September 13, 2019

The April 10, 2018 FAQ “Are individuals with a traumatic brain injury (TBI) subject to PASRR?” confirms that all individuals applying to a Medicaid-certified nursing facility (NF), regardless of diagnosis, 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 may meet the definition of a related condition and require a Level II evaluation if the injury results in impairment of general intellectual functioning or adaptive behavior similar to that of a person with an intellectual disability, or if there is evidence of accompanying mental illness.

TBI and Related Condition: In instances where the injury results in impairments similar to an intellectual disability, a full evaluation should take place if the criteria of “related condition” at 42 CFR 435.1010, are met:

• 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.

It is important to note that it is not a requirement that a TBI results in intellectual impairment; rather, a TBI may create a need for treatment or services to address impairment in adaptive behavior. If the TBI occurred after the age of 22, an evaluation would still be indicated if a qualifying diagnosis of intellectual disability, with onset prior to age 18, is present.

TBI and Mental Illness: A study by the National Institute of Health highlights the linkage of TBI and increased risk of developing post-traumatic stress disorder (PTSD) and/or major depressive disorders. Additionally, an article in The Journal of Neuropsychiatry and Clinical Neurosciences points to direct linkage of TBI with psychiatric disorders. The PASRR process should seek to determine if a qualifying mental health condition existed prior to the injury, if the TBI has exacerbated that condition, or if the injury has led to the onset of a qualifying mental illness.

For TBI/Related Condition and TBI/Mental Illness, the intent of any Level II evaluation is to determine if there are alternatives to the NF or if the individual would benefit from specialized services during their NF stay.