Regardless of their known diagnoses, all individuals applying to a Medicaid-certified nursing facility (NF) must undergo a Level I screen to determine if the individual possibly has a condition meeting PASRR’s definition of mental illness, intellectual disability or a related condition. A person with a TBI could potentially meet the criteria for a “related condition,” and thus require a Level II evaluation and consideration for specialized services.
PASRR regulations at 42 CFR 483.102(3)(i)(ii) include a definition of related condition that incorporates the definition of a related condition at 42 CFR 435.1010 - “Any other condition, other than mental illness, found to be closely related to Intellectual Disability because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons.”
Whether an individual with a TBI is subject to PASRR depends upon whether the TBI diagnosis or possible diagnosis:
- Is severe, chronic, disabling and results in similar impairment of general intellectual function or adaptive behavior similar to that of individuals with intellectual disability and requires similar treatment or services
- Presents before age 22
- Is expected to continue indefinitely, and which
- Results in substantial functional impairments in 3 or more major life activities such as self-care, mobility, understanding and use of language, learning, self-direction and capacity for independent living.
An individual with a TBI meeting these criteria should test positive at a Level I screen and be reviewed for a diagnosis of related condition during the Level II evaluation. An individual who acquired a TBI after the age of 22 should not test positive at Level I, unless there is evidence of a separate PASRR-qualifying mental illness or intellectual disability.
It is important to note that it is not a requirement that a TBI result in intellectual impairment; rather, a TBI may create a need for treatment or services to address impairment in adaptive behavior.