The Minimum Data Set (MDS) is a robust tool used to capture a standardized set of data on every resident in Medicaid certified nursing facilities. MDS 3.0 is the latest version of the MDS and aims to improve the reliability, validity, and usefulness of the MDS. Nursing facilities began using MDS 3.0 on October 1, 2010.
MDS 3.0 – What’s New?
MDS 3.0 is the first version of the MDS that directly addresses PASRR. Specifically, MDS 3.0 includes a question – Question A1500 – that asks whether the individual being assessed has been evaluated by Level II PASRR and determined to have a serious mental illness and/or an intellectual disability or related condition. The purpose of including Question A1500 in MDS 3.0 is twofold: first, A1500 helps nursing facilities adhere to PASRR regulations by creating a linkage between the MDS and the PASRR requirement. Secondly, A1500 provides an opportunity for nursing facilities to better serve individuals through heightened awareness of their needs.
Including the resident in the assessment process and the use of standard protocols used in other settings are two other changes incorporated in MDS 3.0. These changes enhance the accuracy of the tool, which supports the primary legislative intent that MDS be a tool to improve clinical assessment and supports the credibility of programs that rely on MDS.
When are PASRR and the MDS Administered Relative to an Individual’s Admission into a Nursing Facility?
PASRR ensures that individuals with serious mental illness (MI) and/or an intellectual disability and related conditions (ID/RC) are not inappropriately placed in a nursing facility. PASRR applies to all residents in Medicaid-certified nursing facilities regardless of payer source.
The PASRR process consists of two levels. Level I PASRR is administered to all applicants of a Medicaid-certified facility. If Level I PASRR is positive, i.e. identifies the applicant as having possible MI and/or ID/RC, Level II PASRR is administered. Except for temporary stays for rehabilitation following hospital discharge, all PASRR determinations must be completed before admission into a nursing facility. Admission into a nursing facility before a needed PASRR Level II is complete is a violation of PASRR law and regulation (and therefore a survey deficiency).
The MDS assessment is completed after admission into a nursing facility and once every quarter thereafter, and upon a significant change, for all nursing facility residents.
A Resident Review (Level II PASRR) can be triggered by the MDS after an individual is admitted to a nursing facility. Specifically, an affirmative answer to Question A1500 of MDS 3.0 triggers an MDS Significant Change in Status Assessment (SCSA). In this case the nursing facility must consider, though is not required, to make a referral for a Resident Review (PASRR). As a result, states should plan for a likely increase in change of status PASRR Level II referrals.
How is A1500 Coded?
The current version of Question A1500 is as follows:
A1500. Preadmission Screening and Resident Review (PASRR)
Complete only if A0310A = 01
Has the resident been evaluated by Level II PASRR and determined to have a serious mental illness and/or intellectual disability or a related condition?
9. Not a Medicaid certified unit
If the answer is "Yes," and the individual has undergone a significant change in condition that affects his or her MI/ID/RC needs, the nursing facility is required to contact the mental health and/or intellectual disability authority, which will then determine whether a new Level II (Resident Review) is needed. However, because not all changes on condition affect an individual’s MI/ID/RC needs, not all “Yes” answers to A1500 require a referral to the MH/ID authority. Note: intellectual disability (ID) is referred to as intellectual disability (ID) in question A1500.
In this video, Dan Timmel, from CMS, offers a brief overview of the implementation and oversight of the PASRR process. The videoincludes
A review of items A1500 and A1550 of MDS 3.0 and how they are relevant to the oversight of PASSR
Discusses several recurring issues with PASRR oversight, such as checking whether or not an individual has a documented MI, rather than confirming that they have had a PASRR screen.
Offers brief advice on how to confirm that the PASRR process has occurred for all relevant residents and a brief explanation of the consequences for a NF not completing the PASRR process.
What Triggers a Referral for Resident Review?
As with any condition, if need is urgent, an individual should immediately be referred for Resident Review (RR) and/or services. For example, urgent needs include an acute change in affect or behavior that does not call for hospitalization but needs evaluation and change in an individual’s plan of care.
Whenever a Significant Change in Status Assessment (SCSA) is triggered by the MDS and a resident has been evaluated by Level II PASRR and determined to have a serious MI and/or ID/RC (i.e. a “Yes” answer to Question A1500), a referral to the mental health and/or intellectual disability authority for potential RR should be made.
Referrals under MDS 3.0 (Q A1500)
A literal reading of the MDS 3.0 manual explains that all significant changes in an individual’s status trigger a referral to the mental health and/or intellectual disability authorities for potential Resident Review (RR). However, this structure has proven too inflexible as not all significant changes in condition affect an individual’s MI/ID/RC needs. For example, some condition changes that register as significant, like an infection, might have no impact on an individual's MI or ID/RC needs. On the other hand, someone who fractures a hip or breaks a leg, for example, might become more depressed or anxious because their mobility has been restricted. This type of change could have a profound impact on the individual and their MI/ID/RC needs. As such, not all “Yes” answers to A1500 require a referral to the MH/ID authority.
Therefore, if an MDS significant change in status assessment (SCSA) is completed for a resident for whom A1500 is “Yes,” and confirms that the change in status affects the individual’s MI/ID/RC needs, then a referral to the state mental health or intellectual disability authority is required, for possible RR.
This suggests that MH and ID authorities must work closely with nursing facilities to develop a set of experienced-based techniques to determine when a referral is appropriate. The agencies should work to develop a workable system that doesn’t overburden the responsible parties on either side, but still serves the needs of nursing facility residents with MI and or ID/RC.
Additionally, a “Yes” answer to A1500 for nursing facility residents with newly identified or suspected MI or ID/RC who have never been identified through PASRR also require a referral to the state mental health or intellectual disability authority for possible Resident Review.
See our FAQs for additional information on PASRR and MDS: