PASRR - VII. Changes in Condition

1. Application.  This section provides functional guidance to NF staff and assessors regarding changes in condition for mental illness or mental retardation.  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:  a change in status, either physical or mental, which results in a decline or improvement in the mental health or cognitive and functional (for persons with mental retardation) status of the resident, and is unexplained by the use of medication, a medication interaction, an acute illness or infection.  For all persons, 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 people with mental retardation.  The following are specific circumstances and situations that must be considered a change in condition for people with mental retardation:
      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 longerperiods of time;
      9. improvement following intervention;
      10. mental status changes not previously present.
   3. Co-Occurring Disorders.  Persons with known co-occurring disorders (mental illness and mental retardation) 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 DHHS Preadmission Screening Services or Mental Retardation Services 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. Referral.  Preadmission Screening Services or Mental Retardation Services will arrange for a change in condition review, to be conducted by an outside provider or MRS, as applicable.   This should take no more than nine working days.
   4. Evaluation Report.  The outside provider/MRS will complete the review and submit an evaluation report to Preadmission Screening Services or Mental Retardation Services, citing the basis for recommendations.  The report may
      1. recommend continued NF care and identify the specialized services required to meet the person’s needs;
      2. recommend continued NF care and identify the services of a lesser intensity that are required to meet the person’s needs;
      3. recommend another level of care than NF.
   5. Copies of the report must be provided to the person and a legal representative (if one exists), the NF, the attending physician, and  the hospital (if admission is being sought from a hospital).
   6. Notification.  Preadmission Screening services/MRS may notify the NF, the discharging hospital and the person of the recommendations and determination verbally.  A written letter of final determination will be provided to the same people to whom the report was provided.

In condition flowchart