PASRR LEVEL I SCREEN - KePRO

1 PASRR LEVEL I SCREEN . DETERMINATION FOR MENTAL ILLNESS, INTELLECTUAL DISABILITY, AND OTHER RELATED CONDITIONS. IF YOU NEED ASSISTANCE WITH COMPLETING THIS FORM OR HAVE GENERAL QUESTIONS ABOUT PASRR , PLEASE CALL KePRO AT 1-833-525-5784. All LEVEL II Assessment decisions or deferral/waiver of a LEVEL II Assessment must be made by KePRO , a designee of the Maine Department of Health & Human Services (DHHS). PLEASE SUBMIT ALL PAGES, INCLUDING THE SIGNED ATTESTATION ON PAGE 4. 1. SUBMITTING HOSPITAL/AGENCY INFORMATION. HOSPITAL/AGENCY NAME DATE. FAX NUMBER PHONE NUMBER. PRINT NAME/LICENSURE/TITLE OF PERSON COMPLETING FORM. 2. CONSUMER INFORMATION. LAST NAME FIRST NAME DATE OF BIRTH SOCIAL SECURITY NUMBER. MAINECARE NUMBER MEDICARE NUMBER OTHER PAYER SOURCE. HOME STREET ADDRESS TOWN, STATE, ZIP CODE PHONE. 3. EMERGENCY CONTACT INFORMATION.

2 NAME. RELATIONSHIP GUARDIAN Y N. POA Y N. MAILING ADDRESS TOWN, STATE, ZIP CODE. PHONE FAX. 4. ANTICIPATED OR CURRENT NURSING FACILITY. FACILITY NAME (IF UNKNOWN ENTER TBD ) PHONE. FACILITY STREET ADDRESS TOWN, STATE, ZIP CODE. SHORT-TERM REHAB, SKILLED CARE, RESPITE ESTIMATED NUMBER OF DAYS IN FACILITY. PERMANENT PLACEMENT (LTC). 5. DEMENTIA DIAGNOSIS AND/OR SUBSTANCE RELATED DISORDER. DOES THE INDIVIDUAL HAVE A DEMENTIA DIAGNOSIS? Y N. IF YES, DSM CODE (# REQUIRED) _____. IS DEMENTIA THE PRIMARY DIAGNOSIS? Y N IF DEMENTIA IS PRIMARY, PROVIDE THE DATE OF THE DIAGNOSIS. AND THE NAME OF THE CLINICIAN: DOES THE INDIVIDUAL HAVE A SUBSTANCE RELATED DISORDER? Y N. DIAGNOSIS (Dx): PLEASE MARK THIS BOX TO INDICATE IF THIS SCREEN IS FOR A CHANGE IN CONDITION. KePRO Fax 844-356-7500 Page 1 of 4. EFFECTIVE: 1/11/18. PASRR LEVEL I SCREEN .

3 DETERMINATION FOR MENTAL ILLNESS, INTELLECTUAL DISABILITY, AND OTHER RELATED CONDITIONS. IF YOU NEED ASSISTANCE WITH COMPLETING THIS FORM OR HAVE GENERAL QUESTIONS ABOUT PASRR , PLEASE CALL KePRO AT 1-833-525-5784. SE CALL GOOLD HEALTH SYSTEMS AT 1-800-609-7893. APPLICANT NAME: 6. MENTAL ILLNESS (MI). HAS THE INDIVIDUAL EVER BEEN DIAGNOSED WITH OR IS. THERE A SUSPICION OF A MENTAL ILLNESS? Y N. DIAGNOSIS (Dx) OR SUSPECTED MENTAL ILLNESS. HOW LONG HAS THE INDIVIDUAL HAD THIS DIAGNOSIS? DSM CODE (NUMBER REQUIRED). DOES THE INDIVIDUAL Y N INABILITY TO COMMUNICATE EFFECTIVELY WITH OTHERS. HAVE A SUSPECTED Y N INABILITY TO COMPLETE SIMPLE TASKS UNASSISTED. MENTAL ILLNESS AS Y N SERIOUS DIFFICULTY INTERACTING WITH OTHERS APPROPRIATELY. EVIDENCED BY ANY OF. Y N DANGER TO SELF OR OTHERS, AGGRESSIVE, ASSAULTIVE, SUICIDAL.

4 THE FOLLOWING: Y N FREQUENTLY ISOLATES OR AVOIDS OTHERS OR EXHIBITS SIGNS THAT SUGGEST. SEVERE ANXIETY OR FEAR OF STRANGERS. Y N OTHER MAJOR MENTAL HEALTH SYMPTOMS THAT HAVE EMERGED OR. WORSENED AS A RESULT OF RECENT LIFE CHANGES; INDIVIDUAL NOW HAS. ONGOING SYMPTOMS. DID THE INDIVIDUAL Y N HOSPITALIZATION FOR PSYCHIATRIC CARE. HAVE AN Y N SUPPORTIVE SERVICES AT HOME (DAILY LIVING SUPPORT SERVICES/DLSS). INTERVENTION DUE Y N HOUSING OR LAW ENFORCEMENT INTERVENTION. TO A MENTAL ILLNESS. Y N RESIDENTIAL TREATMENT (PNMI LEVEL OF CARE). IN THE PAST 2 YEARS, SUCH AS: Y N INTENSIVE COMMUNITY SUPPORTS (CASE MANAGEMENT SERVICES/CI/ACT). 7. NEXT STEPS. WERE ANY OF THE ANY YES RESPONSE FOR QUESTIONS ( ), ( ) OR ( ) MEETS PASRR CRITERIA FOR THE PRESENCE. RESPONSES ABOVE OF MENTAL ILLNESS OR THAT THE PRESENCE OF MENTAL ILLNESS IS SUSPECTED.

5 FAX THIS ENTIRE. YES ? FORM TO KePRO FOR DETERMINATION ON WHETHER A LEVEL II IS NECESSARY. WERE ALL OF THE IF THE RESPONSES TO THE ABOVE QUESTIONS ARE ALL `NO' AND THERE IS NO MENTAL ILLNESS. RESPONSES ABOVE DIAGNOSIS, OR ONLY A DEMENTIA DIAGNOSIS, FAX THIS FORM TO THE NURSING FACILITY PRIOR. NO ? TO DISCHARGE AND NOT TO KePRO . PASRR SCREENING MATERIAL IS TO BE KEPT IN THE. CONSUMER'S ACTIVE FILE AND MAY BE SUBJECT TO AUDIT. KePRO Fax 844-356-7500 Page 2 of 4. EFFECTIVE: 1/11/18. PASRR LEVEL I SCREEN . DETERMINATION FOR MENTAL ILLNESS, INTELLECTUAL DISABILITY, AND OTHER RELATED CONDITIONS. IF YOU NEED ASSISTANCE WITH COMPLETING THIS FORM OR HAVE GENERAL QUESTIONS ABOUT PASRR , PLEASE CALL KePRO AT 1-833-525-5784. APPLICANT NAME: 8. INTELLECTUAL DISABILITY (ID). An applicant is considered to have an intellectual disability (ID), autism or a pervasive developmental disorder (PDD) if the criteria listed below are met OR the individual has previously been found eligible for services based on a diagnosis of an ID, autism or a PDD.

6 By DHHS. Documentation is not necessary to support the criterion as long as the individual is suspected to meet the criterion based on observations and knowledge about the individual. HAS THE INDIVIDUAL EVER BEEN DIAGNOSED WITH OR IS THERE A SUSPICION OF AN. INTELLECTUAL DISABILITY, AUTISM OR A PDD? Y N. IF YES, PLEASE SPECIFY: ANSWER ALL OF THE QUESTIONS ON THE REST OF THE PAGE EVEN IF THE RESPONSE ABOVE IS NO . THE INDIVIDUAL HAS IMPAIRMENTS IN ADAPTIVE BEHAVIOR THAT SHOW A. SIGNIFICANT LIMITATION IN MEETING THE STANDARDS OF THE FOLLOWING FOR Y N. HIS/HER AGE AND CULTURAL GROUP: MATURATION. LEARNING. PERSONAL INDEPENDENCE. SOCIAL RESPONSIBILITY. THE INDIVIDUAL HAS IMPAIRMENTS IN ADAPTIVE BEHAVIOR THAT. SHOW SUBSTANTIAL FUNCTIONAL LIMITATION IN 3 OR MORE OF THE SELF-CARE. FOLLOWING AREAS OF MAJOR LIFE ACTIVITIES, WHICH ARE NOT UNDERSTANDING/USE OF LANGUAGE.

7 RELATED TO THE NORMAL AGING PROCESS. LEARNING. MOBILITY. CHECK ALL AREAS OF SUBSTANTIAL FUNCTIONAL LIMITATION WHICH SELF-DIRECTION. WERE PRESENT PRIOR TO AGE 18 AND WERE DIRECTLY THE RESULT OF CAPACITY FOR INDEPENDENT LIVING. THE ID. WERE 3 OR MORE LIMITATIONS. NOTED? SERVICES: HAS THE INDIVIDUAL RECEIVED SERVICES FROM A DEVELOPMENTAL. SERVICES AGENCY IN THE PAST OR BEEN FOUND ELIGIBLE FOR SERVICES BY DHHS Y N. BASED ON A DIAGNOSIS OF AN ID, AUTISM OR A PDD? IF YES, PLEASE IDENTIFY DHHS. REGION & CASEWORKER: FACILITIES: HAS THE INDIVIDUAL EVER BEEN A RESIDENT OF A DEVELOPMENTAL. DISABILITY FACILITY OR ICF/IID? IF YES, PLEASE IDENTIFY FACILITY: Y N. 9. NEXT STEPS. WERE ANY OF THE ANY YES RESPONSE FOR QUESTIONS ( , AND ) OR ( ) OR ( ) MEETS PASRR CRITERIA. RESPONSES ABOVE FOR DIAGNOSIS OR SUSPICION OF ID, AUTISM OR PDD.

8 FAX THIS ENTIRE FORM TO KePRO . KePRO . YES ? WILL DETERMINE WHETHER A LEVEL II IS NECESSARY. WERE ALL OF THE IF THE RESPONSES TO THE ABOVE QUESTIONS ARE ALL `NO' AND THERE IS NO MENTAL ILLNESS. RESPONSES ABOVE DIAGNOSIS, OR ONLY A DEMENTIA DIAGNOSIS, FAX THIS FORM TO THE NURSING FACILITY PRIOR TO. NO ? DISCHARGE AND NOT TO KePRO . PASRR SCREENING MATERIAL IS TO BE KEPT IN THE CONSUMER'S. ACTIVE FILE AND MAY BE SUBJECT TO AUDIT. KePRO Fax 844-356-7500 Page 3 of 4. EFFECTIVE: 1/11/18. PASRR LEVEL I SCREEN . DETERMINATION FOR MENTAL ILLNESS, INTELLECTUAL DISABILITY, AND OTHER RELATED CONDITIONS. IF YOU NEED ASSISTANCE WITH COMPLETING THIS FORM OR HAVE GENERAL QUESTIONS ABOUT PASRR , PLEASE CALL KePRO AT 1-833-525-5784. APPLICANT NAME: 10. OTHER RELATED CONDITIONS (ORC). Persons with related conditions means individuals who have a severe, chronic disability that meets all of the following conditions: is attributed to epilepsy or cerebral palsy; or any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of mentally retarded persons, and requires treatment or services similar to those required for these persons; and it is manifested before the person reaches age 22; and it is likely to continue indefinitely.

9 And it results in substantial functional limitations in three or more of the following areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living. HAS THE INDIVIDUAL BEEN DIAGNOSED WITH OR Y N CEREBRAL PALSY. SUSPECTED OF HAVING ONE OR BOTH OF THE. FOLLOWING CONDITIONS? Y N EPILEPSY. DOES THE INDIVIDUAL HAVE ANY OTHER CONDITION, Y N. OTHER THAN A SERIOUS MENTAL ILLNESS THAT: Is closely related to an intellectual disability (ID). IF YES, PLEASE SPECIFY: Results in impairment of general intellectual functioning or adaptive behavior similar to that of individuals with an ID. Requires treatment or services similar to those required for individuals with an ID. IF ALL OF THE QUESTIONS ABOVE RESULTED IN NO STOP HERE AND GO TO SECTION 11 ON THIS PAGE.

10 If more than one condition is YES , answer the remaining questions on this page for each condition. One ORC form may be submitted with separate responses for each condition. DID THE ORC MANIFEST BEFORE THE INDIVIDUAL. Y N. REACHED THE AGE OF 22? IS THE ORC LIKELY TO CONTINUE INDEFINITELY? Y N. CHECK ALL AREAS OF SUBSTANTIAL FUNCTIONAL. SELF-CARE. LIMITATION WHICH WERE PRESENT PRIOR TO AGE 22. UNDERSTANDING/USE OF LANGUAGE. AND WERE DIRECTLY THE RESULT OF THE ORC. LEARNING. MOBILITY. SELF-DIRECTION. CAPACITY FOR INDEPENDENT LIVING. WERE 3 OR MORE LIMITATIONS NOTED? 11. NEXT STEPS. WERE ANY OF THE ANY YES RESPONSE FOR QUESTIONS ( ) OR ( ) AND ( , , ) MEETS PASRR . RESPONSES ABOVE CRITERIA FOR THE DIAGNOSIS OF ORC. FAX THIS ENTIRE FORM TO KePRO . KePRO WILL. YES ? DETERMINE WHETHER A LEVEL II IS NECESSARY. WERE ALL OF THE IF THE RESPONSES TO THE ABOVE QUESTIONS ARE ALL `NO' AND THERE IS NO MENTAL ILLNESS.