PASRR: Specialized Services, Specialized Psychiatric Rehabilitation Services

This term means services that meet the requirements of 42 CFR 483.440(a)(1) and (2), the definition of active treatment in the federal regulations for intermediate care facilities for individuals with intellectual disabilities:

• Each client must receive a continuous active treatment program, which includes aggressive, consistent implementation of a program of specialized and generic training, treatment, health services, and related services that is directed toward
  • The acquisition of the behaviors necessary for the client to function with as much self determination and independence as possible; and
  • The prevention or deceleration of regression or loss of current optimal functional status.
• Active treatment does not include services to maintain generally independent clients who are able to function with little supervision or in the absence of a continuous active treatment program.

This term means the services specified by the state that results in the continuous and assertive implementation of an individual plan of care that:

• Is developed and supervised by an interdisciplinary team, which includes a physician, qualified mental health professionals and, as appropriate, other professionals;
• Prescribes specific therapies and activities for the treatment of persons experiencing an acute episode of serious mental illness, including, for example, persons who are experiencing severe and persistent symptoms, which necessitates supervision by trained mental health personnel; and
• Is directed toward diagnosing and reducing the resident’s behavioral symptoms that necessitated institutionalization, improving his or her level of independent functioning, and achieving a functional level that permits reduction in the intensity of mental health services to below the level of specialized services at the earliest possible time.

This term means the services determined by the comprehensive assessment and the specialized psychiatric rehabilitation services care plan necessary to prevent avoidable physical and mental deterioration and to assist clients in obtaining or maintaining their highest practicable level of functional and psychosocial well-being. Specialized psychiatric rehabilitation services shall include:

• The client’s regular participation, in accordance with their specialized psychiatric rehabilitation services care plan, in professionally developed and supervised activities, experiences and therapies; and
• Activities, experiences, and therapies that reduce the resident’s psychiatric and behavioral symptoms, improve the level of independent functioning, and achieve a functional level that permits reduction in the need for intensive mental health services.

A nursing facility should request a new PASRR Level II screen for an individual who was determined to need specialized services or specialized psychiatric rehabilitation services, but may no longer require specialized services or specialized psychiatric rehabilitation services for one of two reasons:

1. The individual’s independent functioning is not significantly impaired by his/her mental illness or developmental disability; he/she is generally independent. This person still may need supports essential for his/her welfare (example: budgeting), but the needed supports of interventions or monitoring is neither frequent nor intense.
2. The individual’s medical condition (or dementia) has declined to a point to where the individual no longer can participate in or benefit from specialized services or specialized psychiatric rehabilitation services. For example, a person who receives continuous oxygen and cannot tolerate being out of bed for more than 1½ hours per day could be found to no longer need specialized services or specialized psychiatric rehabilitation services (via an abbreviated Level II screen).

It is not possible to achieve the above principles by categorizing a service, such as reality orientation activities, a physician or pharmacist medication review, physical therapy, speech therapy, etc., as exclusively a specialized service or a nursing facility service. Also, it would be difficult to determine what percentage of a service was provided as a specialized service versus a nursing facility service. For example, a physical therapist must take into account a person’s cognitive, emotional, and behavioral functioning (examples: depression resulting in loss of interest in activities and psychomotor retardation) in order to develop an effective rehabilitation plan for a broken hip.

However, it is possible to categorize particular staff functions clearly as a specialized service, a service that is not required to be provided to all nursing facility residents. In Wisconsin, the following staff functions are considered to be specialized services or specialized psychiatric rehabilitation services, which is above and beyond the expectation for services of a lesser intensity:

• Case management functions completed by a qualified intellectual disability professional or a qualified mental health professional include, but are not limited to:
  • At least monthly analysis of data and documentation of determinations to maintain or modify each resident’s specialized services or specialized psychiatric rehabilitation services program.
  • Each resident’s specialized services or specialized psychiatric rehabilitation services program must be integrated, coordinated, and monitored by a qualified mental health professional.
  • Coordination with a county case manager and community agencies, as appropriate, for discharge planning or services provided by the county or a state agency (examples: legal issues, such as assistance to find a volunteer guardian; vocational rehabilitation services; etc.).
  • Development of the specialized services or specialized psychiatric rehabilitation services plan.
• At least quarterly conducting an interdisciplinary team review and updating of the specialized services or specialized psychiatric rehabilitation services plan, as appropriate based on the analysis of the data reflecting progress, regression, or lack of progress towards the objectives.

Qualified mental health professional: A qualified mental health professional is a person who has one year of professional experience working with persons who have a serious mental illness and is one of the following:

• A psychologist licensed under Wis. Stat. ch. 455;
• A physician;
• A registered nurse;
• A human services professional who has a master’s degree in a human services field other than a field under the first three fields listed above, such as social work, rehabilitation counseling, occupational therapy, or psychology; or
• A human services professional who has a bachelor’s degree in a human services field other than a field under the first three fields listed above, such as social work, rehabilitation counseling, occupational therapy, or psychology, and has at least three years of professional experience working with persons with a serious mental illness.

Qualified intellectual disability professional: A qualified intellectual disability professional is a person who meets the requirements of 42 CFR 483.430(a)(1) and (2) of the intermediate care facilities for individuals with intellectual disabilities regulations. They must have specialized training in intellectual disability or at least one year of experience working directly with persons with intellectual disability or other developmental disabilities and is one of the following:

• A doctor of medicine or osteopathy;
• A registered nurse; or
• An individual who holds at least a bachelor’s degree in occupational therapy, physical therapy, psychology, social work, speech pathology/therapy, recreation, dietetics/nutritional science, or a human services field (including, but not limited to, sociology, special education, and rehabilitation psychology).

Facilities do not need any special license or approval from the department to provide specialized services or specialized psychiatric rehabilitation services.

The PASRR regulations require that persons who have a serious mental illness or a developmental disability and are found to need specialized services receive these services. Under these regulations, the state is responsible to provide or arrange for the provision of specialized services. Wisconsin arranges for the provision of specialized services for persons who have a developmental disability by providing an additional reimbursement to nursing facilities that provide specialized services. A nursing facility may choose not to admit or retain a person who requires specialized services.

For persons who have a serious mental illness and need specialized psychiatric rehabilitation services, the federal Medicaid regulations identify the nursing facility as responsible for providing “services of a lesser intensity” or specialized psychiatric rehabilitation services. Therefore, a nursing facility should not categorically refuse to admit or retain a person who requires specialized psychiatric rehabilitation services, simply based on the PASRR determination. A nursing facility is permitted to refuse to admit or involuntarily relocate an individual whose needs cannot be met by the nursing facility, but this must be done based on an assessment of the individual’s needs and an assessment of the facility’s capacity (i.e., knowledge, skills, and resources) to meet the individual’s needs.

A determination that a person with an intellectual disability or a serious mental illness is in need of specialized services or specialized psychiatric rehabilitation services does not change the sources of reimbursement. All services provided by a nursing facility from the facility’s base rate must continue to be provided and funded from the facility’s base rate. All services provided or arranged for by a nursing facility as a direct-billed service, such as psychiatric evaluation or psychotherapy, must continue to be provided, as needed and appropriate; these services continue to be eligible for payment as direct-billed services.

Services to be provided from the base rate or direct-billed services: Nursing facilities are expected to provide “services of a lesser intensity” from the facility’s base rate (examples: activity materials and programs) or as a direct-billed service (examples: occupational therapy services for rehabilitation of a resident’s meal preparation skills that diminished as a result of a stroke; a psychiatric evaluation to determine changes in a resident’s drug regimen; a psychological evaluation as preparation for development of a behavior management program). These services are of a nature, frequency, and intensity that must be provided to any resident of a nursing facility.

Many services that the facility must provide from its base rate or from direct-billed services can be necessary or significant services for a resident’s specialized services or specialized psychiatric rehabilitation services plan and can be identified as such in the resident’s specialized services or specialized psychiatric rehabilitation services plan. However, the source of payment will remain within the facility’s base rate or as a direct-billed service.

Specialized psychiatric rehabilitation services to be provided from the daily specialized psychiatric rehabilitation services supplement: The staff functions noted above are required to be provided only to those residents with a determination that they need specialized psychiatric rehabilitation services; these services are not generally available to other residents through the facility’s base rate payment or as direct-billed services.