Form Fa-18 Pre-Admission Screening Resident Review (Pasrr) Level 1 Identification Screening Page 3
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4SECTION 2: MENTAL RETARDATION (MR) AND RELATED CONDITIONS (RC) SCREENING
1A. Has recipient been diagnosed with MR?
No
Yes—specify type/diagnosis:_____________________________________
1B. Is MR suspected but undiagnosed?
No
Yes
1C. Does recipient have a history of receiving MR services?
No
Yes—specify: _______________________________________
______________________________________________________________________________________________________
2. Was the MR occurrence before age 18?
No
Yes—specify age: ______
2A. Check all related conditions that impair intellectual functioning or adaptive behavior:
Blindness
Cerebral Palsy
Autism
Seizure Disorder
Deafness
Closed head injury
Other—specify: ____________________________________________________________________________________
2B. Check all substantial functional limitations (recipient must have three of the following limitations to meet MR/RC criteria):
Self care
Self direction
Mobility
Capability of independent living
Learning
Understanding/Use of language
2C. Was the condition from item 2A manifested before age 22?
Yes—specify age: ______
No
Hewlett Packard Enterprise Use Only: Meets criteria for MR/MC? No
Yes
SECTION 3: DEMENTIA Check all that apply.
A. Is the recipient’s primary diagnosis Alzheimer’s disease?
No
Yes
Dementia?
No
Yes
B. Does the recipient have any other organic disorders?
No
Yes-specify: _________________________________________
C. Is the recipient disoriented to:
Time?
Place?
Situation?
Does the recipient display:
Severe ST memory deficit?
Pervasive, significant confusion?
Paranoid ideation?
D. Is there evidence of any of the following (which might be confused with dementia)?
Frequent tearfulness
Frequent anxiety
Severe sleep disturbance
Severe appetite disturbance
E. Can the requestor show dementia is the primary diagnosis?
No
Yes—specify:
Dementia work-up
Thorough mental status exam
Medical/functional history prior to onset of dementia
Other—
: _______________________________________________________________________________
specify
Hewlett Packard Enterprise Use Only: Meets criteria for dementia? No
Yes
SECTION 4: EXEMPTED HOSPITAL DISCHARGE (EHD) A recipient meeting all criteria below does not require a PASRR Level II for
30 days. Admitting facility must submit PASRR Level I by 25th day to request PASRR Level II if it becomes apparent the stay will
exceed 30 days. Check all that apply.
Recipient was directly admitted to a Nursing Facility after receiving acute inpatient care in a hospital
Recipient requires Nursing Facility services for the condition for which the recipient received care in the hospital
Attending physician has certified prior to NF admission that the recipient will require less that 30 days of NF services
Name of Certifying Physician: ____________________________________________________________________
(Attach physician certification to justify EHD and check the appropriate box in Section 7, “Attachments.”)
Hewlett Packard Enterprise Use Only: Meets EHD criteria? No
Yes
Limitation Expiration Date:
SECTION 5: ---PASRR LEVEL II--- TIME LIMITED CATEGORICAL DETERMINATIONS If a stay is anticipated to exceed the time limit,
the admitting facility must submit a new PASRR Level I to request PASRR Level II at least 10 business days prior to the end of the time
limit. The following categories indicate the individual requires NF services and does not require specialized services for the time specified.
IIE. Check all that apply:
Convalescent care needed from acute physical illness that required hospitalization. Does not meet all EHD criteria. (Time Limit = 45 days)
Emergency protective service for MI or MR/RC recipient–placement in Nursing Facility not to exceed 7 days. (Time Limit = 7 days)
Delirium precludes ability to accurately diagnose. Facility must obtain PASRR Level II as soon as delirium clears. (Time Limit = 30 days)
Respite care is needed for in-home caregivers to whom the recipient with MI, MR/RC will return. (Time Limit = 30 days)
Hewlett Packard Enterprise
Only: Meets IIE criteria?
No
Yes Appropriate for NF?
No
Yes Number of Days:____
SECTION 6: ---PASRR LEVEL II--- OTHER CATEGORICAL DETERMINATIONS Check all that apply.
IIF. Terminal Illness where physician has certified life expectancy of less than 6 months
(Attach a physician certification of terminal illness and check the appropriate box in Section 7, “Attachments.”)
IIG. Severe Physical Illness limited to coma, ventilator dependence functioning at a brain stem level or a diagnosis of Parkinson’s,
Chronic Obstructive Pulmonary Disease, Huntington’s disease, Amyotrophic lateral sclerosis or congestive heart failure which result
in a level of impairment so severe that the individual could not be expected to benefit from specialized services.
Hewlett Packard Enterprise Use Only: Meets Other Categorical Determination criteria?
Yes
No
SECTION 7: ATTACHMENTS Check all that apply. Submit appropriate documentation with this form.
Supporting documentation is attached (may be required if recipient has indicators of MI, MR/RC).
Physician certification to justify EHD is attached (states that recipient will require no more than a 30 day stay).
Physician certification of terminal illness is attached (states that recipient’s life expectancy is less than 6 months).
Hewlett Packard Enterprise Use Only: Does recipient meet other categorical determination criteria?
Yes
No
Does recipient have MI, MR/RC indicators?
No
Yes
FA-18
Page 3 of 4
PASRR Level 1 Identification Screening - Please Print or Type
11/05/12
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