt of Notice of Denial. Or an Appeal of the denied PAE can be submitted within 30 calendar days of the notice of denial The important thing is to respond to the denial within 30 days If the resident needs help contact Legal aid Ombudsman

15 The Appeal Process The resident, designated correspondent, family, the ombudsman, a friend can appeal a denied PAE The appeal must be received within 30 days of the receipt of the Notice of Denial

16 Appeal Process Continued
Once an appeal of denial is received a Hearing date is scheduled. The individual can be represented at the hearing by anyone of their choice The hearing will be conducted at the nursing facility if the applicant is admitted or if not admitted, a place convenient to the applicant.

17 ALJ Decision The Judge must have his written decision within 90 days of receipt of the appeal letter

18 The Nursing facility can not do an involuntary discharge once an appeal has been received. The NF must notify the resident/family they may be responsible for payment of NF care if judgment is against them.

19 Preadmission Screening and Annual Resident Review
PASRR Survey Process State Survey Agency

20 CFR REQUIREMENTS §483.20(m) “A nursing facility must not admit, on or after January 1, 1989, any new resident with: (i) Mental illness as defined in paragraph (m)(2)(i) of this section, unless the State mental health authority has determined based on an independent physical and mental evaluation performed by a person or entity other than the State mental health authority, prior to admission.

21 Survey Process CFR REQUIREMENTS
(A) That, because of the physical and mental condition of the individual, the individual requires the level of services provided by a nursing facility; and (B) If the individual requires such level of services, whether the individual requires specialized services for mental retardation.

22 Survey Process Intent of: §483.20(m)
To insure that individuals with mental illness and mental retardation receive the care and services they need in the most appropriate setting. The statute mandates preadmission screening for all individuals with mental illness or mental retardation who apply to Nursing Facilities regardless of the applicant’s source of payment.

23 Survey Process Intent of: §483.20(m) Exceptions
The exceptions for preadmission screening are: Residents who are readmitted to the facility. Residents who initially apply to a nursing facility directly following a discharge from an acute care stay are exempt if: (a) Certified by a physician prior to admission to require a nursing facility stay of less than 30 days and; (b) Require care at the nursing facility for the same condition for which they were hospitalized.

24 Survey Process Probes the survey team will use to determine if the facility is in compliance with this regulation. Will place a portion of the residents (if any) who have MI/MR on the survey sample. Will review the PASRR, interview staff, review records and make observations of the sampled resident/s to determine if special activities were recommended, if they have been care planned, and if the care plan is being followed by staff.

25 Survey Process §483.10(j) Visitation Rights
Effective June 17, 2009: F-175 revisions The facility must provide immediate access to any representative of the Secretary of HHS, the State, the resident’s individual physician, the State LTC Ombudsman, or the agencies responsible for the protection and advocacy of {individuals with developmental disabilities or mental illness.}

26 Survey Process §483.10(j) Visitation Rights
The facility cannot refuse to permit residents to talk with surveyors, Representatives of the Dept. of HHS, The State, the State {Long Term Care} ombudsman system and protection and advocacy agencies for {individuals with developmental disabilities or mental illness} are not subject to visiting hour limitations.

27 Resources for Crisis Intervention The National Alliance on Mental Illness (NAMI)

28 Health Plan Crisis Response Service Contacts

29 AmeriChoice Primary Contact: Secondary Contact (please cc):
Leigh Anne Dempsey, QI Specialist 8 Cadillac Drive, Suite 100 Brentwood, TN  37027 (615) Secondary Contact (please cc): Hayley Clothier, Quality Manager Brentwood, TN 37207 (615)

30 Volunteer State Health Plan (VSHP)
Julie Gascay Mgr/ Clinical Services and/ or Debbie Dukes Clinical Director

31 AMERIGROUP Heather Baroni Vice President of Behavioral Operations

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