December 8, 2017
What is considered a "significant change in condition?"
Per Section 1919(e)(7)(B)(iii) of the Social Security Act, Resident Reviews are required for NF residents experiencing a “significant change in condition.” (Note that this provision replaced the requirement that PASRR Resident Reviews must be performed annually.)
The Centers for Medicare & Medicaid Services (CMS) Long-Term Care Facility Resident Assessment Instrument 3.0 User’s Manual, version 1.5, provides guidance to nursing facilities (NF) on when a significant change requires referral for a PASRR Resident Review evaluation if a mental illness, intellectual disability, or related condition is present or is suspected to be present.
The manual notes that a “significant change” is a major decline or improvement in a resident’s status that:
1. Will not normally resolve itself without intervention by staff or by implementing standard disease-related clinical interventions, the decline is not considered “self- limiting”;
2. Impacts more than one area of the resident’s health status; and
3. Requires interdisciplinary review and/or revision of the care plan.
It is important that states understand that the guidance to NFs addresses individuals previously identified by PASRR and individuals who may not have been identified as having a PASRR condition at the time of admission.
In instances where the individual was previously identified by PASRR to have mental illness, intellectual disability, or a related condition, the following conditions may be noted as the reason for referral (note, this is not an exhaustive list):
• A resident who demonstrates increased behavioral, psychiatric, or mood-related symptoms.
• A resident with behavioral, psychiatric, or mood-related symptoms that have not responded to ongoing treatment.
• A resident who experiences an improved medical condition—such that the resident’s plan of care or placement recommendations may require modification.
• A resident whose significant change is physical, but with behavioral, psychiatric, or mood-related symptoms, or cognitive abilities, that may influence adjustment to an altered pattern of daily living.
• A resident who indicates a preference to leave the facility. (This preference may be communicated verbally or through other forms of communication, including behavior.)
• A resident whose condition or treatment is or will be significantly different than described in the resident’s most recent PASRR Level II evaluation and determination.
In instances where the individual had not previously been found by PASRR to have a mental illness, intellectual disability/developmental disability, or a related condition, the following conditions may be noted as the reason for referral (note that this is not an exhaustive list):
• A resident who exhibits behavioral, psychiatric, or mood-related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR §483.102 (where dementia is not the primary diagnosis).
• A resident whose intellectual disability as defined under 42 CFR §483.102, or whose related condition as defined under 42 CFR §435.1010, was not previously identified and evaluated through PASRR.
• A resident transferred, admitted, or readmitted to a NF following an inpatient psychiatric stay or equally intensive treatment.