Federally Mandated Mental Health Screening

Few people realize Federally Mandated Mental Health Screening is conducted in the USA today.  It occurs routinely, especially in assisted living facilities and nursing homes.  (7)

Originally it was developed,  “To ensure that people with mental illnesses in Medicaid-funded nursing homes are being adequately diagnosed and treated.”  (12)

Now, one wonders who’s minding the shop? Especially, when large cohort studies come out which state, “Antipsychotic drugs were associated with the highest incidence of adverse events… Neuropsychiatric symptoms such as oversedation, confusion, hallucinations, and delirium were the most frequently reported adverse events, accounting for 27 percent of the aggregate; the investigators judged that nearly a third of the neuropsychiatric adverse events could have been prevented.”  (10)  Separate investigations concluded similar findings at other institutions.  (8)  (9)

The Code of Federal Regulation (42 CFR 483.100 – 483.138) requires Pre-
Admission Screenings and Resident Review (PASRR) for all residents in
Medicaid certified nursing facilities.  (11)

There is no exception for a patient who has never had a mentally ill diagnosis or is private pay.  One size fits all.  (4)

On the other hand, “one size fits all” does not “fit all” in the area of litigation  and justice when abuse and neglect of the patient in the assisted living and nursing homes occurs.  (6)

One wonders how such a confusing system is created in the first place – one that mandates screenings, but does not mandate evidence based outcomes?  Perhaps it all started with the research originally conducted.  (5)

One study sought unhealthy geriatric patients who suffered from hallucinations, delusions, agitation, and/or aggression to participate in the research.  (2)  One must keep in mind that such individuals would not be admitted into a conventional assisted living facility or nursing home.  These facilities do not have the wherewithal to handle dyscontrol.  (10)

Yet, atypical anti psychotics used in such studies, once they go into production, are being prescribed to assisted living and nursing home patients, many to their detriment. (1)   (9)

The Omnibus Budget Reconciliation Act (OBRA) of 1987 limited the use of psychotropic medications in residents of long-term care facilities. Over the years though, updates of OBRA guidelines have liberalized some dosing restrictions.  (3)

In a system where certain practices are mandated and other practices are liberalized, it looks like the PASRR hasn’t been the panacea desired and now only the retainer of a nationally certified elder lawyer, a clear medical and advance directive,  blended with constant vigil of facility practices will safe guard an elder from widespread abuse from administration of psychiatric medications.    (8)

WARNING

Increased Mortality in Elderly Patients with Dementia-Related Psychosis— Elderly patients with dementia-related psychosis treated with antipsychotic drugs are at an increased risk of death. Analyses of seventeen placebo-controlled trials (modal duration of 10 weeks), largely in patients taking atypical antipsychotic drugs, revealed a risk of death in drug-treated patients of between 1.6 to 1.7 times the risk of death in placebo-treated patients. Over the course of a typical 10-week controlled trial, the rate of death in drug-treated patients was about 4.5%, compared to a rate of about 2.6% in the placebo group. Although the causes of death were varied, most of the deaths appeared to be either cardiovascular (e.g., heart failure, sudden death) or infectious (e.g., pneumonia) in nature. Observational studies suggest that, similar to atypical antipsychotic drugs, treatment with conventional antipsychotic drugs may increase mortality. The extent to which the findings of increased mortality in observational studies may be attributed to the antipsychotic drug as opposed to some characteristic(s) of the patients is not clear. Geodon (ziprasidone) is not approved.  http://www.accessdata.fda.gov/drugsatfda_docs/label/2009/020919s023lbl.pdf

(1)  Abuse of Risperdal, Seroquel, Other Antipsychotic Drugs in Nursing Homes Widespread
Dec 20, 2007 | Parker Waichman Alonso LLP
http://www.yourlawyer.com/articles/read/13548

(2)  Antipsychotic Medication Treatment of Psychosis and Behavioral Dyscontrol in Alzheimer’s Disease
Please refer to this study by identifier 4542
Principal Investigator(s) D.P. Devanand
http://sklad.cumc.columbia.edu/psychiatry/clinical_trials/View_Trial.php?ID=232&type=simple

(3)  Appropriate Use of Psychotropic Drugs in Nursing Homes
TATYANA GURVICH, PHARM.D., and
JANET A. CUNNINGHAM, M.D., M.P.H.
Glendale Adventist Medical Center, Glendale, California
http://www.aafp.org/afp/20000301/1437.html

(4)  Department of Elder Affairs
Comprehensive Assessment And Review For
Long-Term Care Services (CARES)
Instructions For Completing
Level I Preadmission Screening and Resident Review (PASRR)
Screen and Determination; and
Request for Level II PASRR Evaluation and Determination

Click to access Level1ScreenInstructions.pdf

(5)  Geriatrics and Gerontology/Stroud Center
Barry J. Gurland, FRC Physicians (London) FRC Psychiatry, Director
John A. Toner, PhD Senior Research Scientist VI,
Jeanne A. Teresi, EdD, PhD Senior Research Scientist VI

Click to access Geriatrics%20and%20Gerontology%20-%20Stroud%20Ctr.pdf

(6)  Nursing Home Litigation – Defense Perspective
PETER A. MONAHAN
Alholm, Monahan, Keefe & Klauke, L.L.C.
DAWN L. HAGHIGHI
http://www.illinois-law.com/docs/NursingHomeLit.htm

(7)  PASRR Frequently Asked Questions and Answers
For information concerning Pre-Admission Screening and Resident Review
(PASRR), please visit http://elderaffairs.state.fl.us/english/CARES/pasrr.html
(The Web site includes: list of PASRR acronyms, forms, and other training materials)
These Frequently Asked Questions were identified by the following inter-agency
partners participating in PASRR training:
Agency for Health Care Administration (AHCA) Florida Medicaid, and Division of
Health Quality Assurance (HQA)
Agency for Persons with Disabilities (APD)
Department of Health Children’s Multi-Disciplinary Assessment Team (CMAT)
Department of Elder Affairs Comprehensive Assessment and Review for Long
Term Care Services (CARES) Program
Department of Children and Families Substance Abuse and Mental Health (SAMH)
Program

Click to access faq.pdf

(8)  PENNSYLVANIA NURSING HOME INFORMATION & REGISTRY
http://www.memberofthefamily.net/registry/pa.htm

(9)  PRN
Gary Null, PhD
Radio Show Live
Iatrogenic Illness: 5 – Nursing Home Risks
http://www.gnhealth.com/articles/whichArticle.php?article=54

(10)  Psychiatr Serv 53:1407-1413, November 2002
© 2002 American Psychiatric Association
Mental Health Services in Nursing Homes: Psychopharmacologic Interventions in Nursing Homes: What Do We Know and Where Should We Go?
J. Michael Ryan, M.D., Samuel W. Kidder, Pharm.D., M.P.H., Lori A. Daiello, Pharm.D. and Pierre N. Tariot, M.D.
http://psychservices.psychiatryonline.org/cgi/content/full/53/11/1407

(11)  Tennessee Health Care Association
Consumer Information – What to Expect At Admission
http://www.thca.org/admission.htm

(12)  Utah Department of Human Services
Substance Abuse and Mental Health
PASRR
http://www.hsmh.utah.gov/pasrr.htm