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 42 CFR § 483.106. 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 http://www.state.nj.us/humanservices/doas/home/forms.html

№ lp_1_2_44599

File format: docx Character count: 18454 File size: 58 KB

This document is a screening form used for the assessment of mental illness, intellectual disability, developmental disability, and related conditions prior to nursing facility admission, in compliance with federal regulations.

Note: . 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.

Year: N/A

Region / City: N/A

Topic: Mental Illness and Intellectual Disability Screening

Document Type: Form

Institution / Organization: New Jersey Department of Human Services

Author: N/A

Target Audience: Healthcare providers and applicants for nursing facility admission

Effective Period: N/A

Approval Date: N/A

Modification Date: N/A

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