DCIS att 4 39B

Attachment 4.39B

Page 3

STATE PLAN UNDER TITLE XIX OF THE SOCIAL SECURITY ACT

MEDICAL ASSISTANCE PROGRAM

State/Territory:

PASRR Level II Preadmission Screening by Categorical Determination

The following categories developed by the State mental health or mental retardation authorities may be made applicable to individuals identified by Level I as possibly having serious mental illness / mental retardation when existing data on the individual appear to be current and accurate and are sufficient to allow the reviewer readily to determine that the individual fits into the category. The data available includes physical, mental, and functional assessments as required by 42 CFR 483.132(c). An adequate inspection of records for a categorical determination takes the place of the NF or the Specialized Services individualized Level II evaluation. The State mental health or mental retardation authority produces categorical evaluation and determination reports as required by 42 CFR 483.128 and .130, prior to admission. When existing data is not adequate, or any judgment is required about the presence of serious mental illness / mental retardation, the individual is referred for individualized Level II evaluation. Individuals are either discharged or evaluated by Level II Resident Review within the specified time limits (if any). (Check each that applies, and supply definitions and time limits as required.)

Categorical Determination that NF placement is appropriate. Specialized Services evaluation and determination by the SMH/MRA is individualized.

□ Convalescent care from an acute physical illness which required hospitalization and does not meet all the criteria for an exempt hospital discharge, (which, as specified in 42 CFR 483.106(b)(2) is not subject to preadmission screening).

Definition	Time limit

□ Terminal illness, as defined for hospice purposes in 42 CFR 418.3.

Additional Definition (optional)

□ Severe physical illness such as coma, ventilator dependence, functioning at a brain stem level, or diagnosis such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, and congestive heart failure which result in a level of impairment so severe that the individual could not be expected to benefit from specialized services.

Definition

□ Other category(s) defined by the State.

Definition	Time limit (optional)

Categorical Determination that NF placement is appropriate. Option to also categorically determine by the SMH/MRA that Specialized Services (SS) are not needed. No categorical determinations are made that Specialized Services are needed.

□ Provisional admission pending further assessment in case of delirium where an accurate diagnosis cannot be made until the delirium clears.

Additional Definition (optional)	Categorical SS Not Needed	Time limit
	□

□ Provisional admission pending further assessment in emergency situations requiring protective services, with placement in the nursing facility not to exceed 7 days.

Additional Definition (optional)	Categorical SS Not Needed	Time limit (≤7 days)
	□

□ Very brief and finite stays of up to a fixed number of days to provide respite to in-home caregivers to whom the individual with MI or MR is expected to return following the brief NF stay.

Additional Definition (optional)	Categorical SS Not Needed	Time limit
	□

Categorical determination that Specialized Services are not needed. No categorical determinations are made that Specialized Services are needed. Determination by the SMH/MRA that NF placement is appropriate is individualized.

□ Dementia and MR. The State mental retardation authority (not Level I screeners) may make categorical determinations that individuals with dementia, which exists in combination with mental retardation or a related condition, do not need specialized services.

Additional Definition (optional)

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TN# 94-03 Approval Date Effective Date

Supersedes

TN#