Ltc-14 - Level I Screening For Mental Illness (Mi) / Intellectual Disability (Id) / Related Condition (Rc)
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2This Level I Screening Form must be completed prior to admission into a Medicaid Certified Nursing Facility. Failure to complete this form accurately may result in Medicaid Recoupments.
PLEASE PRINT
State of Alabama Department of Mental Health
LTC-14 Rev. 11
Level I Screening for Mental Illness (MI) / Intellectual Disability (ID) / Related Condition (RC)
Page 1 of 2
Use for Medicaid Certified Nursing Home (NH) Only
Name: ________________________________________________________ SSN: _______-_______-________ DOB: _______/_______/_______
________________________________________________________________________________________________________________________
Name of current residence at time of Level I submission
Street address
City, State, and Zip
County
Check Type of Residence:
NF
Hospital
Home
Assisted Living Facility
Group Home
Other________________________
Legal Guardian, If Applicable: __________________________________________ Address: ____________________________________________
Note: Under OBRA ’87, any individual who willfully and knowingly causes another individual to certify a material and false statement in a resident
assessment is subject to a civil money penalty of not more than $ 5,000 with respect to each assessment.
Referral Source and Title: _____________________________________________________________________Date: ________________________
Place of Employment: _____________________________________________Fax #:_______________________Phone #:_____________________
3. Has the individual’s “Medical Condition” required the administration or
1. Does the individual have a suspected diagnosis or history of an Intellectual
Disability or a Related Condition?
Yes
No
prescription of any anti-depressant, anti-psychotic, and /or anti-anxiety
medications within the last 14 days?
Yes
No
1a. Specify.
ID:
Intellectual Disability
3a. If yes, list psychotropic medications for the Medical Condition
Did the ID develop before age 18?
(Do not list PRN medications):_____________________________
Unknown
Yes
No
N/A
______________________________________________________
RC:
Autism
4. Is there a diagnosis of Dementia, Alzheimer’s or any related organic
Did the Autism develop before age 22?
disorders?
Yes
No (Note: If yes is checked, Dementia must be
Unknown
Yes
No
N/A
documented in the medical records by a physician)
Cerebral Palsy
4a. If yes, complete the MSE. (If unable to test due to Dementia, enter “0”
Did the Cerebral Palsy develop before age 22?
as a valid MSE score; if unable to test due to any other condition,
Unknown
Yes
No
N/A
check unable to test, and leave MSE score blank)
Epilepsy/Seizure Disorder
Provide MSE Score: ____ Check if unable to test:
Did the Epilepsy/Seizure Disorder develop before age 22?
4b. If #4 is yes, check level of consciousness:
Unknown
Yes
No
N/A
Alert
Drowsy
Stupor
Coma
N/A
Other Related Condition: ___________________________
4c. If #2 & #4 are yes, which diagnosis is primary? :
Did the Other RC develop before age 22?
Dementia
Mental Illness
N/A
Unknown
Yes
No
N/A
(The primary diagnosis must be documented in the medical records as
“primary” by a physician)
2. Does the individual have a current, suspected or history of a Major Mental
Illness as defined by the Diagnostic & Statistical Manual of Mental
5. Does the individual’s current behavior or recent history within 1 year
Disorders (DSM) current edition? Choose “No” if the person’s symptoms
indicate that they are a danger to self or others? (Suicidal, self-injurious or
are situational or directly related to a medical condition. (e.g. depressive
combative)
Yes
No
symptoms caused by hyperthyroidism, depression caused by stroke or
5a. If yes, explain: ____________________________________________
anxiety due to COPD, these conditions must be documented in the medical
records by a physician)
Yes
No
6. Submission of this Level I is due to one of the following:
2a. If yes, check the appropriate disorder below.
New Nursing Facility Admission
Schizophrenia Schizoaffective Disorder Psychotic Disorder NOS
(For current NH residents, select one of the below Significant Changes):
Major Depression Depressive Disorder NOS Dysthymic Disorder
Medical Improvement
Bipolar Disorder Generalized Anxiety Disorder Panic Disorder
Medical Decline
PTSD OCD Somatoform Disorder Conversion Disorder
Mental Illness Improvement
Personality Disorders Unspecified Mental Disorder
Mental Illness Decline
Other Mental Disorder in the DSM ____________________________
Behavioral Changes
Short Term to Long Term Stay
(only for MI/ID/RC Categorical
2b. Are any of the diagnoses checked on question #2 situational or
conditions that are directly related to a medical condition?
Yes
No
Convalescent Care Residents)
Mental Health Diagnosis Change
(Reminder: If the diagnoses are situational or directly related to a medical
(i.e. New MH diagnosis)
condition, do not check these conditions on #2. However, you must
Previous Level I Incorrect
(For NH use only)
ensure that this information is documented in the person’s medical
No Level I and Determination or/and Level II and Determination upon
records by the physician, for example, depression related to stroke or
NH admission
anxiety due to COPD)
(For NH use only)
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