ࡱ> mpjkl_ ibjbj ;bb[_= NNNNNbbb8&$bubJ V&L&&&'>())Xܪުުުުުު$׭-N,*'',*,*NN&&H/666,*FN&N&ܪ6,*ܪ66bn&g^r*F`ȪE0uJ$* nnN,*,*6,*,*,*,*,*->,*,*,*u,*,*,*,*,*,*,*,*,*,*,*,*,* :  Please print and complete all questions. This form must be completed for all applicants PRIOR TO nursing facility (NF) admission in accordance with Federal PASRR Regulations 42CFR483.106. ALL POSITIVE LEVEL I SCREENS are to be faxed to the appropriate agencies including Office of Community Choice Options (OCCO), Division of Developmental Disabilities (DDD) and/or Division of Mental Health and Addiction Services (DMHAS), as applicable. ALL 30-DAY EXEMPTED HOSPITAL DISCHARGE SCREENS are to be faxed to OCCO, DDD and/or DMHAS, as applicable. For first time identification of mental Illness (MI) and/or intellectual disability/developmental disability/related condition (ID/DD/RC), the Level I Screener must provide written notice to the applicant and/or their legal representative that MI and/or ID/DD/RC is suspected or known and that a referral is being made to DMHAS and/or DDD for a PASRR Level II Evaluation. The Notice of Referral for a PASRR Level II Evaluation form (LTC-29) can be downloaded from the New Jersey DHS, Division of Aging Services forms webpage at  HYPERLINK "http://www.state.nj.us/humanservices/doas/home/forms.html" http://www.state.nj.us/humanservices/doas/home/forms.html. FAILURE TO ABIDE BY PASRR RULES 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 AND CLINICAL ASSESSMENT STATUS Name of Applicant (Last Name, First Name)  FORMTEXT      Social Security Number  FORMTEXT      Current Location Address  FORMTEXT      County of Current Location  FORMTEXT      Date of Birth  FORMTEXT      Current Location Setting  FORMCHECKBOX  Acute Care Hospital  FORMCHECKBOX  Home/Apartment  FORMCHECKBOX  Residential Health Care Facility  FORMCHECKBOX  Group Home/Boarding Home  FORMCHECKBOX  Psychiatric Hospital/Unit  FORMCHECKBOX  Assisted Living Residence  FORMCHECKBOX  Other (Specify):  FORMTEXT __________________ Clinical Assessment/Authorization Status  FORMCHECKBOX  Current Assessment/Authorization Date:  FORMTEXT __________________  FORMCHECKBOX  Referred to OCCO for Clinical Assessment (No MCO Enrollment) - Referral Date:  FORMTEXT __________________  FORMCHECKBOX  Private Pay  FORMCHECKBOX  Other (Specify):  FORMTEXT __________________  SECTION II MENTAL ILLNESS SCREEN 1. Does the individual have a diagnosis or evidence of a major mental illness limited to the following disorders: schizophrenia, schizoaffective, mood (bipolar and major depressive type), paranoid or delusional, panic or other severe anxiety disorder; somatoform or paranoid disorder; personality disorder; atypical psychosis or other psychotic disorder (not otherwise specified); or, another mental disorder that may lead to chronic disability? ..  FORMCHECKBOX  Yes  FORMCHECKBOX  No Specify Diagnosis(es) based on DSM-5 or current ICD criteria and include any current substance-related disorder diagnosis(es):  FORMTEXT _________________________________________________________________________________________2. Has the individual had a significant impairment in functioning related to a suspected or known diagnosis of mental illness? (Record YES if ANY of the three subcategories below are checked) ....... FORMCHECKBOX  Yes  FORMCHECKBOX  No Check all that apply:  FORMCHECKBOX  Interpersonal functioning. The individual has serious difficulty interacting appropriately and communicating effectively with other persons, has a possible history of altercations, evictions, unstable employment, fear of strangers, avoidance of interpersonal relationships and social isolation.  FORMCHECKBOX  Concentration, persistence, and pace. The individual has serious difficulty in sustaining focused attention for a long enough period to permit the completion of tasks commonly found in work settings or in work-like structured activities occurring in school or home settings, difficulties in concentration, inability to complete simple tasks within an established time period, makes frequent errors, or requires assistance in the completion of these task.  FORMCHECKBOX  Adaptation to change. The individual has serious difficulty in adapting to typical changes in circumstances associated with work, school, family or social interactions; agitation, exacerbated signs and symptoms associated with the illness or withdrawal from situations, self-injurious, self-mutilation, suicidal, physical violence or threats, appetite disturbance, delusions, hallucinations, serious loss of interest, tearfulness, irritability or requires intervention by mental health or judicial system.3. Within the last 2 years has the individual (record YES if EITHER/BOTH of the two subcategories below are checked): .  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Experienced one psychiatric treatment episode that was more intensive than routine follow-up care (e.g., had inpatient psychiatric care; was referred to a mental health crisis/screening center; has attended partial care/hospitalization; or has received Program of Assertive Community Treatment (PACT) or Integrated Case Management Services); and/or  FORMCHECKBOX  Due to mental illness, experienced at least one episode of significant disruption to the normal living situation requiring supportive services to maintain functioning while living in the community, or intervention by housing or law enforcement officials? If yes, explain and provide dates:  FORMTEXT _______________________________________________________________________________________  FORMTEXT _______________________________________________________________________________________ SECTION II - SCREENING OUTCOME for MI Screen Questions 1 through 3 (check one outcome only) FORMCHECKBOX  Positive Screen MIIf ALL Questions 1 through 3 are answered YES, screen is Positive for MI. Continue to Section III for ID/DD/RC Screen FORMCHECKBOX  Negative Screen MIIf Questions 1 through 3 are answered with any combination of NO, screen is Negative for MI. Continue to Section III for ID/DD/RC ScreenSECTION III INTELLECTUAL DISABILITY/DEVELOPMENTAL DISABILITY/RELATED CONDITIONS SCREEN4. Intellectual disability (ID) is a significantly decreased level of intellectual functioning measured by a standardized, reliable test of intellectual functioning and encompasses a wide range of conditions and levels of impairment with concurrent impairments in adaptive functioning. The ID must have manifested prior to the age of 18. Does the individual have a current diagnosis or a history of intellectual disability (mild, moderate, severe or profound) and/or is there any presenting evidence (cognitive or behavior characteristics) that may indicate the person has an intellectual disability with date of onset prior to age 18? ............ FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, explain:  FORMTEXT _________________________________________________________________________________  FORMTEXT _____________________________________________________________________________________________ 5. Related conditions (RCs) are severe, chronic developmental disabilities, but not forms of intellectual disabilities, that produce similar functional impairments and require similar treatment or services. RCs must have manifested prior to the age of 22. Does the individual have a current diagnosis, history or evidence of a related condition that may include a severe, chronic disability with date of onset prior to age 22 that is attributable to a condition other than mental illness that results in impairment of general intellectual functioning or adaptive behavior, mobility, self-care, self-direction, learning, understanding/use of language, capacity for independent living (e.g., autism, seizure disorder, cerebral palsy, Spina bifida, fetal alcohol syndrome, muscular dystrophy, deaf or closed head injury)? ............ FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, explain:  FORMTEXT _________________________________________________________________________________  FORMTEXT _____________________________________________________________________________________________ 6. Does the individual currently receive services or previously received services paid through the Division of Developmental Disabilities (DDD) (e.g., day habilitation, group home, case management, Community Care Waiver, Real Life Choices, Family Support of Self Determination), or other agency? ..... FORMCHECKBOX  Yes  FORMCHECKBOX  No7. Was a referral made from an agency that serves individuals with ID/DD/RC in the past? ..... FORMCHECKBOX  Yes  FORMCHECKBOX  No If yes, referred from what agency?  FORMTEXT ____________________________________________________________________ SECTION III - SCREENING OUTCOME for ID/DD/RC Screen Questions 4 through 7 (check one outcome only) FORMCHECKBOX  Positive Screen ID/DD/RCIf ANY responses to Questions 4 through 7 are YES, screen is Positive for ID/DD/RC FORMCHECKBOX  Negative Screen ID/DD/RCIf ALL responses to Questions 4 through 7 are No, screen is Negative for ID/DD/RC (continue to next page)SECTION IV PASRR LEVEL I SCREENING OUTCOME AND REFERRAL, IF INDICATEDSTEP 1: Determine Screening Outcomes for Sections II and III (check ONE response for EACH Section):  FORMCHECKBOX  Positive  FORMCHECKBOX  Negative Section II MI Screen  FORMCHECKBOX  Positive  FORMCHECKBOX  Negative Section III ID/DD/RC Screen STEP 2: Determine Final Level I Screening Outcome (check ONE final screening outcome only):  FORMCHECKBOX  Negative Screen If Step 1 Section II Negative Section III Negative Admit to NF  FORMCHECKBOX  Positive Screen MI Only If Step 1 Section II Positive Section III Negative Refer to DMHAS  FORMCHECKBOX  Positive Screen ID/DD/RC only If Step 1 Section II Negative Section III Positive Refer to DDD  FORMCHECKBOX  Positive Screen MI and ID/DD/RC If Step 1 Section II Positive Section III Positive Refer to both DMHAS and DDD  ALL POSITIVE PASRR LEVEL I SCREENS ARE TO BE FAXED TO OCCO, DMHAS AND/OR DDD, AS APPLICABLE. NF ADMISSION IS CONTINGENT UPON RECEIPT OF LEVEL II EVALUATION AND DETERMINATION. For first time identification of MI and/or /ID/DD/RC, the Level I Screener must provide written notice to the NF applicant or legal representative that MI and/or ID/DD/RC is suspected or known, and that a referral is being made to DMHAS and/or DDD for Level II Evaluation. The Notice of Referral for a Level II Evaluation form (LTC-29) can be downloaded from the New Jersey DHS, Division of Aging Services forms webpage at:  HYPERLINK "https://www.state.nj.us/humanservices/doas/home/forms.html" https://www.state.nj.us/humanservices/doas/home/forms.html Remember, when referring for a Level ll PASRR Evaluation and Determination, Section IX must be completed to ensure notification of the PASRR Level ll Determination.  PASRR LEVEL II DETERMINATION REQUESTS, IF INDICATED If the Level l Screening outcome is positive for MI and/or ID/DD/RC, the Level l Screener can request, as applicable, one of the following PASRR Level ll determination requests: If the Level I Screen is positive for MI only, a MI Primary Dementia Exclusion can be requested by completing Section V. If the Level I Screen is positive for MI and/or ID/DD/RC, a Categorical Level ll Determination can be requested by completing Section Vl. If the Level l Screen is positive for MI and or ID/DD/RC, a 30-Day Exempted Hospital Discharge can be requested by completing Section VII. (continue to next page) SECTION V MENTAL ILLNESS PRIMARY DEMENTIA EXCLUSION for Positive Level l Screens for Mental IllnessThe Mental Illness Primary Dementia Exclusion applies to individuals who have a confirmed diagnosis of dementia and that the dementia diagnosis is documented as primary or more progressed than a co-occurring MI.  FORMCHECKBOX  Primary Dementia Exclusion requested (check if applicable) For an individual with a Positive Level I Screen for MI with a diagnosis of Dementia and the Dementia is primary or more progressed than the co-occurring MI, a referral to the DMHAS for the PASRR Level ll evaluation and determination is required prior to NF admission: Fax the completed Positive Level l Screen, the Notice of Referral for PASRR Level II Evaluation (LTC-29), and the completed PASRR Level II Psychiatric Evaluation form, which can be downloaded from the New Jersey DHS, DMHAS at  HYPERLINK "https://nj.gov/humanservices/dmhas/forms/" https://nj.gov/humanservices/dmhas/forms/, to the DMHAS to 609-341-2307 and to the OCCO Regional Office (see Section XI). The LTC-29 can be downloaded from the New Jersey DHS, Division of Aging Services forms webpage  HYPERLINK "https://www.state.nj.us/humanservices/doas/home/forms.html" https://www.state.nj.us/humanservices/doas/home/forms.html. SECTION VI CATEGORICAL DETERMINATION FOR LEVEL I POSITIVE SCREENSFederal PASRR Regulation 42CFR483.140 permits states to make a categorical determination and omit the full Level II Evaluation in certain circumstances that are time-limited or where the need for NF is clear. Categorical determinations are not exemptions. PASRR Level l Screeners can request a categorical determination for a positive Level I Screen based on any one of four categories. Complete this section if you are requesting a categorical determination for an individual with a positive Level l Screen for MI and/or ID/DD/RC, based on any one of the following: (Check the box for the appropriate condition or circumstance)  FORMCHECKBOX  Terminal Illness - Terminally ill with a medical prognosis of life expectancy six months or less; not a danger to self or others.  FORMCHECKBOX  Severe Physical Illness - A medical condition of such severity that prohibits participation in or benefitting from specialized services.  FORMCHECKBOX  Respite Care To provide short term respite to the caregiver, admission from a noninstitutional setting not to exceed 30 days.  FORMCHECKBOX  Protective Service (APS) - Referred by APS when NF admission is necessary, not to exceed 7 days while alternative arrangements are made. A referral to DMHAS for a categorical determination requires completion of the DMHAS Categorical Determination form, which can be found at the New Jersey DHS, DMHAS website:  HYPERLINK "https://nj.gov/humanservices/dmhas/forms/" https://nj.gov/humanservices/dmhas/forms/. This completed Categorical Determination form, along with the completed positive Level l Screen, and the Notice of Referral for Level II PASRR Evaluation (LTC-29), must be faxed to DMHAS at 609-341-2307 (see Section XI). A referral to DDD for a categorical determination requires the completed positive Level I Screen and the Notice of Referral for Level II PASRR Evaluation (LTC-29) be faxed to the DDD Central Fax Number at 609-341-2349 (see Section XI). The Notice of Referral for Level II PASRR Evaluation (LTC-29) can be downloaded from the New Jersey Department DHS, Division of Aging Services forms webpage at:  HYPERLINK "https://www.state.nj.us/humanservices/doas/home/forms.html" https://www.state.nj.us/humanservices/doas/home/forms.html. All Positive Level I Screens are to be faxed to OCCO (see Section XI). SECTION VII 30-DAY EXEMPTED HOSPITAL DISCHARGE FOR LEVEL I POSITIVE SCREENS FORMCHECKBOX  30-Day Exempted Hospital Discharge - Applies only to INITIAL NF admission NOT resident review, NF readmission or inter-facility transfer. Complete this section for all Positive Screens meeting the following criteria: EXEMPTED HOSPITAL DISCHARGE An individual may be admitted to a skilled NF directly from the hospital after receiving inpatient care (non-psychiatric) at the hospital if: The individual requires skilled nursing facility services for the condition for which he/she received care in the hospital AND The attending hospital physician certifies before the NF admission that the individual is likely to require less than 30 days skilled nursing facility care.Name of Physician (Print):  FORMTEXT ____________________________________Signature of Physician:  FORMTEXT ____________________________________Date:  FORMTEXT ____________________________________NURSING FACILITIES PLEASE NOTE THE FOLLOWING IMPORTANT INFORMATION ABOUT 30-DAY EXEMPTED HOSPITAL DISCHARGES: If the individual requires care beyond the initial 30-day period, the NF must notify DMHAS and/or DDD, as applicable, prior to the individuals 30th day in the NF, and must provide a written explanation of the reason for the continued stay including the anticipated length of stay. Federal regulations require that the PASRR Level II Evaluation and Determination be completed prior to the individuals 40th day in the NF. Admission under the above exemption does not relieve the NF of its responsibility to ensure that specialized services are provided to an individual who has MI or ID/DD/RC needs and who would benefit from those services. FAILURE TO ABIDE BY PASRR RULES WILL RESULT IN FORFEITURE OF MEDICAID REIMBURSEMENT FOR NF SERVICES DURING THE PERIOD OF NON-COMPLIANCE IN ACCORDANCE WITH FEDERAL PASRR REGULATIONS 42 CFR 483.122.SECTION VIII PASRR LEVEL I SCREENING OUTCOME AND CERTIFICATION OF SCREENING PROFESSIONAL COMPLETING LEVEL I FORMOutcome of Level I Screen (check ONE Negative or Positive screening outcome)  FORMCHECKBOX  Negative Screen: Admit to NF  FORMCHECKBOX  Positive Screen: Referring for Level II Evaluation and Determination prior to NF admission (check one of the following)  FORMCHECKBOX  MI  FORMCHECKBOX  ID/DD/RC  FORMCHECKBOX  MI & ID/DD/RC  FORMCHECKBOX  Positive Screen - Requesting Primary Dementia Exclusion Determination: Referring for Level II Evaluation and Determination prior to NF admission.  FORMCHECKBOX  MI  FORMCHECKBOX  Positive Screen - Requesting Categorical Determination: Referring for a Categorical Level II Evaluation and Determination prior to NF Admission (check one of the following)  FORMCHECKBOX  MI  FORMCHECKBOX  ID/DD/RC  FORMCHECKBOX  MI & ID/DD/RC  FORMCHECKBOX  Positive Screen - 30-Day Exempted Hospital Discharge (check one of the following)  FORMCHECKBOX  MI  FORMCHECKBOX  ID/DD/RC  FORMCHECKBOX  MI & ID/DD/RC Attending hospital physician must certify Section VII. Fax completed form to OCCO, DMHAS and/or DDD, as applicable, and then the individual can be discharged to the nursing facility. Name of Provider/Agency/Program:  FORMTEXT ____________________________________________________________ Title of Screening Professional:  FORMTEXT ____________________________________________________________ Screening Professional Phone Number:  FORMTEXT ____________________________________________________________ Screening Professional Fax Number:  FORMTEXT ____________________________________________________________ Name of Screening Professional Completing Form (print):  FORMTEXT ____________________________________________________________ Signature of Screening Professional Completing Form:  FORMTEXT ____________________________________________________________ Date:  FORMTEXT ____________________________________________________________REMEMBER: ALL POSITIVE PASRR LEVEL I SCREENS MUST BE FAXED TO OCCO, DMHAS AND/OR DDD, AS APPLICABLE. THANK YOU.  SECTION Ix Required COntact information for ALL Postive level I screens Name of Referring Entity (Screening professionals affiliation such as agency, hospital, NF, other healthcare provider, MCO, etc.):  FORMTEXT ____________________________________________________________ Address / Street:  FORMTEXT ____________________________________________________________ Town / Zip Code:  FORMTEXT ____________________________________________________________ Phone Number:  FORMTEXT __________________ Fax Number:  FORMTEXT __________________ Consumers Residing Address/Street (Consumers primary residence):  FORMTEXT ____________________________________________________________ Address / Street:  FORMTEXT ____________________________________________________________ Town / Zip Code:  FORMTEXT ____________________________________________________________ Phone Number:  FORMTEXT __________________ Fax Number:  FORMTEXT __________________ Name of Legal Representative (Last Name, First Name):  FORMTEXT ____________________________________________________________ Address / Street:  FORMTEXT ____________________________________________________________ Town / Zip Code:  FORMTEXT ____________________________________________________________ Phone Number:  FORMTEXT __________________ Fax Number:  FORMTEXT __________________ Name of Family Member (if available and consumer or legal representative agrees to family contact/notification):  FORMTEXT ____________________________________________________________ Address / Street:  FORMTEXT ____________________________________________________________ Town / Zip Code:  FORMTEXT ____________________________________________________________ Phone Number:  FORMTEXT __________________ Fax Number:  FORMTEXT __________________ Name of Attending Physician:  FORMTEXT ____________________________________________________________ Address / Street:  FORMTEXT ____________________________________________________________ Town / Zip Code:  FORMTEXT ____________________________________________________________ Phone Number:  FORMTEXT __________________ Fax Number:  FORMTEXT __________________ SECTION X CONTACT INFORMATION Division Of Mental Health and Addiction Services (DMHAS)Division of Aging Services (DoAS) Office of Community Choice Options (OCCO) Regional OfficesDivision of Developmental Disabilities (DDD) Statewide PASRR Coordinator for Mental Health: Phone: 609-438-4152 or 609-438-4146; Fax: 609-341-2307 NORTHERN REGIONAL OFFICE OF COMMUNITY CHOICE OPTIONS (NRO): Bergen, Essex, Hudson, Hunterdon, Middlesex, Morris, Passaic, Somerset, Sussex, Union and Warren Counties Phone: 732-777-4650; Fax: 732-777-4681 SOUTHERN REGIONAL OFFICE OF COMMUNITY CHOICE OPTIONS (SRO): Atlantic, Burlington, Camden, Cape May, Cumberland, Gloucester, Mercer, Monmouth, Ocean and Salem Counties Phone: 609-704-6050; Fax: 609-704-6055DDD Central Fax Number: 609-341-2349 DDD Regional Offices - Phone Numbers NEWARK: Bergen, Essex and Hudson Phone: 973-693-5080 PLAINFIELD: Hunterdon, Somerset and Union Phone: 908-226-7800 FLANDERS: Morris, Passaic, Sussex and Warren Phone: 973-927-2600 FREEHOLD: Middlesex, Monmouth and Ocean Phone: 732-863-4500 TRENTON: Burlington and Mercer Phone: 609-584-1340 MAYS LANDING: Atlantic, Cape May and Cumberland Phone: 609-476-5200 VOORHEES: Camden, Gloucester and Camden Phone: 856-770-6366      Preadmission Screening and Resident Review (PASRR) Level I Screening Tool (continued) LTC-26 FEB 19 Page  PAGE 6 of  NUMPAGES 6 NEW JERSEY DEPARTMENT OF HUMAN SERVICES Pre-admission Screening and Resident Review (PASRR) Level I Screen LTC-26 FEB 19 Page  PAGE 1 of  NUMPAGES 6 *Yarw 7 = > @ f k m t   $ * > G 꽴xxmehxETCJaJhhxETCJaJ hs 5CJhs 5>*CJhhxET5CJaJh9`5CJaJhxET5CJaJ hA|5CJ h9`5CJh9`5>*CJhA|6B*CJphhA|B* CJphh3,B*CJphhA|5>*B*CJphhA|B*CJph hA|CJ hA|CJ$* & w { & F {$If]^`{gdiF & F {$If]^`{gdiF  & F {d$If]^`{gdiF & F {$If^`{gdiF ]^gdr G H N O U Y b c o p z {    $ ) ,   6 7 ~  e f Һ}hA|B* ph 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