OBRA/PASARR

Frequently Asked Questions about

Level II Mental Illness OBRA Screenings

NOTE: the questions & answers below refer to Mental Illness screenings. Only questions 15 F, G & H refer to screenings for those with Developmental Disabilities.

Questions and Answers:

1. When should an OBRA Level II screening be done?
2. For how long is an OBRA Level II screening valid?
3. May an individual with a psychiatric illness be admitted to a nursing facility without an OBRA Level II screening? (No)
4. Do private pay individuals with psychiatric illness require an OBRA Level II screening? (Yes)
5. If a nursing facility resident transfers from one nursing facility to another, is another OBRA Level II screening required?
6. If a nursing facility resident with psychiatric illness is admitted for a medical reason and placed in a different nursing facility upon discharge, is another OBRA Level II screening required?
7. Many nursing facility admissions are considered short term. When should an OBRA Level II screening be done?
8. Is an OBRA Level II screening required if the mental illness is not the primary diagnosis? (Yes)
9. If an individual is prescribed a psychoactive medication but does not have a psychiatric illness diagnosis, does he/she require an OBRA Level II screening?
10. Can an OBRA Level II screening be dated the same day as an admission to a nursing facility? (Yes)
11. Do the HIPAA regulations prevent physicians, hospitals and nursing facilities from releasing information regarding diagnosis, length of treatment, medications, counseling or psychological testing? (No)
12. Depression
    1. To what does “a 10 year history” refer when dealing with unipolar depression?
    2. If an individual has a 10 year history of depression but NO hospitalizations, ECT treatments or medications for the disorder, is an OBRA Level II screening necessary? (No)
    3. If an individual does NOT have a 10 year history of depression but HAS received medications, hospitalizations or ECT treatments, should an OBRA Level II screening be performed? (No)
    4. Who should provide the history of depression? What happens when the individual or the family is not reliable or available?
    5. When should an OBRA Level II screening be done on an individual with a 5 year history of depression who is taking medication?
13. Categorial Determinations
    1. If an individual’s only diagnosis is dementia, is an OBRA Level II screening required? (No)
    2. If an individual has a major mental illness, when may dementia be used as an exemption from OBRA Level II screening?
    3. When can Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) be used as an exemption from OBRA Level II screening?
    4. When can Parkinson’s Disease, Huntington’s Chorea and Amytrophic Lateral Sclerosis (ALS) be used as an exemption from OBRA Level II screening?
    5. When can head injury be used as an exemption from OBRA Level II screening?
    6. If an individual has less than six (6) months to live but the documentation states a prognosis of six to nine (6-9) months, is an OBRA Level II screening required? (Yes)
    7. If an individual is admitted from a medical admission and possibly residing in a nursing facility for less than 30 days, is an OBRA Level II screening required? What documentation is sufficient to qualify for the exemption?
    8. Is an order signed by a nurse practitioner or nurse clinician acceptable to qualify for a 30-day convalescent care exemption? (No)
14. "Significant Change" Indicator
1. If a physician orders an antidepressant for an individual with or without a new diagnosis of depression, should an OBRA Level II screening be done? (No)
2. If an individual with a major mental illness is placed in a nursing facility from an in-patient PSYCHIATRIC admission for less than 30 days, is an OBRA Level II screening required? (Yes)
15. General Questions
1. How can I find out if an OBRA Level II screening has been done in the past?
2. A complete OBRA Level II screening was performed 10 days ago and now the individual has been re-admitted to an in-patient psychiatric unit. Is another OBRA Level II screening required?
3. Once a complete OBRA Level II screening has been performed on an individual, can an abbreviated version be done in the future?
4. What should be done if the individual cannot or will not sign the release of information on page 15 of the OBRA Level II screening tool?
5. When a Level II screening is completed in a (hospital), where should the copies be sent?
6. A potential nursing home resident has both a mental illness and mental retardation. Does he/she require both Level II screenings? (Yes)
7. Who should receive questions about developmental or intellectual disabilities?
8. What is the difference between the terms “OBRA,” “PASARR,” “Level I,” and “Level II”?

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1. When should an OBRA Level II screening be done?

An OBRA Level II screening should be completed when an individual with a major mental illness is seeking nursing facility placement regardless of the patient's age or payor source.

 

2. For how long is an OBRA Level II screening valid?

An OBRA screening is valid until one or more of the following occurs:

1. An inpatient psychiatric hospitalization;
2. A nursing home resident is discharged to the community, decompensates and wishes to be re-admitted to any nursing facility;
3. A federal or state level auditor requests a screening. The Department of Mental Health reserves the right to determine the necessity of the request.
4. A significant change in mental status has occurred that results in a new psychiatric diagnosis for a nursing facility resident.

 

3. May an individual with a psychiatric illness be admitted to a nursing facility without an OBRA Level II screening?

NO. Failure to comply with federal law may result in sanctions and/or fines against the facility.

 

4. Do PRIVATE PAY individuals with psychiatric illness require an OBRA Level II screening?

YES. ALL persons with psychiatric illness, regardless of insurance or payer source, require an OBRA Level II screening by federal law.

 

5. If a nursing facility resident transfers from one nursing facility to another, is another OBRA Level II screening required?

No, unless any of the above criteria under the For how long is an OBRA Level II screening valid? are met. The sending facility should send the screen to the receiving facility.

 

6. If a nursing facility resident with psychiatric illness is admitted for a MEDICAL reason and placed in a different nursing facility upon discharge, is another OBRA Level II screening required?

NO. The only times that individual will require another OBRA Level II screening is if he/she a) is admitted to an in-patient psychiatric hospital, or b) returns to the community and is re-admitted to a nursing facility.

 

7. Many nursing facility admissions are considered SHORT TERM. When should an OBRA Level II screening be done?

An OBRA screening should be done on anyone who meets the criteria for screening and is staying in a nursing facility more than 30 DAYS. This 30 day expectation must be documented by a physician.

 

8. Is an OBRA Level II screening required if the mental illness is not the PRIMARY DIAGNOSIS?

YES. Any diagnosis of mental illness that meets the criteria for screening should be considered, regardless of its place in the listing of a patient’s diagnoses.

 

9. If an individual is prescribed a psychoactive medication but does not have a psychiatric illness diagnosis, does he/she require an OBRA Level II screening?

NO. No OBRA Level II screenings are performed without an indicating diagnosis. However, the reason for psychoactive medication use should be clearly noted in the medical record.

 

10: Can an OBRA Level II screening be dated the same day as an admission to a nursing facility?

YES.

 

11. Do the HIPAA regulations prevent physicians, hospitals and nursing facilities from releasing information regarding diagnosis, length of treatment, medications, counseling or psychological testing?

NO. The HIPAA regulations allow for the release of the above –mentioned information in 45 CFR § 164.501 and 164.512 (d) (1) (i, iii) and42 CFR § 2.53. Performance of the OBRA Level II Pre-Admission Screenings and the inclusion of medical information from patient records will NOT change as a result of HIPAA regulations.

Depression

12A. To what does “a 10 year history” refer when dealing with unipolar depression?

“A 10 year history” refers to at least one episode of depression for which the individual has received medication, hospitalization, ECT and/or counseling treatment. This treatment documentation should include the date(s) of treatment that will establish the history. Please note that the individual may experience periods of remission but history will begin with the earliest date of treatment.

Also there is no limit on the number of hospitalizations, ECT treatment or type/duration of medication.

 

12B. If an individual has a 10 year history of depression but NO hospitalizations, ECT treatments or medications for the disorder, is an OBRA Level II screening necessary?

NO. The criteria for obtaining an OBRA screening for depression includes a 10 year history WITH ONE OF THE FOLLOWING: inpatient psychiatric treatment OR ECT treatment OR medications.

 

12C. If an individual does NOT have a 10 year history of depression but HAS received medications, hospitalizations or ECT treatments, should an OBRA Level II screening be performed?

NO. The individual must have a 10 year history of depression and at least one of the qualifying criteria. However proper documentation should include the dates of any treatments in order to establish a reliable history.

 

12D. Who should provide the history of depression? What happens when the individual or the family is not reliable or available?

The nursing facility is ultimately responsible for all care and documentation of its residents. Any reliable source may provide verbal history but written documentation is necessary to establish a course of treatment. If no proper documentation has been provided at the time of admission to a nursing facility, itis incumbent upon the admissions coordinator or social service staff to investigate and document any information. History may also be established by medication records obtained from physicians that include signatures and dates.

 

12E. Should an OBRA Level II screening be done on an individual with a 5 year history of depression who is taking medication?

An OBRA screening should be done when a 10 -year history of depression with at least one qualifying criterion (inpatient hospitalization, ECT treatment or medication) has been established. Prior to that time documentation should reflect the dates of onset of the disorder and any treatments.

 

13. Categorial Determinations

 

13A. If an individual’s only diagnosis is dementia, is an OBRA Level II screening required?

NO. As long as there is no other psychiatric diagnosis that would indicate the need for an OBRA Level II screening, one need not be done.

 

13B. If an individual has a major mental illness, when may dementia be used as an exemption from OBRA Level II screening?

Dementia may be used as an exemption from OBRA screening when it is properly documented. Proper documentation includes any of the following: results of neurological scans (CT, PET, MRI, etc) documenting significant atrophy, results of neuro-psychological testing performed by a PhD-level psychologist documenting dementia by psychometric testing, notes in nursing/social service section of the record documenting cognitive and/or behavioral declines in functioning consistent with the diagnosis of dementia over a specified period of time. Please note that the diagnosis of dementia MUST appear in the official listing of diagnoses assigned by the primary care physician.

 

13C. When can Congestive Heart Failure (CHF) and Chronic Obstructive Pulmonary Disease (COPD) be used as an exemption from OBRA Level II screening?

CHF and COPD may be used as an exemption from the OBRA Level II mental illness screening when the physician documents an END STAGE condition AND orders 24-hour oxygen.

This exemption does NOT apply to the DD/ID population; the only exemption for the DD/ID population is convalescent care of less than 30 days

 

13D. When can Parkinson’s Disease, Huntington’s Chorea and Amytrophic Lateral Sclerosis (ALS) be used as an exemption from OBRA Level II screening?

Parkinson’s Disease, Huntington’s Chorea and ALS may be used as an exemption from the OBRA Level II screening when the physician documents an END STAGE condition AND the individual is BEDBOUND or BED-TO-CHAIR.

This exemption does NOT apply to the DD/ID population; the only exemption for the DD/ID population is convalescent care of less than 30 days

13E. When can head injury be used as an exemption from OBRA Level II screening?

Head injuries of a severe nature obtained at any age may be used as an exemption from OBRA Level II screening. The defining factor is the inability to diagnose the source of behavior as head injury versus mental illness. Please note that head injuries sustained before age 22 should be reported as developmental disabilities to the Department of Developmental Disabilities.

This exemption does NOT apply to the DD/ID population; the only exemption for the DD/ID population is convalescent care of less than 30 days

 

13F. If an individual has less than six (6) months to live but the documentation states a prognosis of six to nine (6-9) months, is an OBRA Level II screening required?

YES. The documentation must state a prognosis of six months or less and it must be signed by a physician.

This exemption does NOT apply to the DD/ID population; the only exemption for the DD/ID population is convalescent care of less than 30 days

13G. If an individual is admitted from a MEDICAL admission and possibly residing in a nursing facility for LESS THAN 30 days, is an OBRA Level II screening required? What documentation is sufficient to qualify for the exemption?

An OBRA Level II screening is NOT required for an admission to a nursing facility not exceeding 30 days IF it is recommended in writing by a physician. The order for care must state that a stay of less than 30 days is required. A time frame in days must be specified. The phrase “short term rehab” is NOT sufficient to qualify for an exemption.

 

13H. Is an order signed by a nurse practitioner or nurse clinician acceptable to qualify for a 30-day convalescent care exemption?

NO. The order for continuing medical care, specified in number of days, MUST be signed by a physician.

 

14. "Significant Change" Indicator

 

14A. If a physician orders an antidepressant for an individual with or without a new diagnosis of depression, should an OBRA Level II screening be done?

NO. The purpose for using the medication should be the primary consideration for its use. Although most commonly used to treat depression, antidepressants are also useful in the treatment of other disorders such as chronic pain and dementia. Also a new diagnosis must establish a 10 year history of depression before an OBRA Level II screening will be performed.

 

14B. If an individual with a major mental illness is placed in a nursing facility from an in-patient PSYCHIATRIC admission for less than 30 days, is an OBRA Level II screening required?

YES. In-patient psychiatric admissions qualify as a significant change in mental status.

 

15. General Questions

15A. How can I find out if and OBRA Level II screening has been done in the past?

Call UMass Medical Center to inquire (866-385-0933 or email DMHPASRR@umassmed.edu). When inquiring about a specific individual, please have the client’s name and social security number. When leaving a message, please remember your name, telephone number and facility.

 

15B. A complete OBRA Level II screening was performed 10 days ago and now the individual has been re-admitted to an in-patient psychiatric unit. Is another OBRA Level II screening required?

YES. An in-patient psychiatric admission constitutes a significant change in the individual’s mental status. For that reason another OBRA Level II screening must be completed if the individual meets the criteria and has no exemptions. See question below for info on abbreviated version.

 

15C. Once a complete OBRA Level II screening has been performed on an individual, can an abbreviated version be done in the future?

YES. Subsequent OBRA Level II screenings should be marked as such on the front of the document (check-off box). Pages 1, 4, and 12 through 16 should then be completed.

 

15D. What should be done if the individual cannot or will not sign the release of information on page 15 of the OBRA Level II screening tool?

It is recommended that the individual sign the release of information but NOT MANDATORY. According to the Center for Medicare Services (the agency formerly known as Health Care Financing Administration), under regulations of the Social Security Act 42 CFR 482.24 (b)(3) and 483.10 (e) (3) (ii), medical records may be released to authorized auditing personnel such as the OBRA Level II assessors without the express permission of the individual. Therefore, medical records may be reviewed without permission.

 

15E. When a Level II screening is completed in a (hospital), where should the copies be sent?

1. Fax a copy to UMass Medical School Fax: 508-856-7696
   • Important: please indicate on the cover sheet that it is a completed Level II screen.
     • This will be the trigger for them to call you within the hour to approve transfer.
     • Please ensure that your contact info on the cover sheet is complete and legible, as it is not included in the form itself.
2. One copy should be maintained with the hospital records.
3. One copy should be included with the discharge paperwork to the nursing facility admissions department.

 

15F. A potential nursing home resident has both a mental illness and mental retardation. Does he/she require both Level II screenings?

YES. An individual with a dual diagnosis may require both Level II screenings. MGH psychiatrits and social workers complete the Mental Illness screening and contact the OBRA Offices at Health & Education Services, Inc., with the results. For developmental disabilities contact the Department of Developmental Services - they will come in to MGH to conduct this type of screening. See also: OBRA for Developmental disabilities page.

 

15G. Who should receive questions about developmental or intellectual disabilities?

Contact the Intake Desk at the Deparment of Developmental Services PASARR Project at 617-624-7796. See also: OBRA/PASARR for developmental disabilities page. (Caution: previously listed 800 number is an unattended voice-mail.)

 

15H. What is the difference between the terms “OBRA,” “PASARR,” “Level I,” and “Level II”?

OBRA is an acronym for the federal Omnibus Budget Reconciliation Act of 1987 under which both types of screening are required.

PASARR is an acronym for Pre-Admission Screening/Annual Resident Review or the screen itself that is required for both both serious mental illness and developmental disabilities. Some use PASAR to refer to the developmental disabilities screening.

Level I refers to the one-page double-sided form completed by the nursing facility prior to admission of the resident.

Level II (usually) refers to the screenings performed by UMMS, and/or the Department of Developmental Services (formerly Dept of Mental Retardation or DMR). But since MGH is a “delegated hospital”- we are able to complete these Mental Illness screens rather than UMMS. In Developmental Disabilities cases, the Department of Developmental Services completes the pre-admission screen.

 

 

Revised 12/14 (and abridged and annotated for MGH use)