PASRR - VII. Changes in Condition

  1. Application. This section provides functional guidance to NF staff and assessors regarding changes in condition for mental illness, intellectual disability or other related conditions. This is intended to augment, not supplant, definitions of change in condition referenced in the licensing rules for NFs (10-144 CMR 110) or the MDS manual.
  2. Functional Definition: Change in status, either physical or mental, which results in a decline or improvement in the mental health or cognitive and functional (for individuals with intellectual disability and/or other related condition) status of the resident, and is unexplained by the use of medication, a medication interaction, an acute illness or infection. For all, this requires ruling out such things as physical or environmental causes and medication interaction/reaction.
    1. Special considerations for people with mental illness.  The following are specific circumstances and situations that must be considered a change in condition for people with mental illness:
      1. suicidal gestures or ideation;
      2. homicidal gestures or ideation;
      3. rapid onset or otherwise unexplained changes in destructive or violent behavior;
      4. symptoms of depression, including withdrawal in the absence of impending death;
      5. unexplained changes in eating, sleeping, or usual activities;
      6. unexplained changes in agitation, including
        1. increase or reduction without apparent cause, or
        2. agitation not easily addressed or relieved;
      7. unexplained changes in anxiety levels (intensity or duration);
      8. psychosis or psychotic symptoms;
      9. first event of disorder with cyclical pattern (e.g., seasonal affective disorder);
      10. improvement following intervention if there is an indication that specialized services are no longer needed;
      11. new diagnosis of an illness or the exacerbated condition of an existing disorder frequently associated with depression and/or anxiety (e.g., Parkinson’s).
    2. Special considerations for individuals with intellectual disabilities and/or other related conditions.  The following are specific circumstances and situations that must be considered a change in condition for individuals with intellectual disabilities and/or other related conditions:
      1. changes in behavior from the individual’s baseline.  The baseline behavior should be well documented in an initial assessment, care plan or behavioral intervention plan;
      2. changes in agitation, including increase or reduction without apparent cause and/or agitation not easily addressed or relieved;
      3. changes in self injurious behavior from baseline;
      4. repeated or sustained outbursts without apparent cause, that is different from usual or baseline behavior;
      5. changes in sensorium or neurocognitive status, from baseline;
      6. reduced cooperation with, or increased resistance to, habilitation plans or personal care, from baseline;
      7. a change in cognitive abilities and/or social adaptive functioning as determined by a psychological assessment that documents either a significant gain or loss in cognitive abilities and/or social adaptive functioning;
      8. subtle changes, whether a decline or an improvement, over longer periods of time;
      9. improvement following intervention;
      10. mental status changes not previously present.
    3. Co-Occurring Disorders. Individuals with known co-occurring disorders (mental illness, intellectual disabilities and/or other related conditions) must be assessed using BOTH lists of special considerations.
  3. Process.  The process for requesting a change in condition review is similar to the request for a Level II assessment. 
    1. Integration with MDS. The change in condition MUST trigger a reassessment in the Minimum Data Set system. This must be done within 14 calendar days of identification of the change in condition.
    2. Deadline to request a change in condition assessment. NFs must notify APS Healthcare within 7 calendar days following the MDS reassessment, but under no circumstances later than 21 days following the identification of the change in condition.
    3. Notification. APS Healthcare will review the Level I Screen for the Change in Condition and determine if a Level II Assessment is required or not. This should take no more than nine business days from the day all necessary documentation is received by APS Healthcare to complete the Level II Assessment.
    4. Level II Assessment. APS Healthcare will complete the review and submit an evaluation assessment as described below. Specific subsections of Title 42 Subpart C Section 483 of the Code of Federal Regulations are included. The PASRR program is described in detail in 42 CFR Chapter IV, Subpart C (483.100 – 483.138) available at .
    5. Minimum Data That Must be Collected and Reviewed as Part of the Level II Assessment:
      1. Data Required to Determine the Need for NF Services (PASRR – 42 CFR 483.132):
        1. Evaluation of physical status (for example, diagnoses, date of onset, medical history and prognosis);
        2. Evaluation of mental status (for example, diagnoses, date of onset, medical history, likelihood that the individual may be a danger to himself/herself or others); and
        3. Functional assessment (activities of daily living)
      2. Data Required for Individuals Suspected of Having a Mental Illness to Determine the Need for Specialized Services (PASRR – 42 CFR 483.134):
        1. A comprehensive history and physical examination of the person (to include if not previously addressed): complete medical history; review of all body systems; specific evaluation of the person's neurological system in the areas of motor functioning, sensory functioning, (gait, deep tendon reflexes, cranial nerves, and abnormal reflexes); and in case of abnormal findings, which are the basis for an NF placement, additional evaluations conducted by appropriate specialists;
        2. A comprehensive drug history including current or immediate past use of medications that could mask symptoms or mimic mental illness;
        3. A psychosocial evaluation of the person, including current living arrangements and medical and support systems;
        4. A comprehensive psychiatric evaluation including a complete psychiatric history, evaluation of intellectual functioning, memory functioning and orientation, description of current attitudes and overt behaviors, affect, suicidal or homicidal ideation, paranoia, and degree of reality testing (presence and content of delusions) and hallucinations; and a functional assessment of the individual's ability to engage in activities of daily living and the level of support that would be needed to assist the individual to perform these activities while living in the community. The functional assessment must address the following areas: self-monitoring of health status, self-administering and scheduling of medical treatment, including medication compliance, or both, self-monitoring of nutritional status, handling money, dressing appropriately, and grooming.
      3. Data Required for Individuals Suspected of Having an Intellectual Disability or Other Related Condition to Determine the Need for Specialized Services (PASRR – CFR 483.136):
        A comprehensive history and physical examination results to include:
        1. Medical problems and the level of impact these problems have on the individual's independent functioning;
        2. All current medications used by the individual and the current response of the individual to any prescribed medications in the following drug groups: hypnotics, antipsychotics (neuroleptics), mood stabilizers and anti-depressants, anti-anxiety-sedative agents, and anti-Parkinson agents;
        3. Self-monitoring of health status;
        4. Self-administering and scheduling of medical treatments;
        5. Self-monitoring of nutritional status;
        6. Self-help development such as toileting, dressing, grooming, and eating;
        7. Sensorimotor development, such as ambulation, positioning, transfer skills, gross motor dexterity, visual motor perception, fine motor dexterity, eye-hand coordination, and extent to which prosthetic, orthotic, corrective or mechanical supportive devices can improve the individual's functional capacity;
        8. Speech and language (communication) development, such as expressive language (verbal and nonverbal), receptive language (verbal and nonverbal), extent to which non-oral communication systems can improve the individual's functional capacity, auditory functioning, and extent to which amplification devices (for example, hearing aid) or a program of amplification can improve the individual's functional capacity;
        9. Social development, such as interpersonal skills, recreation-leisure skills, and relationships with others;
        10. Academic/educational development, including functional learning skills;
        11. Independent living development such as meal preparation, budgeting,  and personal finances, survival skills, mobility skills (orientation to the neighborhood, town, city), laundry, housekeeping, shopping, bedmaking, care of clothing, and orientation skills (for individuals with visual impairments);
        12. Vocational development, including present vocational skills:
        13. Affective development such as interests, and skills involved with expressing emotions, making judgments, and making independent decisions; and
        14. The presence of identifiable maladaptive or inappropriate behaviors of the individual based on systematic observation (including, but not limited to, the frequency and intensity of identified maladaptive or inappropriate behaviors).
  4. Evaluation Criteria (PASRR – CFR 483.128):
    1. Use of Pre-existing Data.  Evaluators may use relevant evaluative data, obtained prior to initiation of pre-admission screening, if the data are considered valid and accurate and reflect the current functional status of the individual. However, in the case of individualized evaluations, to supplement and verify the currency and accuracy of existing data, there may be a need to gather additional information necessary to assess proper placement and treatment.
    2. Findings. Findings of the evaluation must correspond to the person's current functional status as documented in medical and social history records.
    3. Evaluation Report: Individualized Determinations. Findings must be issued in the form of a written evaluative report which:
      1. Identifies the name and professional title of person(s) who performed the evaluation(s) and the date on which each portion of the evaluation was administered;
      2. Provides a summary of the medical and social history, including the positive traits or developmental strengths and weaknesses or developmental needs of the evaluated individual;
      3. If NF services are recommended, identifies the specific services which are required to meet the evaluated individual's needs;
      4. If specialized services are not recommended, identifies any specific intellectual disability or mental health services which are of a lesser intensity than specialized services that are required to meet the evaluated individual's needs;
      5. If specialized services are recommended, identifies the specific intellectual disability or mental health services required to meet the evaluated individual's needs; and
      6. Includes the bases for the report's conclusions.
  5. Notice of Determination and Contents (PASRR – CFR 483.130):
    1. Notice: The following entities must, in writing, be provided with the determination:
      1. The evaluated individual and his or her legal representative;
      2. The admitting or retaining NF;
      3. The individual or resident's attending physician; and
      4. The discharging hospital, unless the individual is exempt from pre-admission screening
    2. Contents: Each notice of determination must include:
      1. Whether a NF level of services is needed;
      2. Whether specialized services are needed;
      3. The placement options that are available to the individual consistent with these determinations; and
      4. The rights of the individual to appeal the determination.

In condition flowchart (Microsoft Word*)