July 7, 2018
When does a Level II evaluation need to be conducted?
Pre-Admission General Rule. Under 42 CFR §483.102 (a), the PASRR process applies to all Medicaid-certified nursing facility (NF) applicants, regardless of the source of payment for the NF services, and regardless of the individual's or resident's known diagnoses. Therefore, a Level II evaluation must be completed for all such applicants who meet NF level of care requirements, and who have been identified as having suspected mental illness (MI) and/or intellectual disability (ID) by the Level I preadmission screening process.
Exemption to General Rule. There is only one true exemption to this general rule. 42 CFR §483.106(b)(2) permits an “exempted hospital discharge (EHD)” which may be applied to an individual—
(A) Who is admitted to any NF directly from a hospital after receiving acute inpatient care at the hospital;
(B) Who requires NF services for the condition for which he or she received care in the hospital; and
(C) Whose attending physician has certified before admission to the facility that the individual is likely to require less than 30 days of nursing facility services.
The EHD allows an admission without a Level I or Level II. However, if an individual who enters a NF as an exempted hospital discharge is later found to require more than 30 days of NF care, the State mental health or intellectual disability authority must conduct a Level II resident review within 40 calendar days of admission. While not required, states may choose to perform a Level I screen for individuals being admitted to a NF under the EHD as a way to track individuals who might later require a Level II. See FAQ “What is the Exempted Hospital Discharge?”
Abbreviated Level IIs. Under 42 CFR §483.130(b), abbreviated Level II evaluations are permissible under the following circumstances where the need is clear or time-limited:
(1) Advance group determinations, in accordance with this section, by category that take 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 NF is normally needed, or that the provision of specialized services is not normally needed; or
(2) Individualized determinations based on more extensive individualized evaluations as required in 42 CFR §483.132, 42 CFR §483.134, or 42 CFR §483.136 (or, in the case of an individual having both ID and MI, 42 CFR §483.134 and 42 CFR §483.136).
Advance group determinations by category developed by the State mental health or intellectual disability authorities may be made applicable to individuals by the NF or other evaluator following Level I review only if existing data on the individual appear to be current and accurate and are sufficient to allow the Level II evaluator readily to determine that the individual fits into the category established by the State authorities (see 42 CFR §483.132(c)). Sources of existing data on the individual that could form the basis for applying a categorical determination by the State authorities would be hospital records, physician's evaluations, election of hospice status, records of community mental health centers or community intellectual disability or developmental disability providers.
42 CFR §483.130(d) sets out examples of categories for which the State mental health or intellectual disability authority may make an advance group determination that NF services are needed:
(1) Convalescent care from an acute physical illness which required hospitalization and does not meet all the criteria for an exempted hospital discharge;
(2) Terminal illness, as defined for hospice purposes in 42 CFR §418.3;
(3) Severe physical illnesses such as coma, ventilator dependence, functioning at a brain stem level, or diagnoses 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;
(4) Provisional admissions pending further assessment in cases of delirium where an accurate diagnosis cannot be made until the delirium clears;
(5) Provisional admissions pending further assessment in emergency situations requiring protective services, with placement in a NF not to exceed 7 days; and
(6) 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 ID is expected to return following the brief NF stay.
Note that these categories must be approved by CMS as part of the state plan before they can be applied to individual NF applicants. Also note that, while these categories can be applied at Level I, the determination must be made by the Level II evaluator.
Post-admission significant change in condition. Level II evaluations must also be conducted on NF residents with MI and/or ID any time there is a significant change in condition. For information on significant change in condition, see FAQ at What is considered a "significant change in condition?"
CMS recommends that states use Section 2.6 of the MDS 3.0 Version 1.15 Manual change of condition protocol. If the MDS indicates suspected MI and/or ID, the NF must notify the Medicaid agency or its designee, which must then arrange for a Level II Resident Review (RR). If the MDS indicates a significant change in condition, the NF must notify the Medicaid agency or its designee, which must then determine whether the change in condition data support the need for a RR.