Government of the District of Columbia

Level I Pre-Admission Screen/Resident Review for SMI, ID, or Related Conditions

PASRR is required before any admission to a Medicaid-certified nursing facility (NF), regardless of payment source (Medicaid, Medicare, or private pay).

BENEFICIARY INFORMATION

Last Name*

First Name*

M I

Gender*

Insurance coverage type*

Medicaid

Medicare

Commercial

Other

If it is other

DC Medicaid Number (If the beneficiary is new to DC Medicaid and does not yet have a Medicaid number, please note "N/A.”)*

Social Security Number

Date Of Birth*

Current Location*

Select or enter value

Current Location Address*

Beneficiary Phone Number

Facility phone Number (If applicable)

Assessment Type:*

Select or enter value

Authorized Representative

Commitment

Legal Guardian-Conservator

Legal Representative/POA

Applicant agrees to legal guardian and/or family participation?

Yes

Interpreter Required?

Yes

Primary language

Select or enter value

Interpreter Name

Legal Guardian/POA Name

Legal Guardian/POA Telephone #

Phone

Legal Guardian/POA Address (Street, City, State, Zip Code)

Family Member/Caregiver Name

Family Member/Caregiver Telephone #

Phone

Family Member/Caregiver Address (Street, City, State, Zip Code)

SECTION A: EXEMPTING CRITERIA

Beneficiary admitted to nursing facility directly from hospital after receiving acute inpatient care?*

Yes

Beneficiary requires nursing facility services for the condition he/she received acute inpatient care?*

Yes

Beneficiary is likely to require less than 30 days nursing facility services?*

Yes

Print Physician Name and Title (Physician signature is only required if all the three (3) conditions above are met, that is “Yes”)*

Request for Physician signature*

Select

Physician E-mail Address*

Signature of Ordering Physician (I certify the information in this section is accurate to the best of my knowledge and understand that knowingly submitting inaccurate, incomplete, or misleading information constitutes Medicaid fraud)

Date

Further completion of this form is required even if the beneficiary meets all the exemptions listed in Section A. Beneficiary is being admitted under the 30-day hospital discharge exemption. If the beneficiary’s length of stay exceeds 30 days, the Level II evaluation must be completed no later than the 40th day of admission, on or before the date:

SECTION B: EVALUATION CRITERIA FOR SERIOUS MENTAL ILLNESS (SMI)

1. Does the beneficiary have a known diagnosis of a major mental disorder?*

Yes

Unknown

If yes, list diagnosis and DSM Code*

2. Does the beneficiary 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?*

Yes

Unknown

If “Yes” specify diagnosis based on DSM-5 or current ICD criteria.*

3. Does the beneficiary have a history of any substance-related disorder diagnosis?*

Yes

Unknown

If “Yes”, specify diagnosis*

The beneficiary is considered to have a positive serious mental illness (SMI) if (1) questions 1 or 2 in Section B are answered “Yes”. With a positive screen for SMI the beneficiary must be referred to the District of Columbia Department of Behavioral Health or Designee for a Level II evaluation

SECTION C: SYMPTOMS

1. Does the beneficiary have any current or historical significant impairment in functioning related to a suspected or known diagnosis of mental illness?*

Select

If yes, When*

Select or enter value

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.
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.
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.

Check box preceding description if any subcategories below are applicable:*

Interpersonal functioning

Concentration, persistence, and pace

Adaptation to change

N/A

2 a. Within the last two years has the beneficiary 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);*

Yes

2 b. Within the last two years has the beneficiary experienced one psychiatric treatment episode 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?*

Yes

Narrative information including dates

The beneficiary’s behaviors/symptoms are stable and not presenting a risk to self or others?*

Yes

If questions 1 and 2 In Section B are checked“No”, but question 1 in Section C is “Yes” and a box is checked in question 2, the Level 1 form must be sent to the District of Columbia Department of Behavioral Health or Designee to determine if a Level II evaluation is needed.

SECTION D: INTELLECTUAL DISABILITY** (ID)RELATED CONDITIONS(RC)

1. Does the beneficiary have a diagnosis of ID or related condition (mild, moderate, severe, or profound)?*

Select or enter value

List diagnosis (es) or evidence:*

2. Beneficiary diagnosed with ID prior to age 18?*

Yes

3. Presenting evidence (cognitive or behavior functions) indicating beneficiary has ID or related condition that has not been diagnosed?*

Yes

4. Is the beneficiary registered for services with an agency which serves individuals with ID or related conditions?*

Yes

a. If Yes, describe the services the beneficiary is receiving:*

b. Name of service provider and contact information:*

c.If No, is the beneficiary interested in receiving services?*

Yes

5. Has the beneficiary ever been a resident of a state facility including a state hospital, a state school, or other state facility?*

Yes

Unknown

If Yes, indicate the name of the facility and the date(s)*

6. Does the beneficiary have a current diagnosis, history or evidence of a related condition that may include a severe, chronic disability that is attributable to a condition other than mental illness that results in impairment of general intellectual functioning or adaptive behavior?*

Yes

If other

Was the date of onset prior to age 22?*

Yes

If yes, explain*

Beneficiary is considered to have a positive screen for ID or related condition if one or more of the above questions in the above section are answered Yes. As a result, the beneficiary must be referred to the District of Columbia Department of Disability Services or Designee for Level II evaluation. If all of the questions are answered no, the beneficiary has a negative screen for ID or related condition.

SECTION E: DEMENTIA

The beneficiary has a diagnosis of dementia (including Alzheimer’s disease or related disorder) based on criteria in the DSM-5 or current version of the ICD codes:*

Select or enter value

If yes, specify DSM-5 or ICD codes:*

The following criteria were used to establish the basis for a dementia diagnosis*

If other, please specify*

The physician documented dementia as the primary diagnosis OR that dementia is more progressed than a co-occurring mental illness diagnosis. Explain documentation and verification*

A primary diagnosis of dementia, including Alzheimer’s disease or related disorder IS NOT considered a major mental illness. Dementia applies to beneficiaries with a confirmed diagnosis of dementia that has been documented as a primary diagnosis more progressed than a co-occurring mental illness. If there is no confirmed diagnosis of dementia, check N/A. Only if the boxes in front of ALL THREE statements above are checked, is the beneficiary designated as having primary mental illness dementia exclusion. If none of the statements above are checked, then the beneficiary is not designated as having primary mental illness dementia exclusion.

SECTION F: ADVANCE GROUP DETERMINATION

1. Is the beneficiary being admitted for convalescent care not to exceed 120 days due to an acute physical illness which required hospitalization and does not meet all criteria for an exempt hospital discharge (described in Section A)?*

Yes

2. Does the beneficiary have a terminal illness (life expectancy of less than six months) as certified by a physician?*

Yes

3. Does the beneficiary have a severe physical illness, such as coma, ventilator dependence, functioning at a brain stem level or other diagnoses which result in a level of impairment so severe that the beneficiary couldnot be expected to benefitfrom specialized services?*

Yes

4. Is this beneficiary being provisionally admitted pending further assessment due to an emergency situation requiring protective services? The stay will not exceed 7 days.*

Yes

5. Provisional Delirium:The presence of delirium in people with known or suspected MI and/or ID precludes the ability to make an accurate diagnosis. The person’s Level I Screen and LOC will be updated no greater than 7 calendar days following admission to the NF (a physician signed statement certifying the delirium state must accompany this screen).

6. Is the beneficiary being admitted for a stay not to exceed 14 days to provide respite?*

Yes

If the beneficiary is considered to have SMI, ID or RC, complete this section. Otherwise, skip this section and complete Section G. If any questions in this section are checked yes, there is no need for a Level II referral.

SECTION G: RESULTS OF SMI/ID (CHECK ALL THAT APPLY)

Beneficiary has negative screen for serious mental illness and no further action is necessary.

Beneficiary has negative screen for ID or related conditions and no further action is necessary.

Beneficiary has a positive screen for serious mental illness and a PASRR referral Level II evaluation, psycho-social assessment, history and physical and Level of Care (LOC) has been forwarded to DBH or Designee for review

Beneficiary has a possible positive screen and the Level I form has been forwarded to DBH or Designee for review

Beneficiary has a positive screen for intellectual disability and has been referred to DDS or Designee for a Level II evaluation.

Notice of referral for Level II, if applicable, distributed to Beneficiary/Representative

Yes

If yes, Date:

I certify the information in this form is accurate to the best of my knowledge and understand that knowingly submitting inaccurate, incomplete, or misleading information constitutes Medicaid fraud

Submitter Name*

Submitter Email*

Submitter Signature and Title*

Today's Date*

If ePASRR is positive for Level-II, please attach the following required documents for Level-II review:

Psychological evaluation

Psychiatric evaluation

Hospital discharge plans

History and physical including current medications

Assessments pertaining to the medical condition such as therapy notes

Other documents as needed

File Upload

Drag and drop files here or

For individuals who wish to be enrolled in Medicaid-certified nursing facility, please send this form along with the Prescription Order Form (ePOF) to Telligen. For fax option, please fax to 202-974-6703.

Do not forget to check off "Send me a copy of my responses box below" to receive full copy of PASRR Level I Screen then send the full copy to Telligen via DCPASRR@Telligen.com.*

Send me a copy of my responses

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