[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: 42CFR483.134]



[Page 557]

 

                         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.  483.134  Evaluating whether an individual with mental illness 



requires specialized services (PASARR/MI).



    (a) Purpose. The purpose of this section is to identify the minimum 

data needs and process requirements for the State mental health 

authority, which is responsible for determining whether or not the 

applicant or resident with MI, as defined in Sec.  483.102(b)(1) of this 

part, needs a specialized services program for mental illness as defined 

in Sec.  483.120.

    (b) Data. Minimum data collected must include--(1) A comprehensive 

history and physical examination of the person. The following areas must 

be included (if not previously addressed):

    (i) Complete medical history;

    (ii) Review of all body systems;

    (iii) 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

    (iv) 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.

    (5) 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 assessment must determine whether this level of support 

can be provided to the individual in an alternative community setting or 

whether the level of support needed is such that NF placement is 

required.

    (6) 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.

    (c) Personnel requirements. (1) If the history and physical 

examination are not performed by a physician, then a physician must 

review and concur with the conclusions.

    (2) The State may designate the mental health professionals who are 

qualified--

    (i) To perform the evaluations required under paragraph (b) (2)-(6) 

of this section including the--

    (A) Comprehensive drug history;

    (B) Psychosocial evaluation;

    (C) Comprehensive psychiatric evaluation;

    (D) Functional assessment; and

    (ii) To make the determination required in paragraph (d) of this 

section.

    (d) Data interpretation. Based on the data compiled, a qualified 

mental health professional, as designated by the State, must validate 

the diagnosis of mental illness and determine whether a program of 

psychiatric specialized services is needed.