Level I Pasrr Screen And Determination Page 2
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3Name: _________________________________________________________ DOB: ____________________________
SECTION III: EXEMPTED HOSPITAL DISCHARGE
Is the individual being admitted from a hospital after receiving acute inpatient care and requires NF
YES
NO
services for the condition which he or she received care in the hospital and whose attending physician
has certified before admission that the individual is likely to require less than 30 days NF services?
If YES, STOP! This individual can be admitted to a NF. A Level II Evaluation is not needed. Physician should sign and
date Level I Screen. If the individual is later found to require more than 30 days of NF care, a resident review must be
conducted within 40 calendar days of admission.
Physician Signature:
Date Completed:
Print Physician Name:
If NO, proceed to SECTION IV
SECTION IV: ADVANCE GROUP DETERMINATIONS
A Provisional admission to a nursing facility can be made under the following time limited categories:
Pending further assessment of delirium where an accurate diagnosis cannot be made until the
1
YES
NO
delirium clears, not to exceed 30 days.
Pending further assessment in emergency situations requiring protective services with placement
2
YES
NO
in a nursing facility, not to exceed 7 days.
Brief respite care for in-home caregivers, with placement in a nursing facility twice a year, not to
3
YES
NO
exceed 30 days.
If any answer is YES, STOP! This individual can be admitted to a NF. Physician should sign and date Level I Screen. If
the individual is later determined to need a longer stay, identified through a resident review, a Level II Evaluation
and Determination must be conducted before continuation of the stay may be permitted and payment made for
days of NF care beyond the State’s time limit.
Physician Signature:
Date Completed:
Print Physician Name:
SECTION V: INDIVIDUALIZED EVALUATION DETERMINATION
*****This Section is to be completed by OMH and/or OCDD*****
A Level II Evaluation is required for individuals with MI or MR who meet one of the following advanced group
determinations of the need for NF services or for those who do not meet one of the categorical or advanced group
determinations in Sections III, IV or V. The Level II Evaluation and Determination must be received prior to NF admission.
Does the individual require convalescent care from an acute physical illness that required
YES
NO
hospitalization and does not meet all the criteria for an exempt hospital discharge?
YES
NO
Does the individual have a terminal illness as defined for hospice purposes?
Does the individual have a severe physical illness such as coma, ventilator dependence, functioning at
a brain stem level, or diagnoses such as Chronic Obstructive Pulmonary Disease, Parkinson’s Disease,
Huntington’s Disease, Amyotrophic Lateral Sclerosis and Congestive Heart Failure, which result in a
YES
NO
level of impairment so severe that the individual could not be expected to benefit from Specialized
Services?
OMH/OCDD Staff Signature:
Date Completed:
Title:
Date of Mental Health Determination:
Date Referred for Independent Level II Evaluation, if
applicable:
Level II Independent Evaluator Referred to:
Issued - 06/30/2009
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