№ lp_1_2_64612
File format: docx Character count: 11688 File size: 49 KB
Note: Year
Context: Processing and handling procedures for FVO-115 referral forms in client assessment processes for the New Jersey welfare system.
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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
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
Topics: FVO-115 FORMSWHAT faxed