ࡱ> 9<678_ XQbjbj CXbb*T T 8gB\$X$$$% )* f f f f f f f$|i.l1f`+%%`+`+1f$$HNg~.~.~.`+F$$ f~.`+ f~.~.2]b$UJt+_.edg0g_$n(,V$n\b$nb`+`+~.`+`+`+`+`+1f1f~.`+`+`+g`+`+`+`+$n`+`+`+`+`+`+`+`+`+T t: MUST BE COMPLETED BY SCREENERNew Jersey Department of Human Services Office of Community Choice Options EARC-PAS - ENHANCED AT-RISK CRITERIA SCREENING TOOLType of Request  FORMCHECKBOX  NF  FORMCHECKBOX  Vent SCNFIf on Managed Care Medicaid STOP. No EARC required. Refer to the Medicaid MCO for Authorization. If individual is on Medicaid not yet enrolled in MCO then EARC is required if criteria is met.FOR OCCO USE ONLY FORMCHECKBOX  AUTHORIZED:  FORMCHECKBOX  NF  FORMCHECKBOX  Vent SCNF  VALID THROUGH: FORMTEXT      Valid for this Hospital Admission only.IMPORTANT: THIS AUTHORIZATION IS NOT A GUARANTEE OF MEDICAID PAYMENT. MEDICAID PAYMENT IS CONTINGENT UPON FULL CLINICAL AND FINANCIAL ELIGIBILITY WITHIN 90 DAYS OF ADMISSION TO THE NF AS PER N.J.A.C. 8:85-1.8(b). FORMCHECKBOX  NOT AUTHORIZED NF Requires on-site PAS in Hospital. OCCO Regional Office will schedule on-site PAS assessment. OCCO Reviewer Comments: FORMTEXT        OCCO Reviewer Comments:Name of Reviewer (Print)  FORMTEXT      Signature of Reviewer Date of Review  FORMTEXT       SECTION 1 - IDENTIFYING INFORMATION Patient Name (Print) - Last First  FORMTEXT      Social Security Number  FORMTEXT      Street Address  FORMTEXT      Date of Birth (Month / Day / Year)  FORMTEXT _____ / _____ / _____City, State, Zip Code  FORMTEXT      County of Residence  FORMTEXT      Gender  FORMCHECKBOX  Male  FORMCHECKBOX  FemaleWhere did the patient live at time of admission? FORMCHECKBOX  Private Home/Apartment (alone)  FORMCHECKBOX  Private Home/Apartment, with care (family or agency) FORMCHECKBOX  Facility (Specify): FORMTEXT      SECTION 2 - MENTAL ILLNESS, INTELLECTUAL DISABILITY AND/OR DEVELOPMENTAL DISABILITY1. Does the patient have any history of mental illness (such as but not limited to Schizophrenia, Bipolar YES NO Disorder, Major Depression, Anxiety Disorder, Psychotic Disorder), intellectual disability, or developmental disability (such as but not limited to Cerebral Palsy, Epilepsy, Autism, Spina Bifida)?  FORMCHECKBOX   FORMCHECKBOX  a. Date of Level I PASRR Screen: FORMTEXT       b. Level I Screen Outcome:  FORMCHECKBOX  Negative  FORMCHECKBOX  Positive c. Level II Determination outcome (If applicable):  FORMCHECKBOX  Negative  FORMCHECKBOX  Positive d. Did physician certify NF placement as 30-day exempted hospital discharge? ...YES  FORMCHECKBOX  NO  FORMCHECKBOX NOTE: For all PASRR Positive Screens, include a copy of the completed PASRR Level I Screen (Form LTC-26) with this EARC-PAS request. If patient triggers positive and requires specialized services, 1) Hospital patient cannot transfer to NF and 2) NF patient cannot remain in NF. Provider to contact DDD/DMHAS to coordinate specialized services. EARC-PAS referrals will not be authorized until OCCO confirms PASRR Positive Level I Screens as a 30-Day Exempted Hospital Discharge and/or receives results of PASRR Level II Determination from DMHAS and/or DDD that Specialized Services are not required.SECTION 3 - INSURANCE INFORMATION1. Medicare Number: FORMTEXT         FORMCHECKBOX  Traditional Medicare Coverage:  FORMCHECKBOX  Part A  FORMCHECKBOX  Part B  FORMCHECKBOX  Medicare HMO Number of Days Authorized: FORMTEXT      2. Does the patient have other insurance that will cover 100% of the skilled nursing facility stay, including co-insurance payment at 100% if they exceed the first 20 days of Medicare? & ...& & & & & & & & & & & & & & & YES  FORMCHECKBOX & & NO  FORMCHECKBOX  a. Name of Carrier: FORMTEXT       b, Number of Days Authorized: FORMTEXT       c. Type:  FORMCHECKBOX  Primary  FORMCHECKBOX  Secondary  FORMCHECKBOX  Supplemental SECTION 3 - INSURANCE INFORMATION, Continued1. Did patient apply for Medicaid and is application pending?...........................................................................Yes  FORMCHECKBOX ..No  FORMCHECKBOX 2. Is Medicaid expected to pay for any of the cost of the nursing facility stay? Yes  FORMCHECKBOX  ..No  FORMCHECKBOX 3. Will the patients funds last less than six (6) months in a nursing facility?... Yes  FORMCHECKBOX  ..No  FORMCHECKBOX SECTION 4 - COGNITIVE STATUS AND ADL SELF PERFORMANCE 1. How well does patient make decisions about organizing the day (e.g. when to eat, choose clothes, when to go out)?  FORMCHECKBOX  Independent  FORMCHECKBOX  Modified  FORMCHECKBOX  Minimally  FORMCHECKBOX  Moderately  FORMCHECKBOX  Severely Independence Impaired Impaired Impaired 2. Can patient recall 3 items from memory after 5 minutes? Yes  FORMCHECKBOX  No  FORMCHECKBOX  3. How well does patient express or make self-understood (expressing information content, however able)?  FORMCHECKBOX  Understood  FORMCHECKBOX  Usually  FORMCHECKBOX  Often  FORMCHECKBOX  Sometimes  FORMCHECKBOX  Rarely/Never Understood Understood Understood Understood 4. ADL Self Performance (score over past 3 days) Limited Extensive Maximal Total Did Not Independent Set Up Supervision Assistance Assistance Assistance Dependence Occur Bed Mobility  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Transfer  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Locomotion (indoor/outdoor)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Dressing (Upper and/or Lower body)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Eating  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Toileting (toilet use and/or toilet transfer)  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX  Bathing (over last 7 days excluding washing of back and hair).  FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX   FORMCHECKBOX SECTION 5 - MEDICAL1. Diagnosis (es): FORMTEXT       YES NO2. Does the patient have catastrophic illness, a debilitating and/or a chronic illness affecting functional status that may require long term care services?  FORMCHECKBOX   FORMCHECKBOX Specify Major Health Needs:  FORMTEXT      _______________________________________________________________  FORMTEXT      __________________________________________________________________3. Is this patient ventilator dependent?.. FORMCHECKBOX  FORMCHECKBOX SECTION 6 - FINANCIALINCOME YES NO1. Patients monthly income is at, or below, the current NJ Care Special Medicaid Programs maximum monthly income limit of $1,041 or  FORMCHECKBOX   FORMCHECKBOX 2. Patients monthly income is at, or below, the current Medicaid institutional cap of $2,313.  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Haf4yt.Tn..............6/n/p/r/Ⱦt]SI5'jh.h.5>*CJOJQJUh.CJOJQJhh[vCJOJQJ,jhh[v5>*CJOJQJUmHnHu'j~[hh[v5>*CJOJQJUhh[v5>*CJOJQJ!jhh[v5>*CJOJQJUht"CJOJQJht"CJOJQJht9ht9CJOJQJ$jhdphO5CJOJQJU*jcZhdphO5CJOJQJUhdphO5CJOJQJ..p/0v\  @t"%   $If] ^ gdh[v  @t"%  x$If]^ gdh[vlkdZ$$IfTH4G)0*044 Haf4yt.Tr//////// 000#0$07080Y0Z0h0i0ūš|r|h|UG1*j]hdphG5CJOJQJUhdphG5CJOJQJ$jhdphG5CJOJQJUh!]CJOJQJhTCJOJQJhGCJOJQJht"ht"ht"CJOJQJhh[vCJOJQJht"CJOJQJ2jh.h.5>*CJOJQJUmHnHu'jh.h.5>*CJOJQJU-j[h.h.5>*CJOJQJUh.h.5>*CJOJQJ000  @t"% $Iflkdj\$$IfTH4)0*044 Haf4yt.Ti0j0n0o0}0~00000000(1)1,1.1/1112131A1տyn[Mhdpht95CJOJQJ$jhdpht95CJOJQJUht95CJOJQJhnDCJOJQJhFmuCJOJQJhhnDCJOJQJhht9CJOJQJht9CJOJQJht9ht9CJOJQJ*j]hdphG5CJOJQJUhdphG5CJOJQJhGCJOJQJ$jhdphG5CJOJQJU000$$Iflkd]$$IfTH4)0*044 Haf4yt.T000x $$$Ifa$|kd^$$IfTH4|)0*  %044 Haf4p %yt: ]T000}$If|kdV_$$IfTH4s)0*  %044 Haf4p %yt: ]T00V1t $  @t"%   $If] ^ `a$gdFmuikd `$$IfTH4)0*044 Haf4TA1B1C1D1E1S1T1U1V1W1111111111111111111׿ͥ͘׿k׿UͥJht95CJOJQJ*jbhdpht95CJOJQJU*j6bhdpht95CJOJQJUhFmuCJOJQJhhbp[CJOJQJhht9CJOJQJht9*j!ahdpht95CJOJQJUhdpht95CJOJQJht9CJOJQJ$jhdpht95CJOJQJU*j`hdpht95CJOJQJUV1W11w  @t"%   $If] ^ `gdFmuikda$$IfTH4)0*044 Haf4T11Q2w  @t"%  $If]^ `gdFmuikd"c$$IfTH4)0*044 Haf4T11122Q2R2s2t2{2|222#3%3&34353633333333333̴i۪̪S*jfhdpht95CJOJQJU*jehdpht95CJOJQJUhdpht95CJOJQJ$jhdpht95CJOJQJUhGCJOJQJht9CJOJQJh/iht95CJOJQJht9CJOJQJht9hy5CJOJQJht95CJOJQJhFmu5CJOJQJhht95CJOJQJQ2R2s2 $$$Ifikdc$$IfTH4)0*044 Haf4Ts2t2{2{ $$$Ifa$ykd`d$$IfTH4)0*  %044 Haf4p %T{2|2$33fH$  @t"% @$If]^@`a$$  @t"% @P$If]^@`a$ykde$$IfTH4)0*  %044 Haf4p %T33#q $  @t"% @$If]^@`a$gdkVlkd6f$$IfTH4)0*044 Haf4ytkVT,000 (plus $1,500 burial fund), or  FORMCHECKBOX  Patient has a spouse in the community with combined countable resources at or below $128,420 (plus $1,500 burial fund).SECTION 7 - INITIAL PLAN OF CAREProvide information and counsel patient and/or patients family or authorized representative(s) about: 1. Long-term care supportive services including discharge to community with supportive services, referral to ADRC/AAA and placement in Nursing Facility/Sub-Acute, 2. How to submit an application to determine financial eligibility for Medicaid benefits, and 3. Medicaid eligibility dependent upon both clinical and financial eligibility. NF Preadmission Screening (PAS) utilized to determine clinical eligibility following NF admission.Patient Choice of Setting - Check all that apply: FORMCHECKBOX  Nursing Facility Long Term  FORMCHECKBOX  Sub-Acute Nursing Facility Placement Short Term Provider feels there is a potential for discharge of the patient to the Community in the future? .  FORMCHECKBOX  Yes  FORMCHECKBOX  No Patient/family expresses an interest in returning to Community?  FORMCHECKBOX  Yes  FORMCHECKBOX  No Was a referral made to County ADRC/AAA?  FORMCHECKBOX  Yes  FORMCHECKBOX  No FORMCHECKBOX  Other: FORMTEXT      I acknowledge that I was prescreened and received counseling. I also consent to the Plan of Care proposed above.Name of Patient/Authorized Representative (Print)  FORMTEXT      Check One:  FORMCHECKBOX  Patient  FORMCHECKBOX  Authorized RepresentativeSignature of Patient/Authorized RepresentativeDate  FORMTEXT      SECTION 8 - ATTESTATIONI screened the above named patient and counseled the patient on Discharge Options. I attest to the information that appears on this At-Risk Criteria Screening Tool. Name of Certified EARC-PAS Assessor (Print)  FORMTEXT      Certified EARC-PAS Assessor Certification No.  FORMTEXT      Certified EARC-PAS Assessor Telephone  FORMTEXT      Certified EARC-PAS Assessor Fa33"#$%&456;>?@Ll9>?Cɻꘋrnnjcnnnnn hht9hGhhz~ht9CJOJQJaJhFmuCJOJQJhhVBCJOJQJhht9CJOJQJ*jghdpht95CJOJQJUhdpht95CJOJQJ$jhdpht95CJOJQJUht9hkVCJOJQJht9CJOJQJUhuCJOJQJ&#$q $  @t"% @$If]^@`a$gdFmulkdQg$$IfTH4)0*044 Haf4ytkVT  @t"% $Ifikdlh$$IfTH4)0*044 Haf4T$$Ifikd i$$IfTH4t)0*044 Haf4T;?xj`O$If^`gd $If^$If^`  $If] ^ ykdi$$IfTH4)0*  %044 Haf4p %TC'()789XYZhij ()789صxؤdؤP'jRnhdpht9CJOJQJU'jmhdpht9CJOJQJUhT5CJOJQJ'jlhdpht9CJOJQJUhdpht9CJOJQJ!jhdpht9CJOJQJU$jkht95CJOJQJUjht95CJOJQJUht95CJOJQJhVB5CJOJQJht9 hVB56 hhVB'|$$   $If^ a$gdlkdhj$$IfTH4)0*044 Haf4ytVBT'(X$$   $If^ a$lkd k$$IfTH4Y)0*044 Haf4yt/iTXY$$   $If^ a$ikd(l$$IfTH4)0*044 Haf4T=C $$ . <$If^ a$ikd=m$$IfTH4)0*044 Haf4T   " # $ . / = > ? B C D E S T ˷ˣˁmgcO'j?qhdpht9CJOJQJUht9 ht9CJ'j*phdpht9CJOJQJU'johdpht9CJOJQJUhht95CJOJQJ'j>ohdpht9CJOJQJU'jnhdpht9CJOJQJUhdpht9CJOJQJ!jhdpht9CJOJQJUht95CJOJQJhT5CJOJQJC D ]   qb$$  $Ifa$$$  $Ifa$$$   $If^ a$ikdp$$IfTH4    )0*0    44 Haf4TT U ] ^ h i        ` b v x z      ˺զ㢘}jU}B$jhdpht95CJOJQJU)jht95CJOJQJUmHnHu$jTtht95CJOJQJUht95CJOJQJjht95CJOJQJUht9CJOJQJht9&jht9CJOJQJUmHnHu!jqht9CJOJQJUht9CJOJQJjht9CJOJQJUht95CJOJQJ!jhdpht9CJOJQJU   o_  @t"% $Ifkd+r$$IfTH4F()$ 0    44 Haf4T     $If] ^ lkds$$IfTH4)0*044 Haf4ytOT  `   2 zz $If^$$  ($Ifa$ikds$$IfTH4)0*044 Haf4T         2 4            " ȾȾ~kVL?ht956CJOJQJht9CJOJQJ)jht95CJOJQJUmHnHu$j]vht95CJOJQJUht95CJOJQJjht95CJOJQJUht95CJOJQJht9*j@uhdpht95CJOJQJUht9CJOJQJ$jhdpht95CJOJQJU*jthdpht95CJOJQJUhdpht95CJOJQJ2 4    sbX $If^$$  ($Ifa$$$  $Ifa$|kdu$$IfTH40)P044 Haf4T   z$$If|kdv$$IfTH40)P044 Haf4T   Hxg$If]^gd/i$If]^ykdzw$$IfTH4)0*  %044 Haf4p %T" $ H  FHJ&(<>@JLNPʺ}ʺjdʺQ$j\zht95CJOJQJU ht9CJ$j?yht95CJOJQJUht9CJOJQJ)jht95CJOJQJUmHnHu$jxht95CJOJQJUht95CJOJQJjht95CJOJQJUht95CJOJQJht9h/i56CJOJQJht956CJOJQJh56CJOJQJHJ&Nzz $If^$$  ($Ifa$ikd8x$$IfTH4)0*044 Haf4TNP@,@qgqg $If^$$  ($Ifa$|kdy$$IfTH408)044 Haf4T@@@@@@(@*@,@.@@@AAAAAAA4A6A8ALANAPAZA\A^AlAnAAAλ٦Ώ٦q٦kX$jt}ht95CJOJQJU ht9CJ$j|ht95CJOJQJUhkV5CJOJQJ$j{ht95CJOJQJUht9)jht95CJOJQJUmHnHu$jzht95CJOJQJUht95CJOJQJjht95CJOJQJUUht95CJOJQJht9CJOJQJ"x  FORMTEXT      Signature of Certified EARC-PAS AssessorDate Screen Completed by Certified EARC-PAS Assessor  FORMTEXT      Name of Hospital  FORMTEXT      County  FORMTEXT      Date of Admission to Hospital  FORMTEXT      Fax to: OCCO Regional Office  FORMCHECKBOX  NRO Fax  FORMCHECKBOX  SRO Fax (732) 777-3600 (609) 704-6055Date/Time Faxed  FORMTEXT       FAX all three pages of the completed EARC-PAS Screening Tool to OCCO Regional Field Office. 2. Transfer o,@.@@@Aqqg $If^$$  ($Ifa$|kdH{$$IfTH408)044 Haf4TAA6A^AlAAAAqgqgqg $If^$$  ($Ifa$|kdW|$$IfTH408)044 Haf4TAAAAAAAAAAAAAAAB4B6B8BTBVBXBlBnBBBBBBBBʿ՝vcXMh-5CJOJQJh i5CJOJQJ$jqht95CJOJQJU$j~ht95CJOJQJUh/iCJOJQJht9CJOJQJht9$j}ht95CJOJQJUht95CJOJQJht95CJOJQJhkV5CJOJQJ ht9CJ)jht95CJOJQJUmHnHujht95CJOJQJUAA6BBBCo^N;^  $If^gd-  $If^$$  ($Ifa$kd`~$$IfTH4Fh)@ @ 0    44 Haf4TBBBCCCCC$C&C(C*C,CCCCDPP)PbPcPdPePfPhPiPkPlPnPoPӫvti[SOSOSOShjhUhTht95CJOJQJh/i5CJOJQJUh5CJOJQJh?h5CJOJQJhht95CJOJQJht9CJOJQJht9)jht95CJOJQJUmHnHu$jht95CJOJQJUjht95CJOJQJUht9CJOJQJ ht95CJht95CJOJQJC(C*C,CCCcPuq`O:$If]^`gdT$If]^gd & F$If]gdxkd_$$IfTH4A08)044 Haf4yt iT $If^f Hospital Patient to Medicaid Certified NF cannot occur until OCCO issues EARC-PAS authorization.     New Jersey Department of Human Services EARC-PAS - ENHANCED AT-RISK CRITERIA SCREENING TOOL (Continued) PAGE  LTC-34 MAR 19 Page  PAGE 2 of  NUMPAGES 3 Pages. 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