Blank Fhsc 18 Nevada PDF Template

Nevada Medicaid and Nevada Check Up Programs

First Health Services Corporation

LEVEL I IDENTIFICATION SCREENING (for PASRR)

"CONFIDENTIAL"

PHONE: 1-800-525-2395

FAX:

1-866-480-9903

DATE SUBMITTED to FHSC:

INITIAL___ UPDATE___

**PLEASE TYPE OR PRINT**

Patient Name:

SS #:

Home Address:

Medicaid Billing #:

Sex:

DOB:

Pmt. Source:

Marital Status:

Known Diagnoses: _____________________________________________

Original Admit Date:

Admit Date:

Legal Representative:

Admitting Facility:

Provider ID#:

Address:

Requesting Facility:

Contact Name:

Address:

Telephone:

Fax:

Telephone:

Fax:

Patient's Current Location

Home

Acute In-Patient

ER

Requestor:

Acute ObservBed

NF____

Rehab Hosp/Unit___ Other_____

SECTION I: MENTAL ILLNESS (MI) SCREENING

3.B. Concentration/task limitations within past 6 months and due to

MI (exclude problems with medical basis):

1.A. Psychiatric Diagnoses

F

O

N Serious difficulty completing age related tasks.

Severe Anxiety/Panic Disorder

Psychotic disorder

F

O

N Serious loss of interest in things.

Bipolar Disorder

Somatoform disorder

F

O

N Serious difficulty maintaining concentration/attention.

Delusional Disorder

Schizophrenia

F

O

N Numerous errors in completing tasks which he/she

Schizoaffective disorder

Eating disorder (specify)

should be physically capable of accomplishing.

Major depression

F

O

N Requires assistance with tasks for which he/she

Personality disorder

(specify)

should be physically capable of accomplishing.

Other :

F

O

N Other:

Notes:

1.B. Psychiatric Meds

Diagnosis/Purpose

3.C. Significant problems adapting to typical changes within past 6

months and due to MI (exclude problems with medical basis):

Y

N

Requires mental health intervention due to

increased symptoms.

FHSC USE ONLY: Meets diagnosis criteria for chronicity?

Y

N

Requires judicial intervention due to symptoms.

Y

N

Y

N

Symptoms have increased as a result of adaptation

2.A. Psychiatric treatment more intense than outpatient received in past 2 years: (MORE THAN ONCE)

difficulties.

inpatient psych. hosp.(dates)

Y

N

Serious agitation or withdrawal due to adaptation

partial hosp./day treatment(dates)

difficulties.

other(dates)

Y

N

Other

2.B. Intervention to prevent hospitalization: (give dates)

Notes:

supportive living due to MI(dates)

housing intervention due to MI(dates)

FHSC USE ONLY:

MI Decision:

legal intervention due to MI(dates)

Meets criteria for disability?

Meets criteria for SMI:

suicide attempt(dates)

Y

N

Y

N

other

SECTION II: MENTAL RETARDATION (MR) AND RELATED

FHSC USE ONLY: Meets criteria for duration?

CONDITIONS (RC) SCREENING

Y

N

1.A. MR diagnosis:

N

Y (specify)

3. Role limitations in past 6 months due to MI: (excluding medical problems)

B. Undiagnosed but suspected MR:

N

Y

N/A

Indicate: "F" Frequently, "O"

Occasionally, or "N" Never

C. History of receipt of MR services:

N

Y

3. A. Interpersonal Functioning (exclude problems w/medical basis)

(if yes, specify):

F O N

Altercations

F

O

N

Social isolation/avoidance

2. Occurrence before age 18:

N

Y

F O N

Evictions

F

O

N

Excessive irritability

(if yes, specify age):

F O N Fear of strangers

F

O

N

Easily upset/anxious

2.A. Related conditions which impair intellectual functioning or adaptive

F O N Suicidal talk

F

O

N

Hallucinations

behavior.

Blindness

Deafness

F O N Illogical comments

F O N

Serious communication

Cerebral Palsy

Autism

Epilepsy

F O N

Other

difficulties

Closed head injury

Other

F

O

N

Other

B. Substantial functional limitations in 3 or more of the following:

Self-care

Mobility

Learning

Notes:

Self-direction

Capability for independent living

Understanding/use of language

C. Was the condition manifested before age 22?

N

Y (specify)

FHSC USE ONLY: Meets criteria for MR/RC?

MR Decision:

Y

N

Name and Professional Title of Person Completing Form: ___________________________ Date Completed:

Page 1 of 2

FHSC-18

Aug-03

STOP HERE IF NO INDICATORS OF MI, MR OR RC

Nevada Medicaid and Check Up Program

First Health Services Corporation

LEVEL I IDENTIFICATION SCREENING (for PASRR)

"CONFIDENTIAL"

STOP HERE - IF NO INDICATORS OF MI, MR OR RC

SECTION VI: OTHER CATEGORICAL DETERMINATIONS(non-limited)

OTHERWISE CONTINUE

IIF.

Terminal Illness: Physician has certified life expectancy of less

SECTION III: DEMENTIA

(complete for both MI & MR/RC)

than 6 months. (Submit copy of certification).

A. Does the individual have a primary diagnosis of Dementia or

IIG.

Severe Physical Illness limited to:

Alzheimer's Disease?

Coma, Ventilator Dependence, functioning at a brain stem level

Y

N (specify)

or a diagnosis of Parkinson's, Chronic Obstructive Pulmonary

B. Does the individual have any other organic disorders?

Disease, Huntington's disease, Amyotrophic lateral sclerosis

Y

N (specify)

or congestive heart failure which result in a level of

C. Is there evidence of undiagnosed Dementia or other organic

impairment so severe that the individual could not be expected

mental disorders?

to benefit from specialized services.

Y

N

disoriented to time

Y

N

disoriented to situation

Y

N disoriented to place

Y

N

pervasive, significant confusion

FHSC USE ONLY:

Y N severe ST memory

Y N paranoid ideation

Meets Other Categorical Determination criteria?

deficit

Y

N

D. Is there evidence of affective symptoms which might be confused

SECTION VII: REQUESTING PROVIDER TO COMPLETE

with Dementia?

Mailing Information (required if indicators of MI, MR/RC):

Y

N

frequent tearfulness

Y

N

severe sleep disturbance

Legal representative's name and address:

Y

N

frequent anxiety

Y

N

severe appetite disturbance

E. Can the requstor provide any corroborative information to affirm that the

dementing condition exists and is the primary diagnosis?

Dementia work-up

Thorough mental status exam

____ Medical/functional history prior to onset of dementia

Other

Primary physician's name and address:

STOP - If Dementia is primary to MI.

CONTINUE - for all MR/RC or non-primary dementia with MI.

FHSC USE ONLY: Meets dementia criteria?

Y

N

SECTION IV: EXEMPTED HOSPITAL DISCHARGE (EHD)*

A. Does the individual meet all of the following criteria?

Additional supporting documentation is attached/submitted.

Admission to a NF directly from a hospital after receiving

Physician's certification stating a less than 30 day nursing facility

acute in-patient care at the hospital; and

stay is needed to justify EHD is attached/submiited.

Requires NF services for the condition he/she received care in

Physician's certification for a less than six (6) month life

the hospital; and

expectancy for terminal illness is attached/submitted.

The attending physician has certified prior to NF

admission that the individual will require less than 30 days

Date Form Completed:

NF services. (Submit copy)

Name and Professional Title of Person Completing form:

* Individuals meeting all above criteria are exempt from PASRR II

screening for 30 days. The receiving facility must submit a Level I

FHSC OFFICE USE ONLY:

by the 25th day to request PASRR Level II, when it is apparent

SUMMARY and DETERMINATION

the stay will exceed 30 days.

FHSC USE ONLY:

Has indicators of MI, MR/RC

No indicators of MI,

Meets EHD criteria?

Y

N

MR/RC

Limitation Date:

Level I Identification Determination:

PASRR LEVEL II CATEGORICAL DETERMINATIONS

IA - Exempted Hospital Discharge

SECTION V: Time-Limited* CATEGORICAL DETERMINATIONS

IA - Qualifies for Categorical Determination

IIE. The following categories indicate the individual requires NF services

IA - Requires PASRR Level II Individual Evaluation

and does not require specialized services for the time specified.

IB - Has Dementia, Alzheimer's, Organic Brain Syndrome

A. _____ Convalescent care from an acute physical illness which

IC - Not MI, MR/RC or Demented

required hospitalization and does not meet all criteria for an EHD.

B.

Emergency protective service situation for MI or MR/RC

PASRR Level II Categorical Determination:

individual - placement in NF not to exceed 7 days.

PAS (applicant to NF)

RR (resident in NF)

C.

Delirium precludes the ability to accurately diagnose. Facility

must obtain PASRR Level II as soon as the delirium clears.

IIE - Time Limited Approval Limitation Date: ________

D.

Respite is needed for in-home caregivers to whom the MI,

IIF - Terminal Illness

MR/RC individual will return.

IIG - Severe Physical Illness

*If any of the above are checked, receiving facility must submit a

new Level I to request PASRR Level II ten (10) days prior to the

Referral Needed for PASRR Level II Individual Evaluation:

limitation date listed below for resident's whose stay is anticipated

Referred for MI

Date Referred:

to exceed that date.

Referred for MR/RC

Date Referred:

FHSC USE ONLY: Meets IIE Categorical Determination Criteria?

Dual Referral MI and MR/RC

Date:

A.

Y

N

B.

Appropriate for NF

Y

N

Limited to: ____________________

Date Completed

FHSC Reviewer's Name/Signature

Note: Limitations for Convalescent care = 45 days, Emergency Protective Services = 7 days,

Delirium = 30 days, and Respite = 30 days.

FHSC-18

Jul 2003

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