Section A - TMHP

1 PASRR Level 1 Screening, September, 2017, 1 of 12 DLNI ndividualA0800. Position/TitleA0400. Provider StatePASRR Level 1 ScreeningA0600. Date of AssessmentA0700A. First NameA0700B. Middle InitialA0200B. CityA0200D. ZIP CodeA0500. Vendor NPI/APIA0510. CountyA0700C. Last NameA0700D. SuffixA0900B. Other Type of EntityA0900A. Type of EntitySection A1. Acute Care 2. Psychiatric Hospital 3. ICF/IID 4. Family Home 5. Nursing Facility 6. Physician (MD/DO) 7. OtherA0900C. Physician First NameA0900D. Physician Middle InitialA0900E. Physician Last NameA0900F. Physician Suffix A0100. NameSubmitter Information (NF/LA only)A0200A. Street AddressReferring Entity Information (Screener)A1000A. NameA1000B. Street AddressA1000D. StateA1000E. ZIP CodeA1000F. Phone NumberA1000C. CityA1100. Date of Last Physical ExaminationA1200B.

2 Signature DateA1200A. Certification of SignatureI certify that to the best of my knowledge this information is true and Level 1 Screening, September, 2017, 2 of 12 DLNI ndividualB0700A. Previous Residence TypeB0700B. Other Residence Type1. Private Home 2. ICF/IID 3. Waiver Setting 4. Nursing Facility 5. Other 6. UnknownPersonal Information (Individual being screened)B0100A. First NameB0100B. Middle InitialB0100C. Last NameB0100D. SuffixB0200A. social security Medicaid Medicare Birth DateB0500. Age at Time of ScreeningB0600. Gender1. Male 2. FemaleSection BB0700C. Street AddressB0700D. CityB0700E. StateB0700F. ZIP CodePrevious ResidenceB0650. Individual is deceased or has been discharged?0. Deceased 1. DischargedB0655. Deceased/Discharged DateB0700G. County of ResidencePASRR Level 1 Screening, September, 2017, 3 of 12 DLNI ndividualB0800B.

3 Other Relationship to IndividualB0800A. Relationship to Individual1. Legally Authorized Representative 2. Spouse 3. Child 4. Parent 5. Sibling 6. OtherB0800J. StateB0800K. ZIP CodeB0800I. CityB0800C. First NameB0800D. Middle InitialB0800E. Last NameB0800F. SuffixB0800H. Street AddressB0800G. Phone NumberNext of KinPASRR Level 1 Screening, September, 2017, 4 of 12 DLNI ndividualPASRR Screen (Screener) Section CC0100. Mental Illness0. No 1. YesIs there evidence or an indicator this is an individual that has a Mental Illness?C0200. Intellectual DisabilityIs there evidence or an indicator this is an individual that has an Intellectual Disability?C0300. Developmental DisabilityIs there evidence or indicators that this is an individual that has a Developmental Disability (Related Condition) other than an Intellectual Disability ( , Autism, Cerebral Palsy, Spina Bifida)?

4 Local Authority Information (LA only)C0500. LA - MI Vendor LA - MI NPI/API LA - IDD Vendor LA - IDD NPI/API LA - MI Provider LA - IDD Provider No 1. Yes0. No 1. YesPASRR Level 1 Screening, September, 2017, 5 of 12 DLNI ndividualSection D Nursing Facility Choices - 1D0100B. Vendor NPID0100A. Provider Facility NameD0100E. Street AddressD0100H. ZIP CodeD0100I. PhoneD0100G. StateD0100M. NF Contact Suffix D0100K. NF Contact Middle Initial D0100J. NF Contact First NameD0100L. NF Contact Last Name0. No 1. Yes0. No 1. YesD0100P. NF Date of EntryD0100F. CityD0100N. NF is willing and able to serve individualD0100O. NF Admitted the IndividualD0100Q. CommentsPASRR Level 1 Screening, September, 2017, 6 of 12 DLNI ndividualNursing Facility Choices - 2D0100B. Vendor NPID0100A. Provider Facility NameD0100E.

5 Street AddressD0100H. ZIP CodeD0100I. PhoneD0100G. StateD0100M. NF Contact Suffix D0100K. NF Contact Middle Initial D0100J. NF Contact First NameD0100L. NF Contact Last Name0. No 1. Yes0. No 1. YesD0100P. NF Date of EntryD0100F. CityD0100N. NF is willing and able to serve individualD0100O. NF Admitted the IndividualD0100Q. CommentsPASRR Level 1 Screening, September, 2017, 7 of 12 DLNI ndividualNursing Facility Choices - 3D0100B. Vendor NPID0100A. Provider Facility NameD0100E. Street AddressD0100H. ZIP CodeD0100I. PhoneD0100G. StateD0100M. NF Contact Suffix D0100K. NF Contact Middle Initial D0100J. NF Contact First NameD0100L. NF Contact Last Name0. No 1. Yes0. No 1. YesD0100P. NF Date of EntryD0100F. CityD0100N. NF is willing and able to serve individualD0100O. NF Admitted the IndividualD0100Q.

6 CommentsPASRR Level 1 Screening, September, 2017, 8 of 12 DLNI ndividualNursing Facility Choices - 4D0100B. Vendor NPID0100A. Provider Facility NameD0100E. Street AddressD0100H. ZIP CodeD0100I. PhoneD0100G. StateD0100M. NF Contact Suffix D0100K. NF Contact Middle Initial D0100J. NF Contact First NameD0100L. NF Contact Last Name0. No 1. Yes0. No 1. YesD0100P. NF Date of EntryD0100F. CityD0100N. NF is willing and able to serve individualD0100O. NF Admitted the IndividualD0100Q. CommentsPASRR Level 1 Screening, September, 2017, 9 of 12 DLNI ndividualD0100B. Vendor NPID0100A. Provider Facility Choices - 5D0100D. Facility NameD0100E. Street AddressD0100H. ZIP CodeD0100I. PhoneD0100G. StateD0100M. NF Contact Suffix D0100K. NF Contact Middle Initial D0100J. NF Contact First NameD0100L. NF Contact Last Name0.

7 No 1. Yes0. No 1. YesD0100P. NF Date of EntryD0100F. CityD0100N. NF is willing and able to serve individualD0100O. NF Admitted the IndividualD0100Q. CommentsPASRR Level 1 Screening, September, 2017, 10 of 12 DLNI ndividualE0400. Comments about with whom the individual would like to liveE0200. Comments about where the individual would like to liveD. With a lot of friendsF. Other IndividualC. With familyE. OtherG. UnknownE0300. Living Arrangement Options Check all that applyB. With a roommateA. By themselvesG. UnknownF. Other LocationC. A group homeD. Family homeE. OtherB. A place where there is 24 hour careA. Live alone with supportE0100. Where would this individual like to live now? Check all that applySection EAlternate Placement Preferences (Screener)PASRR Level 1 Screening, September, 2017, 11 of 12 DLNI ndividualE0700.

8 Name of ICF/IID FacilityE0800. Own Home/Family Home CommentsE0900. Alternate Placement Date of EntryE0500A. Admitted ToE0500B. Admitted to Other1. Community Program 2. ICF/IID 3. Own home/family home 4. OtherE0600A. Community ProgramE0600B. Other Community Program1. CLASS (SG 2) 2. CBA (SG 3) 3. PACE (SG 11) 4. DBMD (SG 16) 5. MDCP (SG 18) 6. STAR+Plus (SG 19) 7. HCS (SG 21) 8. TxHmL (SG 22) 9. YES (DSHS Waiver) 10. OtherAlternate Placement Disposition (Screener)PASRR Level 1 Screening, September, 2017, 12 of 12 DLNI ndividualF0100. Exempted Hospital Discharge Has a physician certified that individual is likely to require less than 30 days of NF services? (For individuals being admitted from acute care in the hospital) Section F0. No 1. YesAdmission Category (RE/LA)F0200. Expedited Admission Does this individual meet any of the following categories for an expedited admission into the nursing facility?

9 0. Not Expedited Admission 1. Convalescent Care: Individual is admitted from an acute care hospital to an NF for convalescent care with an acute physical illness or injury which required hospitalization and is expected to remain in the NF for greater than 30 days. 2. Terminally Ill: Individual has a medical prognosis that his or her life expectancy is 6 months or less if the illness runs its normal course. An individual's medical prognosis is documented by a physician's certification, which is kept in the individual's medical record maintained by the nursing facility. 3. Severe Physical Illness: An illness resulting in ventilator dependence or diagnosis such as chronic obstructive pulmonary disease, Parkinson's disease, Huntington's disease, amyotrophic lateral sclerosis, congestive heart failure, which result in a level of impairment so severe that the individual could not be expected to benefit from specialized services.

10 4. Delirium: Provisional admission pending further assessment in case of delirium where an accurate diagnosis cannot be made until the delirium clears. 5. Emergency Protective Services: Provisional admission pending further assessment in emergency situations requiring protective services, with placement in the nursing facility not to exceed 7 days. 6. Respite: Very brief and finite stay of up to a fixed number of days to provide respite to in-home caregivers to whom the individual with MI or ID is expected to return following the brief NF stay. 7. Coma: Severe illness or injury resulting in inability to respond to external communication or stimuli, such as coma or functioning at brain stem level.(Please select one category below)