R414-503-6. PASRR Level II Categorical Determinations

  The Level II Evaluator may make one of the following categorical determinations:

  (1) Convalescent Care - The person is eligible for convalescent care for an acute physical illness that requires hospitalization and does not meet the criteria for an exempt hospital discharge, (which, as specified in 42 CFR 483.106(b)(2) is not subject to preadmission screening). The convalescent care determination only applies if the person is at a hospital for a medical condition and is going to the Medicare/Medicaid-certified nursing facility for the same medical condition. The Convalescent Care Categorical Determination is valid for up to 120 days. The nursing facility shall refer the person for a Level II Evaluation before midnight on the 120th day if the placement will extend beyond the 120th day.

  (2) Short-term Stay - The person is eligible for a short-term stay for an acute physical illness in which the person is seeking admission to the nursing facility directly from a community setting. The Short-term Stay Categorical Determination is valid for a maximum of 120 days. The nursing facility shall refer the person for a Level II Evaluation before the end of the number of days specified if the placement will extend beyond the number of days specified by the State Mental Health Authority or Intellectual Disabilities Authority.

  (3) Terminal Illness - The person is eligible for a stay related to a terminal illness when a physician provides a written statement that the person has a terminal illness. If the individual is not receiving hospice services at the time of the Level II Evaluation, an individualized Level II Evaluation is required.

  (4) Severe Physical Illness - The person is eligible for a Severe Physical Illness Categorical Determination when the person has a level of impairment so severe that the individual cannot be expected to benefit from specialized services. This level of impairment includes conditions such as:

  (a) being in a coma;

  (b) being ventilator dependent; or

  (c) functioning at a brain stem level.

  (5) Dementia and Intellectual Disability - The State Intellectual Disability Authority or delegated agency (not Level I screeners) may make categorical determinations that individuals with dementia, which exists in combination with intellectual disability or a related condition, do not need specialized services.

  (6) Dementia and Mental Illness -The health care professional may terminate the PASRR Level II Evaluation if the health care professional discovers that the person has dementia and a serious mental illness during the evaluation process, and there is evidence that dementia is the primary condition. For example, the dementia has resulted in increased functional deficits and is the primary reason for requiring nursing facility services.