September 2018

PENNSYLVANIA DEPARTMENT OF HUMAN SERVICES OFFICE OF LONG-TERM LIVING

Preadmission ScreeningResident Review Process for

Pennsylvania

September 2018 1

Objectives for this Webinar

Overview of the Federal (CMS) Requirements for PASRR and background

What does Preadmission screening mean PASRR Level I Assessment What does meeting Program Office Criteria mean Role of the Program Office Important Websites Who to call for questions PASRR Level II Evaluation (for Aging Well and

Nursing Facility (NF) Field Operations staff only)

September 2018 2

1

September 2018

Items included in the Handouts

Handouts can be found on the same website as the PASRR Training and include the following items: PowerPoint Presentation slides MA bulletin for PASRR Level I form MA bulletin for PASRR Level II form PASRR Level I form (MA 376) PASRR Level II form (MA 367.2)

September 2018 3

PASRR Background Is a requirement under Medicaid, pursuant to

OBRA 1987 (Omnibus Budget ReconciliationAct) and 42 CFR §483.100-483.138

Applies to all individuals seeking admission toa Medicaid certified nursing facility (NF) regardless of the individual’s insurance and ensures that individuals are placed in the leastrestrictive setting possible.

Is part of the licensure for a Medicaidparticipating NF

Provisions were addressed in PA Bulletin, Volume 18, Number 52 on December 24,1988.

September 2018 4

2

September 2018

PASRR Reguires

Requires that a NF does not admit any new resident with Mental Illness (MI), an IntellectualDisability/Developmental Disability (ID/DD) or Related Condition (ORC) unless the individual is determined through a PASRR evaluation to be appropriate for NF services (CFR §483.106(a))

Failure to timely complete (prior to admission)the PASRR process will result in forfeiture of Medicaid Reimbursement to the NF during the period of non-compliance in accordance with Federal PASRR Regulations (CFR §483.122(b))

September 2018 5

Prior to entering Nursing Facility

Prior to Admission to a NF, the following must be done: Preadmission Screening Resident Review

Identification - PASRR Level I Preadmission Screening Resident Review

Evaluation – PASRR Level II (if needed) Program Office Letter of Determination

received if PASRR Level II has been done

September 2018 6

3

September 2018

Preadmission Screening Resident Review Identification Form

(PASRR Level I Form) (MA 376)

September 2018 7

PASRR Level I: Section I – Demographics & Communication

September 2018 8

4

September 2018

PASRR Level I: Section II – Neurocognitive Disorder/Dementia

September 2018 9

PASRR Level I: Section III - Mental Health (MH)

September 2018 10

5

September 2018

PASRR Level I: Section III-B 1 Recent Treatments/History

September 2018 11

PASRR Level I: Section III-B 2 Significant Life Disruption

September 2018 12

6

September 2018

PASRR Level I: Section III-C Level of Impairment

September 2018 13

PASRR Level I: Mental Health Note

September 2018 14

7

September 2018

PASRR Level I: Section IV - Intellectual Disability/Developmental Disability

September 2018 15

PASRR Level I: Section IV-D, E, F

September 2018 16

8

September 2018

PASRR Level I: Intellectual/Developmental Disability Note

September 2018 17

PASRR Level I: Section V - Other Related Conditions

September 2018 18

9

September 2018

PASRR Level I: Other Related Condition Note

September 2018 19

PASRR Level I: Section VI - Home & Community Services

September 2018 20

10

September 2018

PASRR Level I: Section VII -Exceptional Admission

September 2018 21

PASRR Level I: VII-B, C, D Exceptional Admission cont.

September 2018 22

11

September 2018

PASRR Level I: VII - Change in Exceptional Status

September 2018 23

PASRR Level I: Section VIII – Screening Outcome

September 2018 24

12

September 2018

PASRR Level I: Section IX– Individual Completing Form

September 2018 25

Notification of need to have PASRR Level II

September 2018 26

13

September 2018

Meeting “Program Office (PO) criteria”?

When the PO Criteria is met on the PASRR Level I (meaning the greyed out Note section on the form applies to the individual for at least one of the POs):

A PASRR Level II Evaluation must be completed either by Aging Well or Nursing Facility Field Operations, and

A Program Letter of Determination must be received before you can admit an individual to a nursing facility

September 2018 27

When the PO Criteria is met after admission (meaning there has been a change in condition after admission to the NF):

A PASRR Level II Evaluation must be completed Nursing Facility Field Operations will do the PASRR

Level II Evaluation in the NF (MA 408 needs to be faxed to Field Operations), unless Aging Well will be doing an assessment for Medical Assistance (if this is the case, then Aging Well will do the PASRR Level II)

A Program Letter of Determination is sent to the NF

Change in Condition after Admission to the NF

September 2018 28

14

http://www.dhs.pa.gov/provider/longtermcarecasemixinformation/obr atrainingInformation/index.htm

http://www.dhs.pa.gov/provider/longtermcarecasemixinformatio n/obratrainingInformation/nfcareprocess/index.htm

http://www.dhs.pa.gov/provider/longtermcarecasemixinformation/ind

http://www.dhs.pa.gov/dhsassets/maforms/index.htm

September 2018

Role of the Program Office

15

The Department of Human Services Program Offices review the PASRR Evaluation and the additional information sent to them to determine if the individual: o Meets the criteria for the Program Office o Needs the level of services of a nursing facility o Needs Specialized Services

The Program Office Letter of Determination will indicate the above information.

September 2018 29

Pennsylvania PASRR Process Website:

Out of State Process for PASRR

Long Term Care Nursing Facility Providers website:

ex.htm

Important Websites

Order MA Forms:

September 2018 30

September 2018

Pennsylvania PASRR Process Website

• PASRR Forms

• Level I PASRR Identification Form (MA 376)

• Level II PASRR Evaluation Form (MA 376.2)

• Resources for PASRR:

• PASRR Clarifications, Questions and Answer Document

• PASRR Bulletins – MA376

– MA376.2

• Handouts for Webinar Training

• PASRR Level I Tool Form Training Webinar

• Other PASRR Resources

• Who to contact for help with the Pennsylvania PASRR process:

• Field Operations Offices

• Program Office Contacts

• State PASRR Coordinator at 717-214-3736 September 2018 31

Ruth Anne Barnard, B.S.N., R.N. PASRR/MDS/Nursing Facility Field Operations Coordinator ◦ rbarnard@pa.gov ◦ 717-214-3736

Randy Nolen Division Director for Nursing Facility Field Operations ◦ rnolen@pa.gov ◦ 717-772-2543

Program Offices – see list found on the PASRR Website (see previous slide)

Field Operations Supervisors – see list found on the PASRR Website (see previous slide)

Questions?

September 2018 32

16

September 2018

Preadmission ScreeningResident Review Evaluation Form

(PASRR Level II Form) (MA 376.2)

September 2018 33

PASRR Level II: Section I -Demographics

September 2018 34

17

September 2018

PASRR Level II: Section II – Medical Documentation

September 2018 35

II-A: Medical Diagnosis(es) and Onset

PASRR Level II: Section II – Medical Documentation

September 2018 36

II-B: Behaviors

18

September 2018

PASRR Level II: Section II – Medical Documentation

September 2018 37

II-C: Medications

PASRR Level II: Section II – Medical Documentation

September 2018 38

II-D: Neurological

19

September 2018

PASRR Level II: Section II – Medical Documentation

September 2018 39

II-E: Functional Status

PASRR Level II: Section II – Medical Documentation

September 2018 40

II-F: Supports/Socialization

20

September 2018

PASRR Level II: Section III – Review Type

September 2018 41

PASRR Level II: Section IV - Mental Health (MH)

September 2018 42

21

September 2018

PASRR Level II: Section IV-A Treatment History

September 2018 43

PASRR Level II: Section IV–B Supporting Info

September 2018 44

22

September 2018

September 2018 45

PASRR Level II: Section V: Intellectual Disability/Developmental Disability

PASRR Level II: Section V-B: Supporting Information

September 2018 46

23

September 2018

PASRR Level II: Section VI: Other Related Conditions

September 2018 47

PASRR Level II: Section VI-B: Supporting Information

September 2018 48

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September 2018

PASRR Level II: Section VII: Findings & Recommendation

September 2018 49

VII-A: Evaluator’s Recommendation

PASRR Level II: Section VII-B: Desire for Specialized Services

September 2018 50

25

September 2018 51

September 2018

PASRR Level II: Section VII-B: Desire for Specialized Services

a. Mental Health

PASRR Level II: Section VII-B: Desire for Specialized Services

September 2018 52

b. Intellectual Disability/Developmental Disability

26

September 2018

PASRR Level II: Section VII-B: Desire for Specialized Services

September 2018 53

c. Other Related Condition

PASRR Level II: Section VII-B: Desire for Specialized Services

September 2018 54

27

September 2018

PASRR Level II: Section VIII: Notice of Referral for Final Determination

September 2018 55

PASRR Level II: Section IX

September 2018 56

Name and Contact Information of Individual Completing this Form

28

September 2018 57

September 2018

PASRR Level II: Section X Documentation to include for Program Office Review

PASRR Level II: Section XI – Notification Sheet

58September 2018

29

September 2018

PASRR Level II: SLUMS Examination

59September 2018

DHS Program Offices – How do they receive the information

MH – Office of Mental Health And Substance Abuse Services o Information is sent directly to the office

ID/DD – Office of Developmental Programs o Information initially is sent to the County of origin o County concurs or not with Aging Well’s/NF Field

Operation’s recommendation for Long-Term Services and Supports (LTSS)

o Then information is sent to Regional Offices for Letter of Determination

ORC – Office Of Long-Term Living - Bureau of Participant Operations o Information is sent directly to the office

September 2018 60

30

OFFICE OF LONG-TERM

LIVING BULLETIN ISSUE DATE

August 1, 2018

EFFECTIVE DATE

September 1, 2018

NUMBER

01-18-03, 03-18-03, 07-18-03, 59-18-03

SUBJECT:

Revised Pennsylvania Preadmission Screening Resident Review (PASRR) Level I Identification Form (MA 376)

Kevin Hancock Deputy Secretary Office of Long-Term Living

PURPOSE:

The purpose of this bulletin is to issue a revised Pennsylvania Preadmission Screening Resident Review (PASRR) Level I identification form (PASRR Level I). The revised PASRR Level I form replaces the PA-PASRR-ID (Bulletin 01-15-04, 03-15-04, 07-15-04, 55-15-04) dated January 1, 2016.

SCOPE:

This bulletin applies to all entities that perform preadmission screenings for individuals prior to entering a nursing facility enrolled in the Medical Assistance (MA) Program.

BACKGROUND:

In 1987, Congress enacted major nursing home reform legislation that affected all nursing facilities participating in the Medicare and MA Program as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA ʹ87). OBRA ʹ87, among other things, required the implementation of a preadmission screening program, applicable to all persons seeking admission to an MA-certified nursing facility, regardless of payer source. The purpose of the preadmission screening is to determine whether an individual with a mental health condition, intellectual disability/developmental disability, or other related condition requires nursing facility services and, if the individual does, whether that individual meets certain program office criteria and requires specialized services for their condition. See 42 CFR §§ 483.100 -483.138. An MA- certified nursing facility may not admit any new resident with a mental health condition, intellectual disability/developmental disability, or other related condition unless the Department of Human Services (department) has determined and notified the nursing facility in a letter that the individual requires nursing facility services and, if the individual does, whether that individual meets program office criteria and requires specialized services for the mental health condition, intellectual disability/developmental disability, or other related condition. Modifications to the PASRR Level I form were made based on recommended changes from the Centers for Medicare & Medicaid Services (CMS) and the department’s program offices. There have been form changes which are summarized in this bulletin.

COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: Ruth Anne Barnard PA Dept. of Human Services

OLTL/Forum Place 6th Floor Bureau of Quality and Provider Management

P.O. Box 8025 Harrisburg, PA 17105-8025

(717) 772-2570

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Changes to the PASRR Level I form

Effective 09/01/2018

General Changes There were general changes made to the form. In some sections, minor wording changes were made or clarifying language was added to assist individuals in completing the form. Medical terms were aligned with terms used by the department’s Office of Mental Health and Substance Abuse Services (OMHSAS) in certain areas. In addition, in the gray text boxes at the end of Sections III, IV and V the specific program office and field office were added.

Page 3, Section III-C After the first paragraph, added a gray text box to read “A check in any box in Section III-C will require a PASRR Level II evaluation be completed.”

Page 3, Section III-C, gray text box after 3. Adaptation to change

Changed the gray text box to read “Note: A PASRR Level II evaluation must be completed by Aging Well or OLTL Field Operations (for a change in condition in a nursing facility) and forwarded to the OMHSAS program office for final determination if the individual has a “yes” in any of Section III-B and/or III-C as a result of a confirmed or suspected mental health condition”. This change removes the requirement for a Level II evaluation if the individual has a “yes” in Section III-A #1.

Page 4, Section IV Added clarifying language to include “developmental disability (DD)” in addition to intellectual disability language.

Page 4, Section IV-D Added clarifying language to read “Has the individual ever been registered with their county for ID/DD services and/or received services from an ID/DD provider agency within Pennsylvania or in another state.”

Page 4, Section IV, gray text box after IV-F Changed the gray text box to read “Note: A PASRR Level II evaluation must be completed by Aging Well or OLTL Field Operations (for a change in condition in a nursing facility) and forwarded to the ODP Program Office for final determination if: the individual has evidence of an ID or an ID/DD diagnosis and has a “yes” or “cannot determine” in IV-B and a “yes” in IV-C with at least one functional limitation, or the individual has a “yes” in IV-D, or E, or F.

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Page 5, Section V, gray text box after V-B, Capacity for independent living

Changed the gray text box to read “Note: A PASRR Level II evaluation must be completed by Aging Well or OLTL Field Operations (for a change in condition in a nursing facility) and forwarded to the ORC Program Office for final determination, if the individual has an ORC diagnosis prior to the age of 22 and at least one box checked in V-B.

Page 6, Section VII, gray text box Added clarifying language to read “Note: It is the responsibility of the NF to verify that all criteria of the exception are met prior to admission.”

Page 6, Sections VII-A, VII-B, VII-C, and VII-D

Added a check box before each section to check the type of exceptional admission that applies.

Page 6, Section VII-A, first bullet point At the end of the first bullet point, added a note to read “NOTE: Exceptional Hospital Discharge cannot be an admission from any of the following: emergency room, observational hospital stay, rehabilitation unit/hospital, Long-Term Acute Care Hospital (LTACH), inpatient psych, behavioral health unit, or hospice facility.”

Page 6, Section VII-A, third bullet point Added clarifying language to the bold text in parentheses to read “(which the NF must have prior to admission).”

Page 7, Section VIII, second check box Added two sentences at the end to read “You must notify the individual that further evaluation needs to be done. Have the individual or his/her legal representative sign that they have been notified of the need to have a PASRR Level II evaluation done. Indicate by your signature here that you have given the notification (last page of this form) to the individual or his/her legal representative.” Also, added signature requirements for the individual or legal representative who received the notification and for the individual who filled out the PASRR Level I and notification to individual/legal representative.

Page 8 Blank page added.

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Page 9, Notification of the Need for a PASRR Level II Evaluation

This is a new page which notifies individuals or legal representatives that a PASRR Level I form was completed and it indicates the individual needs to have a PASRR Level II evaluation completed. This page should only be given to an individual who meets criteria to have a PASRR Level II evaluation completed. Note: When this page is given to the individual, the person who completed the PASRR Level I and gave this page to the individual /legal representative must ensure the signature requirements are satisfied under Section VIII, second bullet point.

PROCEDURES:

Beginning September 1, 2018, the revised PASRR Level I form must be completed, prior to or no later than the day of admission, for individuals seeking admission to an MA-certified nursing facility, regardless of the individual’s payment source. If the applicant/resident is unable to answer the questions, another person who is knowledgeable about the applicant’s/resident’s medical condition and history (for example: family member, legal representative, or member of the health care team) may help to complete the form. Nursing facilities are responsible for assuring the accuracy of information reported on the PASRR Level I form. For a new resident entering the nursing facility, the nursing facility must make corrections to the PASRR Level I form on the resident’s chart when new or missed information becomes available (for example, information provided by the family or doctor). Do not complete a new PASRR Level I for residents readmitted from a short-term acute care hospital stay that were in the nursing facility prior to the hospital stay. For these individuals, just update the PASRR Level I that was used in the nursing facility prior to the hospital stay. If the individual has a change in condition that affects program office criteria as found on the PASRR Level I form, a PASRR Level II evaluation form will need to be completed. Nursing facilities will communicate the need to have a PASRR Level II form done by notifying the department’s Office of Long-Term Living, Division of Nursing Facility Field Operations Team via the MA 408 form. Nursing facilities are to advise applicants/residents regarding their rights to know how the PASRR process will be used, how to obtain a copy of this form, and the procedure to appeal the results of a decision by the departments program office.

If the applicant meets program office criteria and is not an Exceptional Admission, as defined on page 6 of the PASRR Level I form, the individual’s PASRR Level I form, along with other required documents, must be forwarded to Aging Well, who will complete a PASRR Level II evaluation and will also determine the level of care the individual needs prior to an individual’s admission to the nursing facility.

Failure to complete the PASRR Level I and, when applicable, the PASRR Level II prior to admission or on the day of admission will result in forfeiture of MA reimbursement to the nursing facility during the period of non-compliance in accordance with Federal PASRR Regulations at 42 CFR § 483.122.

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Instructions for completing the revised PASRR Level I are included in the form and the instructional webinar can be found at: http://www.dhs.pa.gov/provider/longtermcarecasemixinformation/obratraininginformation/index. htm.

The revised PASRR Level I form (MA 376 9/18) may be printed at the following website: http://www.dhs.pa.gov/dhsassets/maforms/index.htm.

The revised PASRR Level I form (MA 376 9/18) will be required for admissions on September 1, 2018 and thereafter. Previous versions of the PASRR Level I form are not acceptable for new admissions on September 1, 2018, and thereafter.

INTENTIALLY LEFT BLANK FOR TWO SIDED PRINTING.

ISSUE DATE

August 1, 2018

EFFECTIVE DATE

September 1, 2018

NUMBER

01-18-04, 03-18-04

Kevin Hancock Deputy Secretary, Office of Long-Term Living

SUBJECT:

Revised Pennsylvania Preadmission Screening Resident

Review (PASRR) Level II Evaluation Form (MA 376.2)

OFFICE OF LONG-TERM

LIVING BULLETIN

PURPOSE:

The purpose of this bulletin is to issue a revised Pennsylvania Preadmission Screening Resident Review (PASRR) Level II evaluation form. The revised PASRR Level II replaces the Pennsylvania PASRR evaluation (Bulletin 01-15-05, 03-15-05) dated January 1, 2016.

SCOPE:

This bulletin applies to all agencies that perform PASRR Level II evaluations for individuals either prior to or after the individual is a resident in a Medical Assistance (MA) enrolled nursing facility.

BACKGROUND:

In 1987, Congress enacted major nursing home reform legislation that affected all nursing facilities participating in the Medicare and MA Program as part of the Omnibus Budget Reconciliation Act of 1987 (OBRA ‘87). OBRA ‛87, among other things, required the implementation of a preadmission screening program, applicable to all persons seeking admission to an MA-certified nursing facility, regardless of payer source. The purpose of the preadmission screening is to determine whether an individual with a mental health condition, intellectual disability/developmental disability (ID/DD), or other related condition requires nursing facility services and, if the individual does, whether the individual meets certain program office criteria and requires specialized services for their condition. See 42 CFR §§ 483.100 - 483.138. An MA-certified nursing facility may not admit any new resident with a mental health condition, ID/DD, or other related condition unless the Department of Human Services (department) has determined and notified the nursing facility in a letter that the individual requires nursing facility services and, if the individual does, whether the individual meets program office criteria, and requires specialized services for a mental health condition, ID/DD, or other related condition.

The State must complete a PASRR Level II evaluation if the individual meets any of the program office criteria for a mental health condition, ID/DD, or other related condition on the PASRR Level I (MA 376) form. Modifications to the PASRR Level II form were made based on recommended changes from the Centers for Medicare & Medicaid Services (CMS) and the department’s program offices. There have been form changes which are summarized in this bulletin.

COMMENTS AND QUESTIONS REGARDING THIS BULLETIN SHOULD BE DIRECTED TO: Ruth Anne Barnard

PA Dept. of Human Services

OLTL/Forum Place 6th Floor

Bureau of Quality and Provider Management

P.O. Box 8025 Harrisburg, PA 17105-8025

(717) 772-2570

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Changes to the PASRR Level II form

Effective 09/01/2018

General Changes There were general changes made to the form. In some sections, minor wording changes were made or clarifying language was added to assist assessors in completing the form, some sections were moved and renumbered, and subsections that were deleted from a section were added to a different section. In addition, the SLUMS Examination is now on page 11 instead of page 10.

Page 1, First Paragraph under heading Changed first paragraph under heading to read: “When a Pennsylvania Preadmission Screening Resident Review (PASRR) Evaluation Level II form is completed, all supporting documents (see list in Section X) must be sent to the appropriate Department of Human Services (DHS) program office (Office of Mental Health and Substance Abuse Services, Office of Developmental Programs, or Office of Long-Term Living (ORC)).”

Page 1, Section II Replaced Section II with new Section II titled “Medical Documentation”. Under Section II, added the following subsections: II-A: Medical Diagnosis(es) and Onset; II-B: Behaviors; II-C: Medications; II-D: Neurological; II-E: Functional Status; II-F: Supports/Socialization.

Page 2, Section III Moved “Section-III Mental Illness (MI)” to Section IV and added new “Section-III Review Type”.

Page 4, Section IV Old Section III is new Section IV. Under new Section IV, changed “Section III-Mental Illness (MI)” to “Section IV-Mental Health (MH)”. Deleted the first question under subsection III-A, added clarifying language to the second question and labeled this subsection IV-A. Labeled subsection III-B to IV-B and under the second question added the check box option “Refused Test”. Deleted subsections III-C and III-D.

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Page 5, Section V Moved “Section IV: Intellectual Disability (ID)” to Section V. Under new Section V, changed “Section IV: Intellectual Disability (ID)” to “Section V: Intellectual Disability/Developmental Disability (ID/DD)”. Labeled subsection IV-A to V-A and added additional fields to list supports for an ID/DD diagnosis. Labeled IV-B to V-B and added clarifying language to the second question. Deleted subsections IV-C and IV-D.

Pages 5 and 6, Section VI Moved “Section V: Other Related Conditions (ORC)” to Section VI. Under new Section VI, labeled V-A to VI-A and added an additional field to the first question to list supports for an ORC diagnosis. Labeled V-B to VI-B and added clarifying language to the second question. Deleted subsections V-C and V-D.

Pages 6 - 8, Section VII Moved “Section VII: Notice of Referral for Final Determination” to Section VIII and added new Section VII titled “Findings & Recommendation”. Under Section VII, added the following subsections: VII-A: Evaluator’s Recommendation and VII-B: Desire for Specialized Services.

Page 8, Section VIII Replaced “Section VIII: Documentation to Include for Program Office Review” with new “Section VIII: Notice of Referral for Final Determination”. New Section VIII was old Section VII. Updated wording in paragraphs three through four. The fifth paragraph and signature text box for person who completed the form were deleted.

Page 9, Section IX Moved “Section IX: Notification” to Section XI. Added new Section IX: “Name and Contact Information of Individual Completing this Form”.

Page 9, Section X Added Section X: “Documentation to Include for Program Office Review”.

Page 10, Section XI Old “Section IX: Notification” is new Section XI. Under new Section XI, changed “Section IX: Notification” to “Section XI: Notification Sheet”. Under number “5. List Full Name of Discharging Hospital” added a field for ”Contact Email”.

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PROCEDURES:

Beginning September 1, 2018, the revised PASRR Level II form (MA 376.2) must be completed if the individual is identified as meeting program office criteria on the PASRR Level I form, has a change in condition, and is not an exceptional admission, as defined on page 6 of the PASRR Level I form. Aging Well or the department’s Office of Long-Term Living, Division of Nursing Facility Field Operations, (if the individual is already in a nursing facility and there has been a change in condition) is responsible for completing the PASRR Level II form, including gathering the accompanying documentation, and for forwarding the information to the Office of Mental Health Substance Abuse Services (OMHSAS), Office of Developmental Programs (ODP), or Office of Long-Term Living (OLTL) program office. The program office will review the information to determine if the individual meets Nursing Facility Clinical Eligibility, program office criteria, and the need for Specialized Services as defined on pages 7 and 8 of the PASRR Level II form. The program office will issue its decision to all appropriate parties through a Program Office Letter of Determination.

Failure to complete the PASRR Level I and, when applicable, the PASRR Level II prior to admission or on the day of admission will result in forfeiture of MA reimbursement to the nursing facility during the period of non-compliance in accordance with Federal PASRR Regulations at 42 CFR § 483.122.

The revised PASRR Level II (MA 376.2 7/18) form may be downloaded or printed at the following website: http://www.dhs.pa.gov/dhsassets/maforms/index.htm.

If an individual meets the program office criteria on the PASRR Level I form completed on September 1, 2018 and thereafter, the revised PASRR Level II (MA 376.2 9/18) must be completed. Previous versions of the PASRR Level II form are not acceptable beginning September 1, 2018.

PENNSYLVANIA PREADMISSION SCREENING RESIDENT REVIEW (PASRR) IDENTIFICATION LEVEL I FORM

(Revised 9/1/2018)

This process applies to all nursing facility (NF) applicants, regardless of payer source. All current NF residents must have the

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Level II evaluation form, if necessary, must be completed prior to admission as per Federal PASRR Regulations 42 CFR § 483.106.

NOTE: FAILURE TO TIMELY COMPLETE THE PASRR PROCESS WILL RESULT IN FORFEITURE OF MEDICAID REIMBURSEMENT TO THE NF DURING PERIOD OF NON-COMPLIANCE IN ACCORDANCE WITH FEDERAL PASRR REGULATIONS 42 CFR § 483.122.

Section I – DEMOGRAPHICS

DATE THE FORM IS COMPLETED: SOCIAL SECURITY NUMBER (all 9 digits): – –

APPLICANT/RESIDENT NAME - LAST, FIRST:

Communication

Does the applicant/resident require assistance with communication, such as an interpreter or other accommodation, to participate in or understand the PASRR process? NO YES

Section II – NEUROCOGNITIVE DISORDER (NCD)/DEMENTIA

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1. Does the individual have a diagnosis of a Mild or Major NCD?

NO – Skip to Section III YES

2. Has the psychiatrist/physician indicated the level of NCD?

NO YES – indicate the level: Mild Major

3. Is there corroborative testing or other information available to verify the presence or progression of the NCD?

NO YES – indicate what testing or other information:

NCD/Dementia Work up Comprehensive Mental Status Exam

Other (Specify):

NOTE: A DIAGNOSIS OF MILD NCD WILL NOT AUTOMATICALLY EXCLUDE AN INDIVIDUAL FROM A PASRR LEVEL II EVALUATION.

Page 1 of 9 MA 376 9/18

Name SS# (last 4 digits):

Section III – MENTAL HEALTH (MH)

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Personality Disorder, Panic or Other Severe Anxiety Disorder, Somatic Symptom Disorder, Bipolar Disorder, Depressive Disorder,

or another mental disorder that may lead to chronic disability.

III-A – RELATED QUESTIONS

1. Diagnosis

Does the individual have a mental health condition or suspected mental health condition, other than Dementia, that may lead to a chronic disability?

NO YES

List Mental Health Diagnosis(es):

2. Substance related disorder

a. Does the individual have a diagnosis of a substance related disorder, documented by a physician, within the last two years?

NO YES

b. List the substance(s):

c. Is the need for NF placement associated with this diagnosis?

NO YES UNKNOWN

III-B – RECENT TREATMENTS/HISTORY: The treatment history for the mental disorder indicates that the individual has experienced at least one of the following:

A “YES” TO ANY QUESTION IN SECTION III-B WILL REQUIRE A PASRR LEVEL II EVALUATION BE COMPLETED.

1. Mental Health Services (check all that apply):

a. Treatment in an acute psychiatric hospital at least once in the past 2 years:

NO

YES – Indicate name of hospital and date(s):

b. Treatment in a partial psychiatric program (Day Treatment Program) at least once in the past 2 years:

NO

YES – Indicate name of program and date(s):

c. Any admission to a state hospital:

NO

YES – Indicate name of hospital and date(s):

d. One stay in a Long-Term Structured Residence (LTSR) in the past 2 years:

A LTSR is a highly structured therapeutic residential mental health treatment facility designed to serve persons ���\HDUV�RI�DJH�RU�ROGHU�ZKR�DUH�HOLJLEOH�IRU�KRVSLWDOL]DWLRQ�EXW�ZKR�FDQ�UHFHLYH�DGHTXDWH�FDUH�LQ�DQ�/765��$GPLVVLRQ� may occur voluntarily.

NO

YES – Indicate name of LTSR and date(s):

e. Electroconvulsive Therapy (ECT) for the Mental Health Condition within the past 2 years:

NO YES – Date(s):

Page 2 of 9 MA 376 9/18

Name SS# (last 4 digits):

f. Does the individual have a Mental Health Case Manager (Intensive Case Manager (ICM), Blended or Targeted Case Manager, Resource Coordinator (RC), Community Treatment Team (CTT) or Assertive Community Treatment (ACT))?

NO YES

Indicate Name, Agency, and Telephone Number of Mental Health Case Manager:

��� 6LJQL¿FDQW�/LIH�GLVUXSWLRQ�GXH�WR�D�0HQWDO�+HDOWK�&RQGLWLRQ

([SHULHQFHG�DQ�HSLVRGH�RI�VLJQL¿FDQW�GLVUXSWLRQ��PD\�RU�PD\�QRW�KDYH�UHVXOWHG�LQ�D�����FRPPLWPHQW��GXH�WR�D�0HQWDO�+HDOWK� Condition within the past 2 years:

a. Suicide attempt or ideation with a plan:

NO YES – List Date(s) and Explain:

b. Legal/law intervention: NO YES – Explain:

c. Loss of housing/Life change(s): NO YES – Explain:

d. Other: NO YES – Explain:

III-C – LEVEL OF IMPAIRMENT: The mental disorder has resulted in functional limitations in major life activities that are

not appropriate for the individual’s developmental stage. An individual typically has at least one of the following

characteristics on a continuing or intermittent basis.

A CHECK IN ANY BOX IN SECTION III-C WILL REQUIRE A PASRR LEVEL II EVALUATION BE COMPLETED.

. ��� ,QWHUSHUVRQDO�IXQFWLRQLQJ���7KH�LQGLYLGXDO�KDV�VHULRXV�GLႈFXOW\�LQWHUDFWLQJ�DSSURSULDWHO\�DQG�FRPPXQLFDWLQJ�

HႇHFWLYHO\�ZLWK�RWKHU�LQGLYLGXDOV��KDV�D�SRVVLEOH�KLVWRU\�RI�DOWHUFDWLRQV��HYLFWLRQV��¿ULQJ��IHDU�RI�VWUDQJHUV��

avoidance of interpersonal relationships and social isolation.

. 2. Concentration, persistence and pace -�7KH�LQGLYLGXDO�KDV�VHULRXV�GLႈFXOW\�LQ�VXVWDLQLQJ�IRFXVHG�DWWHQWLRQ�IRU�D�

long enough period to permit the completion of tasks commonly found in work settings, or in work-like structured

DFWLYLWLHV�RFFXUULQJ�LQ�VFKRRO�RU�KRPH�VHWWLQJV��PDQLIHVWV�GLႈFXOWLHV�LQ�FRQFHQWUDWLRQ��LV�XQDEOH�WR�FRPSOHWH�VLPSOH�

tasks within an established time period, makes frequent errors, or requires assistance in the completion of these

tasks.

. 3. Adaptation to change - 7KH�LQGLYLGXDO�KDV�VHULRXV�GLႈFXOW\�DGDSWLQJ�WR�W\SLFDO�FKDQJHV�LQ�FLUFXPVWDQFHV�

associated with work, school, family, or social interaction; manifests agitation, exacerbated signs and

symptoms associated with the illness; or withdrawal from the situation; or requires intervention by the mental

health or Judicial system.

NOTE: A PASRR LEVEL II EVALUATION MUST BE COMPLETED BY AGING WELL OR OLTL FIELD OPERATIONS (FOR A CHANGE IN CONDITION IN A NURSING FACILITY) AND FORWARDED TO THE OMHSAS PROGRAM OFFICE FOR FINAL DETERMINATION IF THE INDIVIDUAL HAS A “YES” IN ANY OF SECTION III-B AND/OR III-C AS A RESULT OF A CONFIRMED OR SUSPECTED MENTAL HEALTH CONDITION.

Page 3 of 9 MA 376 9/18

Name SS# (last 4 digits):

Section IV– INTELLECTUAL DISABILITY/DEVELOPMENTAL DISABILITY (ID/DD)

An individual is considered to have evidence of an intellectual disability/developmental disability if they have a diagnosis of ID/DD and/or have received services from an ID/DD agency in the past.

IV-A – Does the individual have current evidence of an ID/DD or ID/DD diagnosis (mild, moderate, severe or profound)?

NO – Skip to IV-C YES – List diagnosis(es) or evidence:

IV-B – Did this condition occur prior to age 18? NO YES CANNOT DETERMINE

IV-C – Is there a history of a severe, chronic disability that is attributable to a condition other than a mental health condition that could result in impairment of functioning in general intellectual and adaptive behavior?

NO – Skip to Section IV-D YES – Check below, all that applied prior to age 18:

6HOI�FDUH���$�ORQJ�WHUP�FRQGLWLRQ�ZKLFK�UHTXLUHV�WKH�LQGLYLGXDO�WR�QHHG�VLJQL¿FDQW�DVVLVWDQFH�ZLWK�SHUVRQDO�QHHGV�

VXFK�DV�HDWLQJ��K\JLHQH��DQG�DSSHDUDQFH��6LJQL¿FDQW�DVVLVWDQFH�PD\�EH�GH¿QHG�DV�DVVLVWDQFH�DW�OHDVW�RQH�KDOI�RI�DOO�

activities normally required for self-care.

Receptive and expressive language:��$Q�LQGLYLGXDO�LV�XQDEOH�WR�HႇHFWLYHO\�FRPPXQLFDWH�ZLWK�DQRWKHU�SHUVRQ�ZLWK�

out the aid of a third person, a person with special skill or with a mechanical device, or a condition which prevents

articulation of thoughts.

Learning: An individual that has a condition which seriously interferes with cognition, visual or aural communication,

or use of hands to the extent that special intervention or special programs are required to aid in learning.

Mobility:��$Q�LQGLYLGXDO�WKDW�LV�LPSDLUHG�LQ�KLV�KHU�XVH�RI�¿QH�DQG�RU�JURVV�PRWRU�VNLOOV�WR�WKH�H[WHQW�WKDW�DVVLVWDQFH�RI�

another person and/or a mechanical device is needed in order for the individual to move from place to place.

6HOI�GLUHFWLRQ� An individual that requires assistance in being able to make independent decisions concerning social

DQG�LQGLYLGXDO�DFWLYLWLHV�DQG�RU�LQ�KDQGOLQJ�SHUVRQDO�¿QDQFHV�DQG�RU�SURWHFWLQJ�RZQ�VHOI�LQWHUHVW��

&DSDFLW\�IRU�LQGHSHQGHQW�OLYLQJ� An individual that is limited in performing normal societal roles or is unsafe for the

individual to live alone to such as extent that assistance, supervision or presence of a second person is required more

than half the time (during waking hours).

IV-D – Has the individual ever been registered with their county for ID/DD services and/or received services from an ID/DD provider agency within Pennsylvania or in another state? NO YES UNKNOWN

,I�\HV��LQGLFDWH�FRXQW\�QDPH�DJHQF\�DQG�VWDWH�LI�GLႇHUHQW�WKDQ�3HQQV\OYDQLD�

Name of Support Coordinator (if known)

IV-E – Was the individual referred for placement by an agency that serves individuals with ID/DD? NO YES

IV-F – Has the individual ever been a resident of a state facility including a state hospital, state operated ID center, or a state school?

NO

YES – Indicate the name of the facility and the date(s):

UNKNOWN

NOTE: A PASRR LEVEL II EVALUATION MUST BE COMPLETED BY AGING WELL OR OLTL FIELD OPERATIONS (FORA CHANGE IN CONDITION IN A NURSING FACILITY) AND FORWARDED TO THE ODP PROGRAM OFFICE FORFINAL DETERMINATION IF:• THE INDIVIDUAL HAS EVIDENCE OF AN ID OR AN ID/DD DIAGNOSIS AND HAS A “YES” OR “CANNOT DETERMINE” IN IV-B AND A “YES” IN IV-C WITH AT LEAST ONE FUNCTIONAL LIMITATION, OR

• THE INDIVIDUAL HAS A “YES” IN IV-D, OR E, OR F.

Page 4 of 9 MA 376 9/18

Name SS# (last 4 digits):

Section V– OTHER RELATED CONDITIONS (ORC)

“ORC” include physical, sensory or neurological disability(ies). Examples of an ORC may include but are not limited to: Arthritis,

Juvenile Rheumatoid Arthritis, Cerebral Palsy, Autism, Epilepsy, Seizure Disorder, Tourette’s Syndrome, Meningitis, Encephalitis,

+\GURFHSKDOXV��+XQWLQJGRQ¶V�&KRUHD��0XOWLSOH�6FOHURVLV��0XVFXODU�'\VWURSK\��3ROLR��6SLQD�%L¿GD��$QR[LF�%UDLQ�'DPDJH��%OLQGQHVV�

and Deafness, Paraplegia or Quadriplegia, head injuries (e.g. gunshot wound) or other injuries (e.g. spinal injury), so long as the

injuries were sustained SULRU�WR�DJH�RI����

V-A – Does the individual have an ORC diagnosis that manifested prior to age 22�DQG�LV�H[SHFWHG�WR�FRQWLQXH�LQGH¿QLWHO\"��

NO – Skip to Section VI

YES – Specify the ORC Diagnosis(es):

V-B – Check all areas of substantial functional limitation which were present SULRU�WR�DJH�RI��� and were directly the result of the ORC:

6HOI�FDUH���$�ORQJ�WHUP�FRQGLWLRQ�ZKLFK�UHTXLUHV�WKH�LQGLYLGXDO�WR�QHHG�VLJQL¿FDQW�DVVLVWDQFH�ZLWK�SHUVRQDO�QHHGV�

VXFK�DV�HDWLQJ��K\JLHQH��DQG�DSSHDUDQFH��6LJQL¿FDQW�DVVLVWDQFH�PD\�EH�GH¿QHG�DV�DVVLVWDQFH�DW�OHDVW�RQH�KDOI�RI�DOO�

activities normally required for self-care.

Receptive and expressive language: $Q�LQGLYLGXDO�LV�XQDEOH�WR�HႇHFWLYHO\�FRPPXQLFDWH�ZLWK�DQRWKHU�SHUVRQ�

without the aid of a third person, a person with special skill or with a mechanical device, or a condition which prevents

articulation of thoughts.

Learning: An individual that has a condition which seriously interferes with cognition, visual or aural communication,

or use of hands to the extent that special intervention or special programs are required to aid in learning.

Mobility: $Q�LQGLYLGXDO�WKDW�LV�LPSDLUHG�LQ�KLV�KHU�XVH�RI�¿QH�DQG�RU�JURVV�PRWRU�VNLOOV�WR�WKH�H[WHQW�WKDW�DVVLVWDQFH�RI�

another person and/or a mechanical device is needed in order for the individual to move from place to place.

6HOI�GLUHFWLRQ� An individual that requires assistance in being able to make independent decisions concerning social

DQG�LQGLYLGXDO�DFWLYLWLHV�DQG�RU�LQ�KDQGOLQJ�SHUVRQDO�¿QDQFHV�DQG�RU�SURWHFWLQJ�RZQ�VHOI�LQWHUHVW��

&DSDFLW\�IRU�LQGHSHQGHQW�OLYLQJ� An individual that is limited in performing normal societal roles or is unsafe for the

individual to live alone to such as extent that assistance, supervision or presence of a second person is required more

than half the time (during waking hours).

NOTE: A PASRR LEVEL II EVALUATION MUST BE COMPLETED BY AGING WELL OR OLTL FIELD OPERATIONS (FOR A CHANGE IN CONDITION IN A NURSING FACILITY) AND FORWARDED TO THE ORC PROGRAM OFFICE FOR FINAL DETERMINATION, IF THE INDIVIDUAL HAS AN ORC DIAGNOSIS PRIOR TO THE AGE OF 22 AND AT LEAST ONE BOX CHECKED IN V-B.

Section VI – HOME AND COMMUNITY SERVICES

Was the individual/family informed about Home and Community Based Services that are available?

NO YES

Is the individual/family interested in the individual going back home, back to the prior living arrangement, or exploring other community living options?

NO YES

Page 5 of 9 MA 376 9/18

Name SS# (last 4 digits):

Section VII – EXCEPTIONAL ADMISSION

'RHV�WKH�LQGLYLGXDO�PHHW�WKH�FULWHULD�WR�KDYH�D�3$655�/HYHO�,,�(YDOXDWLRQ�GRQH�E\�RQH�RI�WKH�3URJUDP�2ႈFHV��LV�QRW�D�GDQJHU�WR� self and/or others, and meets the criteria for Exceptional Admission to a NF?

NO – Skip to Section VIII YES

NOTE: IT IS THE RESPONSIBILITY OF THE NF TO VERIFY THAT ALL CRITERIA OF THE EXCEPTION ARE MET PRIOR TO ADMISSION.

Check the Exceptional Admission that applies:

VII-A – Individual Is an Exceptional Hospital Discharge - Must meet all the following prior to NF Admission and have a known

MI, ID/DD, or ORC:

• Admission to NF directly from the Acute Care Hospital after receiving inpatient medical care, AND

NOTE: Exceptional Hospital Discharge cannot be an admission from any of the following: emergency room, observational hospital stay, rehabilitation

unit/hospital, Long-Term Acute Care Hospital (LTACH), inpatient psych, behavioral health unit, or hospice facility.

•Requires NF services for the same medical condition for which he/she received care in the Acute Care Hospital,

(Specify the condition: ), AND

• The hospital physician shall document on the medical record (which the NF must have prior to admission) that the

LQGLYLGXDO�ZLOO�UHTXLUH�OHVV�WKDQ����FDOHQGDU�GD\V�RI�1)�VHUYLFH�DQG�WKH�LQGLYLGXDO¶V�V\PSWRPV�RU�EHKDYLRUV�

are stable.

NO YES – Physician’s name:

VII-B – Individual Requires Respite Care - An individual with a serious MI, ID/DD, or ORC, may be admitted for Respite Care

IRU�D�SHULRG�XS�WR����GD\V�ZLWKRXW�IXUWKHU�HYDOXDWLRQ�LI�KH�VKH�LV�FHUWL¿HG�E\�D�UHIHUULQJ�RU�LQGLYLGXDO¶V�DWWHQGLQJ�SK\VLFLDQ�

to require 24-hour nursing facility services and supervision.

NO YES

VII-C – Individual Requires Emergency Placement - An individual with a serious MI, ID/DD, or ORC, may be admitted for

emergency placement for a period of up to 30-days without further evaluation if the Protective Services Agency and their

SK\VLFLDQ�KDV�FHUWL¿HG�WKDW�VXFK�SODFHPHQW�LV�QHHGHG�

NO YES

VII-D – Individual is in a FRPD�RU�IXQFWLRQV�DW�EUDLQ�VWHP�OHYHO - An individual with a serious MI, ID/DD, ORC may be

DGPLWWHG�ZLWKRXW�IXUWKHU�HYDOXDWLRQ�LI�FHUWL¿HG�E\�WKH�UHIHUULQJ�RU�DWWHQGLQJ�SK\VLFLDQ�WR�EH�LQ�D�FRPD�RU�ZKR�IXQFWLRQV�DW�

brain stem level. The condition must require intense 24-hour nursing facility services and supervision and is so extreme

WKDW�WKH�LQGLYLGXDO�FDQQRW�IRFXV�XSRQ��SDUWLFLSDWH�LQ��RU�EHQH¿W�IURP�VSHFLDOL]HG�VHUYLFHV�

NO YES

FOR A CHANGE IN EXCEPTIONAL STATUS:

,)�7+(�,1',9,'8$/¶6�&21',7,21�&+$1*(6�25�+(�6+(�:,//�%(�,1�5(6,'(1&(�)25�025(�7+$1�7+(�$//277('�'$<6�

�� 7KH�GHSDUWPHQW�PXVW�EH�QRWL¿HG�RQ�WKH�0$�����within 48 hours that a PASRR Level II Evaluation needs to be completed.

• The PASRR Level II Evaluation must be done on or before the 40th day from date of admission.

• Do not complete a new PASRR Level I form; just update the current form with the changes and initial the changes. Enter your full signature and date below to indicate you made the changes to this form.

SIGNATURE: DATE:

Page 6 of 9 MA 376 9/18

Name SS# (last 4 digits):

SECTION VIII – PASRR LEVEL I SCREENING OUTCOME

Check appropriate outcome:

Individual has negative screen�IRU�6HULRXV�0HQWDO�,OOQHVV��,QWHOOHFWXDO�'LVDELOLW\�'HYHORSPHQWDO�'LVDELOLW\��RU�

2WKHU�5HODWHG�&RQGLWLRQ��QR�IXUWKHU�HYDOXDWLRQ��/HYHO�,,��LV�QHFHVVDU\�

Individual has a positive screen�IRU�6HULRXV�0HQWDO�,OOQHVV��,QWHOOHFWXDO�'LVDELOLW\�'HYHORSPHQWDO�'LVDELOLW\��

DQG�RU�2WKHU�5HODWHG�&RQGLWLRQ��KH�VKH�UHTXLUHV�D�IXUWKHU�3$655�/HYHO�,,�HYDOXDWLRQ��<RX�PXVW�QRWLI\�WKH�

LQGLYLGXDO�WKDW�D�IXUWKHU�HYDOXDWLRQ�QHHGV�WR�EH�GRQH��+DYH�WKH�LQGLYLGXDO�RU�KLV�KHU�OHJDO�UHSUHVHQWDWLYH�VLJQ�

WKDW�WKH\�KDYH�EHHQ�QRWL¿HG�RI�WKH�QHHG�WR�KDYH�D�3$655�/HYHO�,,�HYDOXDWLRQ�GRQH��,QGLFDWH�E\�\RXU�VLJQDWXUH�

KHUH�WKDW�\RX�KDYH�JLYHQ�WKH�QRWL¿FDWLRQ��ODVW�SDJH�RI�WKLV�IRUP��WR�WKH�LQGLYLGXDO�RU�KLV�KHU�OHJDO�UHSUHVHQWDWLYH�

� 1DPH�RI�,QGLYLGXDO�RU�OHJDO�UHSUHVHQWDWLYH�WKDW�KDV�UHFHLYHG�WKH�QRWL¿FDWLRQ��SDJH����

NAME: SIGNATURE: (print) (sign)

1DPH�RI�LQGLYLGXDO�ZKR�¿OOHG�RXW�WKH�3$655�/HYHO�,�DQG�JDYH�WKH�QRWL¿FDWLRQ�WR�WKH�LQGLYLGXDO�OHJDO�

representative:

NAME: SIGNATURE: (print) (sign)

Individual has positive screen�IRU�D�IXUWKHU�3$655�/HYHO�,,�HYDOXDWLRQ�but has a condition which meets the

FULWHULD�IRU�DQ�([FHSWLRQDO�$GPLVVLRQ indicated in Section VII. NF must report Exceptional Admissions on the

Target Resident Reporting Form (MA 408).

SECTION IX – INDIVIDUAL COMPLETING FORM

By entering my name below, I certify the information provided is accurate to the best of my knowledge and understand that knowingly submitting inaccurate, incomplete, or misleading information constitutes Medicaid fraud.

PRINT NAME: SIGNATURE: DATE:

FACILITY: TELEPHONE NUMBER:

$ႈ[�1XUVLQJ�)DFLOLW\�)LHOG�2SHUDWLRQV�VWDPS�KHUH�

Page 7 of 9 MA 376 9/18

INTENTIALLY LEFT BLANK FOR TWO SIDED PRINTING.

NOTIFICATION OF THE NEED FOR A PASRR LEVEL II EVALUATION

All persons considering admission to a nursing facility for care must be screened with the Preadmission

Screening Resident Review (PASRR) Level I to identify for any evidence of mental illness (MI),

intellectual disability/developmental disability (ID/DD), or an other related condition (ORC). If you

do have evidence or suspicion of MI, ID/DD, or ORC, you need to have a further PASRR Level II

evaluation completed before you can be admitted to a nursing facility for care.

You have had the PASRR Level I screening process done and you are in need of a further PASRR

Level II evaluation to make certain that a nursing facility is the most appropriate setting/placement

for you and to identify the need for possible MI, ID/DD, or ORC services in the nursing facility’s plan

of care for you, if you choose to be admitted to a nursing facility.

You will have this evaluation done within the next several days to determine your needs.

The federal regulation for the above is the following:

��������� 3$655� HYDOXDWLRQ� FULWHULD� �D�� /HYHO� ,�� ,GHQWL¿FDWLRQ� RI� LQGLYLGXDOV� ZLWK� 0,� RU� ,'�� 7KH� VWDWH¶V� 3$655� SURJUDP� PXVW� LGHQWLI\� DOO� LQGLYLGXDOV�ZKR�DUH�VXVSHFWHG�RI�KDYLQJ�0,�RU�,'�DV�GH¿QHG�LQ�����������7KLV�LGHQWL¿FDWLRQ�IXQFWLRQ�LV�WHUPHG�/HYHO�,��/HYHO�,,�LV�WKH�IXQFWLRQ� RI�HYDOXDWLQJ�DQG�GHWHUPLQLQJ�ZKHWKHU�1)�VHUYLFHV�DQG�VSHFLDOL]HG�VHUYLFHV�DUH�QHHGHG��7KH�VWDWH¶V�SHUIRUPDQFH�RI�WKH�/HYHO�,�LGHQWL¿FDWLRQ� IXQFWLRQ�PXVW�SURYLGH�DW�OHDVW��LQ�WKH�FDVH�RI�¿UVW�WLPH�LGHQWL¿FDWLRQV��IRU�WKH�LVVXDQFH�RI�ZULWWHQ�QRWLFH�WR�WKH�LQGLYLGXDO�RU�UHVLGHQW�DQG�KLV�RU�KHU� legal representative that the individual or resident is suspected of having MI or ID and is being referred to the state mental health or intellectual disability authority for Level II screening.

Page 9 of 9 MA 376 9/18

INTENTIALLY LEFT BLANK FOR TWO SIDED PRINTING.

PENNSYLVANIA PREADMISSION SCREENING RESIDENT REVIEW (PASRR) EVALUATION LEVEL II FORM (Revised 9/1/2018)

When a Pennsylvania Preadmission Screening Resident Review (PASRR) Evaluation Level II form is completed, all supporting documents (see list in Section

;��PXVW�EH�VHQW�WR�WKH�DSSURSULDWH�'HSDUWPHQW�RI�+XPDQ�6HUYLFHV��'+6��SURJUDP�RI¿FH��2I¿FH�RI�0HQWDO�+HDOWK�DQG�6XEVWDQFH�$EXVH�6HUYLFHV��2I¿FH�RI� 'HYHORSPHQWDO�3URJUDPV��RU�2I¿FH�RI�/RQJ�7HUP�/LYLQJ��25&���

DATE OF ASSESSMENT:

SECTION I - DEMOGRAPHICS

$33/,&$17�5(6,'(17¶6�1$0(� 62&,$/�6(&85,7<�180%(5� $*(� %,57+�'$7(� &2817<�2)�25,*,1�

0$�180%(5� ,V�WKH�DSSOLFDQW�UHVLGHQW�HQUROOHG�LQ�RU�DSSO\LQJ�IRU�0HGLFDO�$VVLVWDQFH��0$�"

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SECTION II - MEDICAL DOCUMENTATION

II-A: MEDICAL DIAGNOSIS(ES) AND ONSET

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DIAGNOSIS DATE OF ONSET DIAGNOSIS DATE OF ONSET

II-B: BEHAVIORS

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� $VVDXOWLYH�DQG�RU�VHOI�DEXVLYH�� �12��� �<(6� 'HSUHVVLRQ�� �12��� �<(6

� $JJUHVVLYH�� �12��� �<(6� $Q[LHW\�� �12��� �<(6

� 'LVUXSWLYH�� �12��� �<(6� )HHOLQJV�RI�ORQHOLQHVV�� �12��� �<(6

� ,QDSSURSULDWHQHVV�� �12��� �<(6� )HHOLQJV�RI�ZRUWKOHVVQHVV�� �12��� �<(6

([SODQDWLRQ�RI�DQ\�RI�WKH�V\PSWRPV�RU�EHKDYLRUV�DERYH�

II-C: MEDICATIONS

��� /LVW�DOO�FXUUHQW�PHGLFDWLRQV�DQG�WKH�GLDJQRVLV�HV��IRU�WDNLQJ�WKH�PHGLFDWLRQ��DWWDFK�DGGLWLRQDO�SDJH�V��DV�QHFHVVDU\�� MEDICATION DIAGNOSIS DOSE FREQUENCY SIDE EFFECTS

MA 376.2 9/18Page 1 of 11

NAME SSN (LAST 4 DIGITS)

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II-D: NEUROLOGICAL

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�5LJKW�VLGHG�SDUDO\VLV�

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�8QVWHDG\�JDLW�

�6KXIÀLQJ�JDLW�

�([FHVVLYHO\�VORZ�PRYHPHQWV�

�8VH�RI�DVVLVWLYH�GHYLFH�V����/LVW�W\SH�V���

�:HDNQHVV�LQ�DUPV

�:HDNQHVV�LQ�OHJV

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�:HDNQHVV�LQ�IHHW

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�8QFRQWUROOHG�PRYHPHQWV

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II-E: FUNCTIONAL STATUS

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II-F: SUPPORTS/SOCIALIZATION

��� ,QGLYLGXDO�DSSURSULDWHO\�UHVSRQGV�WR�RWKHUV¶�LQLWLDWLRQV"� �12��� �<(6�

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Page 2 of 11 MA 376.2 9/18

NAME SSN (LAST 4 DIGITS)

��� /LVW�DFWLYLWLHV�WKDW�GHPRQVWUDWH�WKH�LQGLYLGXDO�VRFLDOL]HV�ZLWK�RWKHUV�

SECTION III - REVIEW TYPE

6HOHFW�W\SH�V��RI�3URJUDP�2I¿FH�UHYLHZ�

�0HQWDO�+HDOWK��0+����6HFWLRQ�,9

�,QWHOOHFWXDO�'LVDELOLWLHV�'HYHORSPHQWDO�'LVDELOLWLHV��,'�''����6HFWLRQ�9

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Complete each section(s) for the review type(s) checked above. Once the appropriate section(s) noted

above have been completed, complete the remaining Sections VII through XI.

MA 376.2 9/18Page 3 of 11

NAME SSN (LAST 4 DIGITS)

SECTION IV - MENTAL HEALTH (MH)

IV-A: DOCUMENTATION OF THE DIAGNOSIS

��� )RU�PASRR�SXUSRVHV��6HULRXV�0HQWDO�,OOQHVV�LQFOXGHV�WKH�IROORZLQJ��3URYLGH�D�UHVSRQVH�IRU�HDFK�GLDJQRVLV�OLVWHG��:KHQ�FKHFNLQJ�³<(6´�IRU�D�FXUUHQW� GLDJQRVLV��HQWHU�WKH�\HDU�RI�RQVHW�DQG�DWWDFK�GRFXPHQWDWLRQ��([DPSOHV�RI�DFFHSWDEOH�GRFXPHQWDWLRQ�LQFOXGH�D�FXUUHQW�SV\FKLDWULF�DVVHVVPHQW�ZLWK� GLDJQRVLV�RU�RWKHU�SURIHVVLRQDOO\�DFFHSWHG�GLDJQRVWLF�SUDFWLFHV�E\�D�TXDOL¿HG�SK\VLFLDQ�RU�SV\FKLDWULVW���VHH�&)5������������

DIAGNOSIS

6FKL]RSKUHQLD 6FKL]RDIIHFWLYH�GLVRUGHU Delusional disorder

%LSRODU�GLVRUGHU Psychotic disorder

CURRENT? ONSET YEAR DIAGNOSIS

3DQLF�RU�RWKHU�VHYHUH�DQ[LHW\�GLVRUGHU�12��� �<(6 Somatic Symptom disorder�12��� �<(6 Personality disorder�12��� �<(6 Depressive disorder�12��� �<(6 2WKHU�12��� �<(6

CURRENT?

�12��� �<(6 �12��� �<(6 �12��� �<(6 �12��� �<(6 �12��� �<(6

ONSET YEAR

��� 'RHV�D�UHYLHZ�RI�WKH�DSSOLFDQW�UHVLGHQW¶V�FDVH�KLVWRU\�DQG�RU�PHGLFDO�UHFRUG�VXEVWDQWLDWH�WKDW�WKH�PHQWDO�GLVRUGHU�LV�UHVSRQVLEOH�IRU�WKH�IXQFWLRQDO� limitations in the last 3-6 months�LQ�WKH�IROORZLQJ�DUHDV"��6HH�3$655�/HYHO�,�IRU�GH¿QLWLRQV��

Interpersonal functioning �12��� �<(6

&RQFHQWUDWLRQ��SHUVLVWHQFH��DQG�SDFH �12��� �<(6

Adaptation to change �12��� �<(6

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D�� 3V\FKLDWULF�WUHDWPHQW�PRUH�LQWHQVLYH�WKDQ�RXWSDWLHQW�FDUH�� �12� �<(6

� ,I�\HV��GHVFULEH��

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IV-B: SUPPORTING INFORMATION

��� 7KH�DVVHVVRU�VXEPLWV�WKH�LWHPV�EHORZ�WR�WKH�2I¿FH�RI�0HQWDO�+HDOWK�DQG�6XEVWDQFH�$EXVH�6HUYLFHV�IRU�DQ�HYDOXDWLRQ�RI�WKH�LQGLYLGXDO¶V�IXQFWLRQDO�OHYHO�DQG�WR� LGHQWLI\�WKH�QHHGV�RI�WKH�LQGLYLGXDO��&KHFN�RII�HDFK�LWHP�WKDW�KDV�EHHQ�LQFOXGHG�LQ�WKH�VXEPLVVLRQ�DQG�DWWDFK�WKH�GRFXPHQWDWLRQ�WR�WKH�3$655�/HYHO�,,�(YDOXDWLRQ�

&RPSOHWH�PHGLFDO�KLVWRU\�

5HYLHZ�RI�DOO�ERG\�V\VWHPV� 6SHFL¿F�HYDOXDWLRQ�RI�WKH�SHUVRQ¶V�QHXURORJLFDO�V\VWHP�LQ�WKH�DUHDV�RI�PRWRU�IXQFWLRQLQJ��VHQVRU\�IXQFWLRQLQJ��JDLW��GHHS�WHQGRQ�UHÀH[HV��FUDQLDO�QHUYHV��DQG�DEQRUPDO�UHÀH[HV��DGGLWLRQDO�HYDOXDWLRQV�FRQGXFWHG�E\�DSSURSULDWH�VSHFLDOLVWV� $�FRPSUHKHQVLYH�GUXJ�KLVWRU\�LQFOXGLQJ�FXUUHQW�RU�LPPHGLDWH�SDVW�XVH�RI�PHGLFDWLRQV�WKDW�FRXOG�PDVN�V\PSWRP�RU�PLPLF�PHQWDO�LOOQHVV� $�SV\FKRVRFLDO�HYDOXDWLRQ�RI�WKH�LQGLYLGXDO��LQFOXGLQJ�FXUUHQW�OLYLQJ�DUUDQJHPHQWV��PHGLFDO��DQG�VXSSRUW�V\VWHPV� A comprehensive psychiatric evaluation including a complete psychiatric history, evaluation of intellectual functioning, memory functioning and orientation, description of current attitudes and overt behaviors, affect, suicidal or homicidal ideation, paranoia, DQG�GHJUHH�RI�UHDOLW\�WHVWLQJ��SUHVHQFH�DQG�FRQWHQW�RI�GHOXVLRQV��DQG�KDOOXFLQDWLRQV� )XQFWLRQDO�DVVHVVPHQW�RI�WKH�LQGLYLGXDO¶V�DELOLW\�WR�HQJDJH�LQ�DFWLYLWLHV�RI�GDLO\�OLYLQJ��,QFOXGH�WKH�OHYHO�RI�VXSSRUW�WKDW�ZRXOG�EH�QHHGHG�WR�DVVLVW�WKH�LQGLYLGXDO�WR�SHUIRUP�WKHVH�DFWLYLWLHV�ZKLOH�OLYLQJ�LQ�WKH�FRPPXQLW\���7KH�DVVHVVPHQW�PXVW�DOVR� determine whether this level of support can be provided to the individual in an alternative community setting or whether the OHYHO�RI�VXSSRUW�QHHGHG�LV�VXFK�WKDW�QXUVLQJ�IDFLOLW\�SODFHPHQW�LV�UHTXLUHG��7KH�IXQFWLRQDO�DVVHVVPHQW�PXVW�DGGUHVV�WKH� IROORZLQJ�DUHDV��6HOI�PRQLWRULQJ�RI�KHDOWK�VWDWXV��VHOI�DGPLQLVWHULQJ�DQG�VFKHGXOLQJ�RI�PHGLFDO�WUHDWPHQW��LQFOXGLQJ�PHGLFDWLRQ� FRPSOLDQFH��RU�ERWK��VHOI�PRQLWRULQJ�RI�QXWULWLRQDO�VWDWXV��KDQGOLQJ�PRQH\��GUHVVLQJ�DSSURSULDWHO\��DQG�JURRPLQJ�

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��� (VWLPDWHG�OHYHO�RI�LQWHOOLJHQFH�RI�WKH�LQGLYLGXDO�GXULQJ�WKLV�HYDOXDWLRQ�� High Average Low �8QNQRZQ

3DJH���RI��� MA 376.2 9/18

NAME SSN (LAST 4 DIGITS)

SECTION V: INTELLECTUAL DISABILITY/DEVELOPMENTAL DISABILITY (ID/DD)

V-A: DOCUMENTATION OF THE DIAGNOSIS

��� 'RHV�WKH�GRFXPHQWDWLRQ�LQGLFDWH�D�GLDJQRVLV�RI�DQ�,'�''"� �12� �<(6

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/LVW�WKH�GRFXPHQWDWLRQ�WKDW�VXSSRUWV�,'�''�GLDJQRVLV�

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��� 'RHV�WKH�GRFXPHQWDWLRQ�SURYLGH�HYLGHQFH�RI�WKH�IROORZLQJ�FKDUDFWHULVWLFV"

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V-B: SUPPORTING INFORMATION

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6HOI�PRQLWRULQJ�RI�KHDOWK�VWDWXV�

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6HOI�PRQLWRULQJ�RI�QXWULWLRQDO�VWDWXV�

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$FDGHPLF�DQG�HGXFDWLRQDO�VNLOOV�LQFOXGLQJ�IXQFWLRQDO�OHDUQLQJ�VNLOOV� ,QGHSHQGHQW�OLYLQJ�VNLOOV�LQYROYLQJ�PHDO�SUHSDUDWLRQ��EXGJHWLQJ�DQG�SHUVRQDO�¿QDQFHV��VXUYLYDO�VNLOOV��PRELOLW\�VNLOOV��RULHQWDWLRQ�WR�QHLJKERUKRRG��WRZQ��FLW\��HWF����RULHQWDWLRQ�VNLOOV�IRU�LQGLYLGXDOV�ZLWK�YLVXDO�LPSDLUPHQWV��ODXQGU\��KRXVHNHHSLQJ��VKRSSLQJ��EHG�PDNLQJ��DQG�FDUH�RI�FORWKLQJ�� 9RFDWLRQDO�VNLOOV�

$IIHFWLYH�VNLOOV�LQFOXGLQJ�LQWHUHVWV��DELOLW\�WR�H[SUHVV�HPRWLRQ��PDNLQJ�MXGJHPHQWV��DQG�LQGHSHQGHQW�GHFLVLRQ�PDNLQJ�

3UHVHQFH�RI�PDODGDSWLYH�RU�LQDSSURSULDWH�EHKDYLRUV�LQFOXGLQJ�WKHLU�GHVFULSWLRQ��IUHTXHQF\��DQG�LQWHQVLW\�

SECTION VI: OTHER RELATED CONDITIONS (ORC)

³2WKHU�5HODWHG�&RQGLWLRQV´�LQFOXGH�SK\VLFDO��VHQVRU\�RU�QHXURORJLFDO�GLVDELOLWLHV�ZKLFK�PDQLIHVWHG�EHIRUH�DJH����DUH�OLNHO\�WR�FRQWLQXH�LQGH¿QLWHO\�DQG�UHVXOW�LQ� substantial functional limitations in three or more�RI�WKH�IROORZLQJ�DUHDV�RI�PDMRU�OLIH�DFWLYLW\��VHOI�FDUH��UHFHSWLYH�DQG�H[SUHVVLYH�ODQJXDJH��OHDUQLQJ��PRELOLW\�� VHOI�GLUHFWLRQ��DQG�FDSDFLW\�IRU�LQGHSHQGHQW�OLYLQJ��,W�LV�LPSRUWDQW�WR�QRWH�WKDW�D�SHUVRQ�FDQ�KDYH�DQ�³2WKHU�5HODWHG�&RQGLWLRQ´�regardless of whether the ORC

impairs their intellectual abilities.

VI-A: DOCUMENTATION OF THE DIAGNOSIS

��� ,V�WKHUH�GRFXPHQWDWLRQ�WR�VXEVWDQWLDWH�WKDW�WKH�LQGLYLGXDO�PHHWV�WKH�IROORZLQJ�FULWHULD�IRU�DQ�25&"� �12� �<(6

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/LVW�WKH�GRFXPHQWDWLRQ�WKDW�VXSSRUWV�25&�GLDJQRVLV�

MA 376.2 9/18Page 5 of 11

NAME SSN (LAST 4 DIGITS)

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�12� �<(6���6SHFLI\�FRQGLWLRQ�GLDJQRVLV�HV���

E��7KH�FRQGLWLRQ�PDQLIHVWHG�EHIRUH�DJH���"� �12� �<(6

F��7KH�FRQGLWLRQ�LV�H[SHFWHG�WR�FRQWLQXH�LQGH¿QLWHO\�� �12� �<(6

VI-B: SUPPORTING DOCUMENTATION

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Self-care:�$�ORQJ�WHUP�FRQGLWLRQ�ZKLFK�UHTXLUHV�WKH�LQGLYLGXDO�WR�QHHG�VLJQL¿FDQW�DVVLVWDQFH�ZLWK�SHUVRQDO�QHHGV�VXFK�DV�HDWLQJ��K\JLHQH�DQG� DSSHDUDQFH��6LJQL¿FDQW�DVVLVWDQFH�PD\�EH�GH¿QHG�DV�DVVLVWDQFH�DW�OHDVW�RQH�KDOI�RI�DOO�DFWLYLWLHV�QRUPDOO\�UHTXLUHG�IRU�VHOI�FDUH� Receptive and expressive language: An individual is unable to effectively communicate with another person without the aid of a third person, a

SHUVRQ�ZLWK�VSHFLDO�VNLOO�RU�ZLWK�D�PHFKDQLFDO�GHYLFH��RU�D�FRQGLWLRQ�ZKLFK�SUHYHQWV�DUWLFXODWLRQ�RI�WKRXJKWV� Learning:�$Q�LQGLYLGXDO�WKDW�KDV�D�FRQGLWLRQ�ZKLFK�VHULRXVO\�LQWHUIHUHV�ZLWK�FRJQLWLRQ��YLVXDO�RU�DXUDO�FRPPXQLFDWLRQ��RU�XVH�RI�KDQGV�WR�WKH�H[WHQW�WKDW� VSHFLDO�LQWHUYHQWLRQ�RU�VSHFLDO�SURJUDPV�DUH�UHTXLUHG�WR�DLG�LQ�OHDUQLQJ� Mobility:�$Q�LQGLYLGXDO�WKDW�LV�LPSDLUHG�LQ�KLV�KHU�XVH�RI�¿QH�DQG�RU�JURVV�PRWRU�VNLOOV�WR�WKH�H[WHQW�WKDW�DVVLVWDQFH�RI�DQRWKHU�SHUVRQ�DQG�RU�D� PHFKDQLFDO�GHYLFH�LV�QHHGHG�LQ�RUGHU�IRU�WKH�LQGLYLGXDO�WR�PRYH�IURP�SODFH�WR�SODFH� Self-direction:�$Q�LQGLYLGXDO�WKDW�UHTXLUHV�DVVLVWDQFH�LQ�EHLQJ�DEOH�WR�PDNH�LQGHSHQGHQW�GHFLVLRQV�FRQFHUQLQJ�VRFLDO�DQG�LQGLYLGXDO�DFWLYLWLHV�DQG�RU�LQ� KDQGOLQJ�SHUVRQDO�¿QDQFHV�DQG�RU�SURWHFWLQJ�RZQ�VHOI�LQWHUHVW� Capacity for independent living: An individual that is limited in performing normal societal roles or is unsafe for the individual to live alone to such as

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SECTION VII: FINDINGS & RECOMMENDATION

VII-A: EVALUATOR’S RECOMMENDATION

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VII-B: DESIRE FOR SPECIALIZED SERVICES

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NAME SSN (LAST 4 DIGITS)

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a. Mental Health

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• Partial Psychiatric Hospitalization�±�6HUYLFHV�SURYLGHG�LQ�D�QRQ�UHVLGHQWLDO�WUHDWPHQW�VHWWLQJ�ZKLFK�LQFOXGHV�SV\FKLDWULF��SV\FKRORJLFDO��VRFLDO�� DQG�YRFDWLRQDO�HOHPHQWV�XQGHU�PHGLFDO�VXSHUYLVLRQ��'HVLJQHG�IRU�SDWLHQWV�ZLWK�PRGHUDWH�WR�VHYHUH�PHQWDO�LOOQHVV�ZKR�UHTXLUH�OHVV�WKDQ����KRXU� FRQWLQXRXV�FDUH�EXW�UHTXLUH�PRUH�LQWHQVLYH�DQG�FRPSUHKHQVLYH�VHUYLFHV�WKDQ�RIIHUHG�LQ�RXWSDWLHQW��6HUYLFHV�DUH�SURYLGHG�RQ�D�SODQQHG�DQG� UHJXODUO\�VFKHGXOHG�EDVLV�IRU�D�PLQLPXP�RI�WKUHH�KRXUV��EXW�OHVV�WKDQ����KRXUV�LQ�DQ\�RQH�GD\�

• Psychiatric Outpatient Clinic – Psychiatric, psychologist, social, educational, and other related services provided under medical supervision in

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• Mobile Mental Health Treatment (MMHT) – A service array for adults and older adults with a mental illness who encounter barriers to, or have

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• Crisis Intervention Services�±�,PPHGLDWH��FULVLV�RULHQWHG�VHUYLFHV�GHVLJQHG�WR�DPHOLRUDWH�RU�UHVROYH�SUHFLSLWDWLQJ�VWUHVV��3URYLGHG�WR�SHUVRQV� ZKR�H[KLELW�DFXWH�SUREOHPV�RI�GLVWXUEHG�WKRXJKW��EHKDYLRU��PRRG��RU�VRFLDO�UHODWLRQVKLSV�

• Targeted Mental Health Case Management (Intensive Case Management (ICM) and Resource Coordination (RC))�±�,&0�VHUYLFHV�DUH� provided to assist adults with serious and persistent mental illness to gain access to needed resources such as medical, social, educational, and

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• Peer Support Services�±�3HUVRQ�FHQWHUHG�DQG�UHFRYHU\�IRFXVHG�VHUYLFHV�IRU�DGXOWV�ZLWK�VHULRXV�DQG�SHUVLVWHQW�PHQWDO�LOOQHVV��7KH�VHUYLFHV�DUH� SURYLGHG�E\�LQGLYLGXDOV�ZKR�KDYH�EHHQ�VHUYHG�LQ�WKH�SXEOLF�EHKDYLRUDO�KHDOWK�V\VWHP��7KH�VHUYLFH�LV�GHVLJQHG�WR�SURPRWH�HPSRZHUPHQW��VHOI� GHWHUPLQDWLRQ��XQGHUVWDQGLQJ�DQG�FRSLQJ�VNLOOV�WKURXJK�PHQWRULQJ�DQG�VHUYLFH�FRRUGLQDWLRQ�VXSSRUWV�WKDW�DOORZ�SHRSOH�ZLWK�VHYHUH�DQG�SHUVLVWHQW� PHQWDO�LOOQHVV�WR�DFKLHYH�SHUVRQDO�ZHOOQHVV�DQG�FRSH�ZLWK�WKH�VWUHVVRUV�DQG�EDUULHUV�HQFRXQWHUHG�ZKHQ�UHFRYHULQJ�IURP�WKHLU�GLVDELOLWLHV��3HHU� 6SHFLDOLVWV�PD\�SURYLGH�VLWH�EDVHG�DQG�RU�PRELOH�SHHU�VXSSRUW�VHUYLFHV��RII�VLWH�LQ�WKH�FRPPXQLW\�

• Outpatient D&A Services, including Methadone Maintenance Clinic�±�$Q�RUJDQL]HG��QRQ�UHVLGHQWLDO��GUXJ�IUHH�WUHDWPHQW�VHUYLFH�SURYLGLQJ� SV\FKRWKHUDS\�LQ�ZKLFK�WKH�FOLHQW�UHVLGHV�RXWVLGH�WKH�IDFLOLW\��6HUYLFHV�DUH�XVXDOO\�SURYLGHG�LQ�UHJXODUO\�VFKHGXOHG�WUHDWPHQW�VHVVLRQV�IRU��DW�PRVW�� ¿YH�FRQWDFW�KRXUV�SHU�ZHHN�

If the individual meets the clinical criteria for a serious mental illness and is admitted to a nursing facility, some mental health or substance use

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b. Intellectual Disability/Developmental Disability

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• Assistive Technology�±�$Q�LWHP��SLHFH�RI�HTXLSPHQW��RU�SURGXFW�V\VWHP�WKDW�LV�XVHG�WR�LQFUHDVH��PDLQWDLQ��RU�LPSURYH�DQ�LQGLYLGXDO¶V�IXQFWLRQLQJ�� $VVLVWLYH�WHFKQRORJ\�VHUYLFHV�LQFOXGH�GLUHFW�VXSSRUW�WR�DQ�LQGLYLGXDO�LQ�WKH�VHOHFWLRQ��DFTXLVLWLRQ��RU�XVH�RI�DQ�DVVLVWLYH�WHFKQRORJ\�GHYLFH�

• Behavioral Support�±�7KLV�VHUYLFH�LQFOXGHV�IXQFWLRQDO�DVVHVVPHQW��GHYHORSPHQW�RI�VWUDWHJLHV�WR�VXSSRUW�WKH�LQGLYLGXDO�EDVHG�RQ�DVVHVVPHQW�� DQG�WKH�SURYLVLRQ�RI�WUDLQLQJ�WR�LQGLYLGXDOV��VWDII��SDUHQWV��DQG�FDUHJLYHUV��6HUYLFHV�PXVW�EH�UHTXLUHG�WR�PHHW�WKH�FXUUHQW�QHHGV�RI�WKH�LQGLYLGXDO�

• Communication Specialist�±�6XSSRUWV�SDUWLFLSDQWV�ZLWK�QRQ�WUDGLWLRQDO�FRPPXQLFDWLRQ�QHHGV�E\�GHWHUPLQLQJ�WKH�SDUWLFLSDQW¶V�FRPPXQLFDWLRQ�QHHGV�� HGXFDWLQJ�WKH�SDUWLFLSDQW�DQG�KLV�KHU�FDUHJLYHUV�RQ�WKH�SDUWLFLSDQW¶V�FRPPXQLFDWLRQ�QHHGV�DQG�WKH�EHVW�ZD\�WR�PHHW�WKRVH�QHHGV�LQ�WKHLU�GDLO\�OLYHV�

• Companion Services – Services are provided to individuals for the limited purposes of providing supervision and assistance focused on

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• Housing Transition and Tenancy Sustaining Services�±�7KLV�VHUYLFH�LQFOXGHV�SUH�WHQDQF\ and housing sustaining supports to assist

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• In-Home and Community Support�±�,Q�KRPH�DQG�&RPPXQLW\�6XSSRUW�LV�D�GLUHFW�VHUYLFH�SURYLGHG�LQ�KRPH�DQG�FRPPXQLW\�VHWWLQJV�WR�DVVLVW� SDUWLFLSDQWV�LQ�DFTXLULQJ��PDLQWDLQLQJ��DQG�LPSURYLQJ�WKH�VNLOOV�QHFHVVDU\�WR�OLYH�LQ�WKH�FRPPXQLW\��WR�OLYH�PRUH�LQGHSHQGHQWO\��DQG�WR�SDUWLFLSDWH� PHDQLQJIXOO\�LQ�FRPPXQLW\�OLIH�

• Supports Coordination�±�7KLV�LV�D�VHUYLFH�WKDW�LQYROYHV�WKH�SULPDU\�IXQFWLRQV�RI�ORFDWLQJ��FRRUGLQDWLQJ��DQG�PRQLWRULQJ�QHHGHG�VHUYLFHV�DQG� VXSSRUWV��/RFDWLQJ�VHUYLFHV�DQG�VXSSRUWV�FRQVLVWV�RI�DVVLVWDQFH�WR�WKH�LQGLYLGXDO�DQG�KLV�RU�KHU�IDPLO\�LQ�OLQNLQJ��DUUDQJLQJ�IRU��DQG�REWDLQLQJ� VHUYLFHV�VSHFL¿HG�LQ�DQ�,63��LQFOXGLQJ�QHHGHG�PHGLFDO��VRFLDO��KDELOLWDWLRQ��HGXFDWLRQ��RU�RWKHU�QHHGHG�FRPPXQLW\�VHUYLFHV�

• Support (Medical Environment)�±�7KLV�VHUYLFH�PD\�EH�XVHG�WR�SURYLGH�VXSSRUW�LQ�JHQHUDO�KRVSLWDO�RU�QXUVLQJ�KRPH�VHWWLQJV��ZKHQ�WKHUH�LV�D� GRFXPHQWHG�QHHG�DQG�WKH�FRXQW\�SURJUDP�DGPLQLVWUDWRU�RU�GLUHFWRU�DSSURYHV�WKH�VXSSRUW�LQ�D�PHGLFDO�IDFLOLW\��7KH�VHUYLFH�LV�LQWHQGHG�WR�VXSSO\� WKH�DGGLWLRQDO�VXSSRUW�WKDW�WKH�KRVSLWDO�RU�QXUVLQJ�KRPH�LV�XQDEOH�WR�SURYLGH�GXH�WR�WKH�LQGLYLGXDO¶V�XQLTXH�EHKDYLRUDO�RU�SK\VLFDO�QHHGV�

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c. Other Related Condition

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SECTION VIII: NOTICE OF REFERRAL FOR FINAL DETERMINATION

<RX�PXVW�QRZ�H[SODLQ�WR�WKH�LQGLYLGXDO��OHJDO�UHSUHVHQWDWLYH��IDPLO\�PHPEHU�DQG�RU�VLJQL¿FDQW�RWKHU��LI�WKH�LQGLYLGXDO�DJUHHV�WR�IDPLO\�SDUWLFLSDWLRQ��WKDW�SHUVRQV� ZLWK�D�VHULRXV�0HQWDO�,OOQHVV��,QWHOOHFWXDO�'LVDELOLW\��RU�DQ�2WKHU�5HODWHG�&RQGLWLRQ�PD\�QRW�DOZD\V�QHHG�QXUVLQJ�IDFLOLW\�VHUYLFHV��DQG�VKRXOG�EH�LQ�SODFHV�PRUH� VXLWHG�WR�WKHLU�QHHGV��([SODLQ�WKDW�WKLV�DVVHVVPHQW�LV�D�ZD\�IRU�PDNLQJ�VXUH�WKH�LQGLYLGXDO�LV�UHFHLYLQJ�WKH�DSSURSULDWH�VHUYLFHV�WR�PHHW�KLV�KHU�QHHGV�DQG� UHFHLYLQJ�WKH�VHUYLFHV�LQ�WKH�VHWWLQJ�WKDW�EHVW�¿WV�KLV�KHU�QHHGV�

For Persons with a Mental Health Condition: <RX�KDYH��\RXU�UHODWLYH�IULHQG�UHVSRQVLEOH�SDUW\�KDV��EHHQ�LGHQWL¿HG�DV�UHTXLULQJ�IXUWKHU�HYDOXDWLRQ�E\�WKH�'+6� 2I¿FH�RI�0HQWDO�+HDOWK�DQG�6XEVWDQFH�$EXVH�6HUYLFHV��20+6$6���7KLV�IRUP�DQG�UHODWHG�LQIRUPDWLRQ�ZLOO�EH�IRUZDUGHG�LQ�RUGHU�WR�REWDLQ�D�¿QDO�GHWHUPLQDWLRQ� UHJDUGLQJ�WKH�QHHG�DQG�DSSURSULDWHQHVV�IRU�QXUVLQJ�IDFLOLW\�FDUH�DQG�VSHFLDOL]HG�VHUYLFHV��<RX�ZLOO�UHFHLYH�D�OHWWHU�IURP�20+6$6�RXWOLQLQJ�WKHLU�GHFLVLRQ�

For Persons with Intellectual Disability/Developmental Disability:�<RX�KDYH��\RXU�UHODWLYH�IULHQG�UHVSRQVLEOH�SDUW\�KDV��EHHQ�LGHQWL¿HG�DV�UHTXLULQJ�IXUWKHU� HYDOXDWLRQ�E\�WKH�'+6�2I¿FH�RI�'HYHORSPHQWDO�3URJUDPV��2'3���7KLV�IRUP�DQG�UHODWHG�LQIRUPDWLRQ�ZLOO�EH�IRUZDUGHG�LQ�RUGHU�WR�REWDLQ�D�¿QDO�GHWHUPLQDWLRQ� UHJDUGLQJ�WKH�QHHG�DQG�DSSURSULDWHQHVV�IRU�QXUVLQJ�IDFLOLW\�FDUH�DQG�VSHFLDOL]HG�VHUYLFHV��<RX�ZLOO�UHFHLYH�D�OHWWHU�IURP�2'3�RXWOLQLQJ�WKHLU�GHFLVLRQ�

For Persons with an Other Related Condition:�<RX�KDYH��\RXU�UHODWLYH�IULHQG�UHVSRQVLEOH�SDUW\�KDV��EHHQ�LGHQWL¿HG�DV�UHTXLULQJ�IXUWKHU�HYDOXDWLRQ�E\�WKH� '+6�2I¿FH�RI�/RQJ�7HUP�/LYLQJ��2/7/���7KLV�IRUP�DQG�UHODWHG�LQIRUPDWLRQ�ZLOO�EH�IRUZDUGHG�LQ�RUGHU�WR�REWDLQ�D�¿QDO�GHWHUPLQDWLRQ�UHJDUGLQJ�WKH�QHHG�DQG� DSSURSULDWHQHVV�IRU�QXUVLQJ�IDFLOLW\�FDUH�DQG�VSHFLDOL]HG�VHUYLFHV��<RX�ZLOO�UHFHLYH�D�OHWWHU�IURP�2/7/�RXWOLQLQJ�WKHLU�GHFLVLRQ�

3DJH���RI��� MA 376.2 9/18

NAME SSN (LAST 4 DIGITS)

SECTION IX: NAME AND CONTACT INFORMATION OF INDIVIDUAL COMPLETING THIS FORM

35,17�1$0(� 7,7/(�

6,*1$785(� '$7(�

$*(1&<�

'$7(�

7(/(3+21(�

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SECTION X: DOCUMENTATION TO INCLUDE FOR PROGRAM OFFICE REVIEW

6HQG�WKH�EHORZ�GRFXPHQWDWLRQ�WR�WKH�3URJUDP�2I¿FH�LQ�WKH�RUGHU�LW�LV�OLVWHG�EHORZ�

MH

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1RWL¿FDWLRQ�6KHHW�±� Reminder�±�,QFOXGH�WKH�)$;�QXPEHU�IRU� WKH�KRVSLWDO�1)�

PASRR Level I & Level II

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&RPSUHKHQVLYH�+LVWRU\��3K\VLFDO� ([DP

&RPSUHKHQVLYH�0HGLFDWLRQ�+LVWRU\� (most current and immediate past)

&RPSUHKHQVLYH�3V\FKRVRFLDO� Evaluation

&RPSUHKHQVLYH�3V\FKLDWULF�(YDOXDWLRQ

/RQJ�7HUP�6HUYLFHV�DQG�6XSSRUWV� �/766��DVVHVVPHQW�

Last 3 days of the most current

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&XUUHQW�PHGLFDWLRQ�UHFRUG

&7�1HXURORJ\�&RQVXOWV�LI�DSSOLFDEOH

0'6�±�LI�LQGLYLGXDO�LV�DOUHDG\�LQ�WKH�1)

ID

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PASRR Level I & Level II

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/RQJ�7HUP�6HUYLFHV�DQG�6XSSRUWV� �/766��DVVHVVPHQW� $GPLVVLRQ�5HSRUW�±�7R�LQFOXGH�+LVWRU\�� 'LDJQRVHV��3K\VLFDO�([DP� 1XUVHV�1RWHV�±�RQO\�WKH�PRVW�UHFHQW���� ZHHN�SULRU�WR�1)�$GPLVVLRQ�

&XUUHQW�0HGLFDWLRQ�UHFRUG

&RXUVH�RI�6WD\�±�DQ\�LPSRUWDQW�LVVXHV� during stay

Psychological evaluation – include

school records with an IQ score before

DJH�RI����LI�SRVVLEOH�

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PASRR Level I & Level II

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1XUVHV�QRWHV�LQFOXGLQJ�ZKDW�6SHFLDOL]HG� Service would be helpful

&RXUVH�RI�6WD\�±�DQ\�LPSRUWDQW�LVVXHV� during stay

Psychological evaluation

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3DJH���RI��� MA 376.2 9/18

NAME SSN (LAST 4 DIGITS)

SECTION XI: NOTIFICATION SHEET

$VVHVVRU�VKRXOG�

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�� 0DNH�D�FRS\�RI�WKH�DVVHVVPHQW�SDFNHW�IRU�WKHLU�UHFRUGV��DQG�WKHQ�

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COPIES OF THE EVALUATION REPORT SHOULD BE SENT TO EACH OF THE FOLLOWING:

1. THE INDIVIDUAL BEING ASSESSED

1$0(�

2. THE LEGAL REPRESENTATIVE - A PERSON DESIGNATED BY STATE LAW TO REPRESENT THE INDIVIDUAL. THIS INCLUDES A COURT-APPOINTED

GUARDIAN OR AN INDIVIDUAL HAVING POWER OF ATTORNEY. 1$0(�

$''5(66�

&,7<�

3. ADMITTING/RETAINING NURSING FACILITY (NF) (if known)

1$0(�

$''5(66�

&,7<�

$77(17,21�

4. INDIVIDUAL’S ATTENDING PHYSICIAN

1$0(�

$''5(66�

&,7<�

62&,$/�6(&85,7<�180%(5�

67$7(�

67$7(�

67$7(�

7(/(3+21(�180%(5�

7(/(3+21(�180%(5�

=,3�&2'(�

7(/(3+21(�180%(5�

)$;�180%(5�

=,3�&2'(�

7(/(3+21(�180%(5�

)$;�180%(5�

=,3�&2'(�

7(/(3+21(�180%(5�

)$;�180%(5�

=,3�&2'(�

CONTACT EMAIL:

5. LIST FULL NAME OF DISCHARGING HOSPITAL (if individual is seeking nursing facility admission directly from a hospital)

1$0(�

$''5(66�

&,7<� 67$7(�

CONTACT PERSON: CONTACT TELEPHONE:

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3DJH����RI��� MA 376.2 9/18

SLUMS EXAMINATION ,QVWUXFWLRQV�FDQ�EH�IRXQG�DW��KWWS���ZZZ�HOGHUJXUX�FRP�GRZQORDGV�6/806BLQVWUXFWLRQV�SGI

NAME: AGE:

IS THE PATIENT ALERT? LEVEL OF EDUCATION:

BBB����

BBB����

BBB����

BBB����

BBB����

BBB����

BBB����

BBB����

BBB����

BBB����

TOTAL

SCORE:

1

1

1

1

1

1. What day of the week is it?

2. What is the year?

3. What state are we in?

� ��� 3OHDVH�UHPHPEHU�WKHVH�¿YH�REMHFWV��,�ZLOO�DVN�\RX�ZKDW�WKH\�DUH�ODWHU� Apple Pen Tie House Car

5. You have $100 and you go to the store and buy a dozen apples for $3 and a tricycle for $20.

How much did you spend?

How much do you have left?

1

2

6. Please name as many animals as you can in one minute.

0-4 animals0 5-9 animals1 10-14 animals2 15+ animals3

���� :KDW�ZHUH�WKH�¿YH�REMHFWV�,�DVNHG�\RX�WR�UHPHPEHU"���SRLQW�IRU�HDFK�RQH�FRUUHFW�

8. I am going to give you a series of numbers and I would like you to give

them to me backwards. For example, if I say 42, you would say 24.

0 87 1 648 1 8537

9. This is a clock face. Please put in the hour markers and the time at ten min-

utes to eleven o’clock.

2

2

Hour markers ok.

Time correct.

10. Please place an X in the triangle

� � :KLFK�RI�WKH�DERYH�¿JXUHV�LV�ODUJ-

est?

11. I am going to tell you a story. Please listen carefully because afterwards, I’m going to ask you some questions about it.

-LOO�ZDV�D�YHU\�VXFFHVVIXO�VWRFNEURNHU��6KH�PDGH�D�ORW�RI�PRQH\�RQ�WKH�VWRFN�PDUNHW��6KH�WKHQ�PHW�-DFN��D� GHYDVWDWLQJO\�KDQGVRPH�PDQ��6KH�PDUULHG�KLP�DQG�KDG�WKUHH�FKLOGUHQ��7KH\�OLYHG�LQ�&KLFDJR��6KH�WKHQ�VWRSSHG� ZRUN�DQG�VWD\HG�DW�KRPH�WR�EULQJ�XS�KHU�FKLOGUHQ��:KHQ�WKH\�ZHUH�WHHQDJHUV��VKH�ZHQW�EDFN�WR�ZRUN��6KH�DQG�-DFN� OLYHG�KDSSLO\�HYHU�DIWHU�

2

2

What was the female’s name? 2

2

What work did she do?

When did she go back to work? What state did she live in?

SCORING

HIGH SCHOOL EDUCATION LESS THAN HIGH SCHOOL EDUCATION

������� � �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �1250$/� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� ������� ������� � �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� � 0,/'�1(852&2*1,7,9(�',625'(5 � �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� ������� ������ � �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� � '(0(17,$ � �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� �� ������

CLINICIAN’S SIGNATURE DATE TIME

6+�7DULT��1�7XPRVD��-7�&KLEQDOO��+0�3HUU\�,,,��DQG�-(�0RUOH\��7KH�6DLQW�/RXLV�8QLYHUVLW\�0HQWDO�6WDWXV��6/806��([DPLQDWLRQ�IRU�GHWHFWLQJ�PLOG�FRJQLWLYH� LPSDLUPHQW�DQG�GHPHQWLD�LV�PRUH�VHQVLWLYH�WKDQ�WKH�0LQL��0HQWDO�6WDWXV�([DPLQDWLRQ��006(����$�SLORW�VWXG\��$P�-�*HULDWU�3V\FK�����������������

Page 11 of 11 MA 376.2 9/18