[Code of Federal Regulations] [Title 42, Volume 4] [Revised as of October 1, 2006] From the U.S. Government Printing Office via GPO Access [CITE: 42CFR483.128] [Page 552-554] TITLE 42--PUBLIC HEALTH CHAPTER IV--CENTERS FOR MEDICARE & MEDICAID SERVICES, DEPARTMENT OF HEALTH AND HUMAN SERVICES (CONTINUED) PART 483_REQUIREMENTS FOR STATES AND LONG TERM CARE FACILITIES--Table of Contents Subpart C_Preadmission Screening and Annual Review of Mentally Ill and Mentally Retarded Individuals Sec. 483.128 PASARR evaluation criteria. (a) Level I: Identification of individuals with MI or MR. The State's PASARR program must identify all individuals who are suspected of having MI or MR as defined in Sec. 483.102. This identification function is termed Level I. Level II is the function of evaluating and determining whether NF services and specialized services are needed. The State's performance of the Level I identification function must provide at least, in the case of first time identifications, for the issuance of written notice to the individual or resident and his or her legal representative that the individual or resident is suspected of having MI or MR and is being referred to the State mental health or mental retardation authority for Level II screening. (b) Adaptation to culture, language, ethnic origin. Evaluations performed under PASARR and PASARR notices must be adapted to the cultural background, language, ethnic origin and means of communication used by the individual being evaluated. (c) Participation by individual and family. PASARR evaluations must involve-- (1) The individual being evaluated; (2) The individual's legal representative, if one has been designated under State law; and (3) The individual's family if-- (i) Available; and (ii) The individual or the legal representative agrees to family participation. (d) Interdisciplinary coordination. When parts of a PASARR evaluation are performed by more than one evaluator, the State must ensure that there is interdisciplinary coordination among the evaluators. (e) The State's PASARR program must use at least the evaluative criteria of Sec. 483.130 (if one or both determinations can easily be made categorically as described in Sec. 483.130) or of Sec. Sec. 483.132 and 483.134 or Sec. 483.136 (or, in the case of individuals with both MI and MR, Sec. Sec. 483.132, 483.134 and 483.136 if a more extensive individualized evaluation is required). (f) Data. In the case of individualized evaluations, information that is necessary for determining whether it is appropriate for the individual with MI or MR to be placed in an NF or in another appropriate setting should be [[Page 553]] gathered throughout all applicable portions of the PASARR evaluation (Sec. Sec. 483.132 and 483.134 and/or Sec. 483.136). The two determinations relating to the need for NF level of care and specialized services are interrelated and must be based upon a comprehensive analysis of all data concerning the individual. (g) Preexisting data. Evaluators may use relevant evaluative data, obtained prior to initiation of preadmission screening or annual resident review, 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, the State's PASARR program may need to gather additional information necessary to assess proper placement and treatment. (h) Findings. For both categorical and individualized determinations, findings of the evaluation must correspond to the person's current functional status as documented in medical and social history records. (i) Evaluation report: Individualized determinations. For individualized PASARR 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, including services required in paragraph (i)(5) of this section; (4) If specialized services are not recommended, identifies any specific mental retardation 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 mental retardation or mental health services required to meet the evaluated individual's needs; and (6) Includes the bases for the report's conclusions. (j) Evaluation report: Categorical determinations. For categorical PASARR determinations, findings must be issued in the form of an abbreviated written evaluative report which-- (1) Identifies the name and professional title of the person applying the categorical determination and the data on which the application was made; (2) Explains the categorical determination(s) that has (have) been made and, if only one of the two required determinations can be made categorically, describes the nature of any further screening which is required; (3) Identifies, to the extent possible, based on the available data, NF services, including any mental health or specialized psychiatric rehabilitative services, that may be needed; and (4) Includes the bases for the report's conclusions. (k) Interpretation of findings to individual. For both categorical and individualized determinations, findings of the evaluation must be interpreted and explained to the individual and, where applicable, to a legal representative designated under State law. (l) Evaluation report. The evaluator must send a copy of the evaluation report to the-- (1) Individual or resident and his or her legal representative; (2) Appropriate State authority in sufficient time for the State authorities to meet the times identified in Sec. 483.112(c) for PASs and Sec. 483.114(c) for ARRs; (3) Admitting or retaining NF; (4) Individual's attending physician; and (5) The discharging hospital if the individual is seeking NF admission from a hospital. (m) The evaluation may be terminated if the evaluator finds at any time during the evaluation that the individual being evaluated-- (1) Does not have MI or MR; or (2) Has-- [[Page 554]] (i) A primary diagnosis of dementia (including Alzheimer's Disease or a related disorder); or (ii) A non-primary diagnosis of dementia without a primary diagnosis that is a serious mental illness, and does not have a diagnosis of MR or a related condition. [57 FR 56506, Nov. 30, 1992; 58 FR 25784, Apr. 28, 1993]