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DDES Memo Series 2004-17

February 9, 2005

STATE OF WISCONSIN
Department of Health and Family Services
Division of Disability and Elder Services

To:
Area Administrators/ Human Services Area Coordinators
Bureau Directors
County Departments of Community Programs Directors
County Departments of Developmental Disabilities
Services Directors
County Departments of Human Services Directors
County Departments of Social Services Directors
Facilities Serving People with Developmental Disabilities
Hospitals
Licensing Chiefs/Section Chiefs
Nursing Homes
Tribal Chairpersons/Human Services Facilitators

From: 
Sinikka Santala
Administrator

The Division of Disability and Elder Services is making several changes to the DSL-822 form and renumbering the form as DDE-822. For example, the following changes were made:

  • A clarification was added to indicate that the Preadmission Screen and Resident Review (PASARR) short-term exemptions cannot be used consecutively/piggybacked.
  • Another option was added to indicate, "Person has a brain injury that occurred after 22nd birthday and does not have an additional developmental disability or an accompanying mental illness requiring a PASARR Level II Screen."
  • An option was added to indicate that the county believes that the person does not have mental illness or developmental disability as defined in s. 51.01, Stats., and therefore, county approval is not necessary.

A copy of the revised form is attached. It replaces the "DSL-822 (Revised 6/97)" form. Begin using the current version of the DDE-822 now. The form may be downloaded from the Department through http://www.dhs.wisconsin.gov/forms1/f2/f20822.pdf, an Adobe Acrobat fillable format or http://www.dhs.wisconsin.gov/forms1/f2/f20822.doc, a Microsoft Word 97 fillable format.

Wisconsin counties continue to have responsibility and authority to review referrals to a nursing home or an ICF/MR for people with developmental disabilities, and referrals to a nursing home or a Medicaid-certified Institution for Mental Disease (IMD) for people with mental illness. Persons with a developmentally disability or mental illness cannot be admitted to such facilities unless the responsible county agency has reviewed the admission referral and has documented its appropriateness through the completion of the DDE-822, irrespective of the nature or expected duration of the admission.

Please note that Act 33 of 2003 made several changes to Chs. 49 and 55, Stats., involving the placement of persons who have a developmental disability into a nursing home or a facility serving people with developmental disabilities. These changes are outlined in the DDES Memo 2004-16.

Many individuals have noted that the county approval via the DDE-822 form seems to duplicate the requirements for the Preadmission Screening and Annual Resident Review (PASARR) process, setting of a nursing facility care level by a Bureau of Quality Assurance surveyor, physician certification of the need for nursing facility placement, and, if necessary, a protective placement order. Despite the appearance, these processes do not duplicate one another. Each of these processes are required by State or federal law/regulation and serve different purposes. Because of the different purposes for each of these approval processes, the requirements for the qualifications of personnel conducting evaluations, type of evaluations performed, and the criteria for determining if a person should be admitted to a nursing facility differ.

PASARR only applies to Medicaid certified nursing homes. Any person, regardless of age or payment source, seeking admission to or residing in a Medicaid certified nursing home or a nursing facility-IMD must receive at least a Level I Screen from a nursing home or hospital to determine if the person has a developmental disability or mental illness. We are continuing to link the DDE-822 form with the PASARR process because of the important relationships among the counties, the nursing homes and the PASARR contractor in addressing the support needs of individuals. The DDE-822 form must be completed for persons with a developmental disability and/or mental illness who are seeking admission to any of the types of facilities identified on the form, without regard to the person's age or payment source.

PASARR does not permit any permanent exemptions. There are four allowable short-term admission exemptions that are noted on the DDE-822 form: Hospital Discharge-30 day maximum; Pending Alternate placement-30 day maximum; Emergency Placement-7 day maximum and; Respite Care-30 days per year maximum. Those four exemptions correspond with the exemptions on the Level I Screen (see page 3, Section B of the Level I Screen). The Level I Screen states that if a person meets one of the four short-term admission exemptions "the individual may enter the nursing facility with county approval through the DDE-822 form, for the specified period of time without a referral for a PASARR Level II Screen." Note: Short-term exemptions may not be used consecutively to extend the time in a facility without a PASARR Level II Screen, when a PASARR Level II Screen is warranted. These exemptions are described in the paragraphs below.

Hospital Discharge Exemption - 30 days maximum. 
Under this exemption an individual may enter the nursing home from a hospital for the purpose of convalescing from a medical problem for 30 days or less if the person meets a required nursing care level (a skilled nursing facility level of care (SNF) for persons with developmental disabilities). If it appears that more than a 30 day post-hospital stay in a nursing home is needed, the nursing home will need to contact the PASARR contractor to complete a Level II Screen as soon as the nursing home believes that the person will need to stay beyond 30 days. The county should complete another DDE-822 form if the county recommends a longer stay than is allowed in one of the short-term admission exemptions. This is explained below under "Level II Screen required." The county has the discretion to check both the "hospital discharge exemption" box and the "person needs a Level II Screen " box when initially completing the form to avoid filling out two DDE-822 forms.

The Pending Alternate Placement - 30 days maximum. 
This exemption is an attempt to respond to those situations in which the person's community placement has dissolved and nursing care is needed, but hospitalization was found to be unnecessary. As above, the person must meet a required nursing home level of care to be admitted. The intent of this short-term exemption is for the person to return to a non-institutional setting. It is not acceptable to use this exemption to admit a person to a nursing home when the intent is for long term care. Any person needing long-term nursing home care needs to be referred by a hospital or nursing home to the PASARR contractor via a Level I Screen so that a Level II Screen can be completed. To remain in compliance with federal PASARR rules, the Department will monitor the use of this exemption and may remove it as a short-term exemption option if it is not used appropriately.

Emergency Placement - 7 day maximum. 
This exemption is to be used in situations where protective services (i.e., the person's health, safety, and welfare are immediately at risk if action is not taken) are needed and a nursing facility stay of no more than 7 days is needed for further assessment and emergency planning purposes. For example, a person is admitted to an emergency room with a broken leg. The physician indicates that the person does not need to be hospitalized, but the person must remain off his/her feet to permit the leg to heal properly. However, due to the person's developmental disability or serious mental illness, the person is not likely to stay off his/her feet and the person's prior living arrangement either cannot provide the appropriate supervision, accommodate a wheelchair or ensure safe evacuation of the person in the event of an emergency. This person may be admitted to a nursing facility to ensure his/her health, safety and welfare. If the nursing facility believes that the person has a developmental disability or serious mental illness, then the facility must make a referral for a PASARR Level II Screen within seven (7) days unless the person is discharged within this time period.

Respite Care - Up to 7 days at a time for up to 30 days per year maximum. 
This short-term exemption is to be used for the benefit of providing relief to in-home caregivers to whom the person will be returning after a brief stay. As in the above exemptions, the individual needs to meet a required nursing care level for admission. Respite care in a nursing home is not presently funded by Medicaid under the nursing facility benefit, however Medicaid Home and Community-Based Waiver funds (i.e., CIP 1A, CIP 1B, CIP II, and COP-W) are permitted to be used to pay for respite care.

When to check the section "Level II Screen required." 
For admissions of persons with developmental disabilities and/or mental illness to nursing homes for other than the four short-term exemptions, a Level II Screen will need to be completed by the PASARR contractor prior to admission. In those situations the nursing home or hospital will contact the contracted PASARR contractor. The PASARR contractor will in turn inform the county PASARR liaison (identified in DDES Memo 2004-xx) to notify them that a Level I Screen has been received so that any necessary planning at the county level can begin. In many cases the nursing home will have already requested DDE-822 approval from the county prior to the county being contacted by the PASARR contractor. The overlap is due to the nursing home's responsibility to meet separate PASARR requirements and Wisconsin nursing home administrative code requirements.

There will be situations when a second DDE-822 approval may be needed within a relatively short period of time. For example, if the person has been admitted under one of the four short-term exemptions and needs to stay for a longer period the county should complete another DDE-822 form if the county agrees with the longer nursing home stay. In most cases, the PASARR contractor would need to be involved in the Level II Screening process for stays beyond the short-term exemption periods.

The separate category "Admission to a licensed nursing home that is not Medicaid certified" refers to the few Medicare/private pay only nursing homes in Wisconsin. Individuals entering those facilities do not require PASARR Level I or Level II Screens, but do require DDE-822 approval if they have a developmental disability or mental illness.

Persons entering an ICF/MR (FDD) are not subject to PASARR, but do require DDE-822 approval. (A person transferring from an ICF/MR, including a distinct-part ICF/MR, to a Medicaid-certified nursing facility is subject to PASARR.)

Special Note Regarding Persons Who Have Had A Brain Injury:
If the brain injury occurred prior to the person's 22nd birthday, then a PASARR Level II Screen likely is required. Complete the DDE-822 form as instructed above. If the brain injury occurred after the person's 22nd birthday a PASARR Level II Screen is not required unless the person has an additional developmental disability and/or mental illness diagnosis, however a DDE-822 is required. The reason for the distinction is the fact that the Wisconsin statutory definition of developmental disability specifically includes brain injury regardless of age of onset. There is a separate option on the DDE-822 form to identify a person whose brain injury occurred after his/her 22nd birthday and does not have an additional developmental disability or an accompanying mental illness. Such a person does not need a PASARR Level II Screen. However, if a person has a brain injury that occurred after his/her 22nd birthday and he/she had a pre-existing developmental disability or now has an accompanying mental illness, then he/she needs a PASARR Level II Screen.

Special Note Regarding Use for Out-of-State Circumstances:
Counties should complete the DDE-822 form for each county resident who will be placed in a facility in another state. The DDE-822 form should be completed for a person who currently is a resident of another state, not under guardianship or an involuntary commitment order, and voluntarily is choosing to permanently reside in Wisconsin and has stated an intent to do so. The county that will become the place of such a person's residence should be the county to complete the DDE-822 form. If a person who is not a Wisconsin resident is under guardianship, an involuntary commitment order, intends to return to their home that is not in Wisconsin, or is seeking admission to a Wisconsin facility because of the lack of available resources in their home state, then the facility or the county staff should contact Dan Zimmerman for consultation in addressing residency, legal and payment issues.

Routing directions are identified on the bottom of the DDE-822 form.

CENTRAL OFFICE CONTACT: 
Dan Zimmerman
Bureau of Mental Health and Substance Abuse Services
1 W. Wilson Street, room 850
PO Box 7851
Madison, WI 53707-7851
(608) 266-7072
(608) 267-7793 (fax)
zimmeds@wisconsin.gov (e-mail)

MEMO WEB SITE: 
http://www.dhs.wisconsin.gov/partners/local.htm

Attachments

cc: 
County PASARR Liaisons

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