Level One Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability, or Related Condition

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Level of Care Determination by DRL Central Office

Meets level of care:

______

DCN: ______ | | P#: ______

______, ______

Point Count

______	DHSS COMRU
______	Submitter

Signature:

Date:

______

Referral's Email: ______

Level 2 Referral: ______

Facility ID #

______ |

Name of Proposed SNF

______

NF Admit Date

______

Date signed by Physician

______

Name of Entity

______

Record ID: ______

Last Name:		First Name:
Middle Initial:		Suffix
DCN (Medicaid Number):		SSN Number:
Date of Birth:		Race:
Gender:		Education Level:
Occupation:

Previous Residence Type (Residency Prior to this Current SNF Placement)

Street Address

City

State

Zip Code

Legal Guardian or Designated Contact Person Information

* must provide value

None Legal Guardian Designated Contact Person

reset

First Name

Last Name

Relationship

E-mail (An email address is only required for a Legal Guardian.)

Street Address

City

State

Zip

Telephone Number

First Name

Last Name

Position/Title

Type of Entity

Name of Entity

Telephone Number

Email Address

Fax Number

1. Does the individual show any signs or symptoms of a Major Mental Illness?

Signs/Symptoms:

(Please do not provide diagnosis)

_____________________________________________________________________________________________________

2. Does the individual have a current, suspected, or history of a Major Mental Illness as defined by the Diagnostic & Statistical Manual of Mental Disorders (DSM) current edition?
(Please refer to the Physician order/report and indicate ALL Major Mental Illness diagnosis)

_____________________________________________________________________________________________________

3. Does the individual have any area of impairment due to serious mental illness?

(Record YES if any of the subcategories below are checked)

(Impairments indicated should be associated with the serious mental illness diagnosis indicated in Section D #2 above)

_____________________________________________________________________________________________________

4. Within the last 2 years, has the individual:

(Record YES if Either/Both of the two subcategories below are checked)

Check yes, if treatment history for the past two years is unknown or treatment was unavailable but otherwise appropriate to consider individual positive for serious mental illness.

_____________________________________________________________________________________________________

5. Does the individual have a substance related disorder?

Is the need for a skilled nursing facility placement associated with substance abuse?

When did the most recent substance abuse occur?

_____________________________________________________________________________________________________

6. Does the individual have a diagnosis of Major Neurocognitive Disorder (MNCD) i.e., dementia or Alzheimer's?

1. Is the individual known or suspected to have a diagnosis of Intellectual Disability that originated prior to age 18?

If Yes, indicated diagnosis:

_____________________________________________________________________________________________________

2a. Does the individual have a suspected diagnosis or history of an Intellectual Disability/Related Condition?
(Please refer to the Physician order/report and indicate ALL Intellectual Disability Related Conditions)

* must provide value

No Functional Limitations

* must provide value

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Special Admission Category instructions:	Click to display:
	Reset SAC:

0 - None

1 - Terminal Illness
Expected to result in death in six months or less

2 - Serious Physical Illness
Severe/end stage disease (or physical condition)

3 - Respite Care
Stays not more than thirty (30) days to provide relief for in-home caregivers

4 - Emergency Provisional Admission
Must be hotlined. Stays not more than 7 days to protect person from serious physical harm to self and others.
Hotline must be reported to the Adult Abuse and Neglect Hotline (1-800-392-0210 or https://health.mo.gov/safety/abuse/)

5 - Direct Transfer From a Hospital
Stays not more than thirty (30) days for the condition for which the person is currently receiving hospital care.
Must include the hospital history and physical.

COVID 19 Waiver - If admitted from the Hospital, provide a copy of History and Physical
(Not Valid for SNF Admissions after 05-11-2023)

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1 - Terminal Illness
Expected to result in death in six months or less

2 - Serious Physical Illness
Severe/end stage disease (or physical condition)

3 - Respite Care
Stays not more than thirty (30) days to provide relief for in-home caregivers

COVID 19 Waiver - If admitted from the Hospital, provide a copy of History and Physical
(Not Valid for SNF Admissions after 05-11-2023)

reset

Click to display the Covid19 Guidelines

Diagnosis:

Currently on Hospice:

Diagnosis:

The client is going to be short term:

Reason for Respite Care:

Reason for Hotline:

The client is going to be short term:
Reason for Transfer:
What is the plan after 30 days?

The client is going to stay past 30 days at the SNF:
Admission date to SNF (Blank = Not admitted yet):
Discharge date from SNF (if applicable):
Comment:

April 22, 2020- Updated

IMPORTANT INFORMATION REGARDING 1135 WAIVER IMPLEMENTATION FOR PRE-ADMISSION
SCREENING AND RESIDENT REVIEW (PASRR)

Background:
On March 25, 2020, the Centers for Medicare and Medicaid Services notified MO HealthNet Division of
their approval of a Federal Section 1135 Waiver request to suspend pre-admission screening and
annual resident review (PASRR) Section 1919(e)(7) of the Act allows Level I and Level II assessments to
be waived for 30 days. All new admissions can be treated like exempted hospital discharges. After 30
days, new admissions with mental illness (MI) or intellectual disability (ID) should receive a Resident
Review as soon as resources become available. On April 21, 2020, CMS issued a COVID-19 Emergency
Declaration Blanket Waivers for Health Care Providers, which extends the PASRR approval through the
end of the emergency declaration.

Effective April 2, 2020 and through the end of the Federal Emergency Declaration, certified Skilled
Nursing Facilities and Intermediate Care Facilities may follow the process outlined below for new
admissions into Medicaid-certified beds.

For an applicant that may require a Level II evaluation (have a qualifying mental illness (MI) or
intellectual disability (ID) diagnosis):
- The applicant may enter the Skilled Nursing Facility (SNF) prior to completion of a Level II PASRR
evaluation or Special Admission Category.
- The Hospital (or other individual completing the paperwork) will send the completed DA 124 C
form to the SNF prior to discharge. The SNF should review the client's information to ensure the Level
of Care points (24) would meet prior to admission and ensure they have enough information to
determine if they can meet the medical and behavioral needs of the individual.
- The SNF will submit the entire DA 124 application (DA 124 A/B, DA 124 C and any other
supporting documentation) with a Special Admission Category form indicating "Waiver due to COVID -
19" to COMRU@health.mo.gov. The SNF should indicate if the client plans to reside at the SNF after
30 days.
- DHSS recommends that SNFs submit the complete DA 124 application to COMRU within 14 days
of admission to the SNF.
- Once received, COMRU will determine if the applicant meets Level of Care and refer applicants
requiring a Level II PASRR screening to DMH.
- After 30 days, new admissions with mental illness (MI) or intellectual disability (ID) will receive a
Resident Review as soon as resources become available.

For completed applications already submitted to COMRU for processing:
- The applicant may enter the Skilled Nursing Facility (SNF) prior to completion of a Level II PASRR
evaluation or Special Admission Category.
- COMRU will process all pending Level II PASRR applications as Special Admission Category #5
indicating "Waiver due to COVID -19".
- Upon discharge, the hospital or other submitter will notify COMRU via email of the following
information: the client's name, DCN or SSN#, and the receiving SNF information (Name, Telephone
number and fax number).
- The hospital/submitter will ensure a copy of the DA 124 application (DA 124 A/B form and DA
124 C form) are sent to the accepting SNF prior to discharge.
This information should be added to the DA 124 application in process and sent to DMH. For the DA
124 applications that were already referred for Level II PASRR screening, DHSS will notify DMH and
Bock & Associates via email of the individuals change in location.
Questions regarding this process should be directed to COMRU@health.mo.gov.
The DA 124 application (DA 124 A/B form, DA 124 C form and Special Admission Category Referral
form) are accessible at https://health.mo.gov/seniors/nursinghomes/pasrr.php.

www.health.mo.gov

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The Missouri Department of Health and Senior Services will be the leader in promoting, protecting and partnering for health.

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Attachment:COVID 19 Guidelines.pdf

Send to Physician

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Record ID: ______

This section must be signed by a Physician.

It cannot be signed by a Nurse Practitioner or a Physician Assistant.

I attest that the information on these forms is complete and correct as known to me.

Physician Signature

Physician Date:

Physician Name

Discipline

License Number

Survey Link:

https://redcapdrlltcc.azurewebsites.net/redcap/surveys/?s=WA9KMWXC7L7LAMTP

* must provide value

M-D-Y

Date Completed:

M-D-Y

Last Name:	______	First Name:	______
Middle Initial:	______	Suffix:	______
DCN (Medicaid Number):	______	SSN Number:	______
Date of Birth:	______	Race:	______
Gender:	______

Reason for Submitting Application:

* must provide value

Corrected reason for submitting application:
______

If this option is selected, the client has previously had a Level 2 screening and a Significant Change in Status MDS has recently been completed by the SNF OR the client did not trigger a Level 2 screening on the last processed application, but now triggers a Level 2 review.

The Submitter will need to provide a comment in Section C (Recent Medical Incidents) indicating the following:

Does the SNF have a copy of the Previous Level 2 screening?
When was the Significant Change in Status MDS completed (provide date)?
What triggered the Significant Change in Status MDS to be completed (provide summary)?

If this option is selected, the SNF is unable to locate any of the following records:

The approved Level 1 application was processed prior to 2013.

The approved Level 2 screening was completed over 1 year ago.

Individual's Current Physical Location:

* must provide value

Name of Proposed Skilled Nursing Facility:

(Provide the SNF's full name)

Facility ID Number:

Facility ID Directory

Admit Date to NF:

Discharge Date From NF:

Expand

Provide date and reason for recent Hospitalization or attach a copy of the Hospital History and Physical

Indicate the Diagnoses Relevant to Applicant's Functional and/or Skilled Nursing Needs
(Do not list Diagnosis Codes)

(Please ensure the applicant's name is indicated on all attachments)

A diagnosis list must be provided.

Additional Documentation:

Upload file

Behavioral:

Determine if the applicant or recipient:
- Receives monitoring for mental condition
- Exhibits one of the following mood or behavior symptoms - wandering, physical abuse, socially inappropriate or disruptive behavior, inappropriate public sexual behavior, or public disrobing; resists care
- Exhibits one of the following psychiatric conditions - abnormal thoughts, delusions, hallucinations

Date of the last consult completed by a physician or licensed mental health professional (This is not a medical consult):
(Blank = None Reported)

Behavioral Symptoms:

	None	Min	Mod	Max
Withdrawn/Depressed
Suspicious/Paranoid
Wanders
Hallucinations/Delusions
Abnormal Thought Process
Aggressive(Physical/Verbal)


Restraints
Sexually Inappropriate
Controlled with Medications

Comment:

Cognition:

Determine if the applicant or recipient has an issue in one or more of the following areas:
- Cognitive skills for daily decision making
- Memory or recall ability (short-term, procedural, situational memory)
- Disorganized thinking/awareness - mental function varies over the course of the day
- Ability to understand others or to be understood

Orientation:

Memory:

Level of Supervision:

Ability to Make a Path to Safety:

Hearing Impairment:

Speech Impairment:

Comment:

Mobility:

Determine the applicant or recipient's primary mode of locomotion
Determine the amount of assistance the applicant or recipient needs with:
- Locomotion - how moves walking or wheeling, if wheeling how much assistance is needed once in the chair
- Bed Mobility - transition from lying to sitting, turning, etc.

Comment:

Eating:

Determine the amount of assistance the applicant or recipient needs with eating and drinking. Includes intake of nourishment by other means (e.g. tube feeding or total parenteral nutrition (TPN).
Determine if the participant requires a physician ordered therapeutic diet.

Diet Ordered by Physician:

Comment:

Toileting:

Determine the amount of assistance the applicant or recipient needs with toileting. Toileting includes: the actual use of the toilet room (or commode, bedpan, or urinal), transferring on/off the toilet, cleansing self, adjusting clothes, managing catheters/ostomies, and managing incontinence episodes.

Comment:

Bathing:

Determine the amount of assistance the applicant or recipient needs with bathing. Bathing includes: taking a full body bath/shower and the transferring in and out of the bath/shower.

Comment:

Dressing and Grooming:

Determine the amount of assistance needed by the applicant or recipient to dress, undress, and complete daily grooming tasks

Comment:

Rehabilitative Services:

Determine if the applicant or recipient has the following medically ordered rehabilitative services:
Physical therapy/Occupational therapy/Speech therapy/Cardiac rehabilitation/Audiology

Type of Physician-Ordered Rehabilitative Services:

Frequency (days per week)

Comment:

Add all the Rehab Services Frequencies together to obtain the total point count.

Treatments:

Determine if the applicant or recipient requires any of the following treatments:
- Catheter/Ostomy care
- Alternate modes of nutrition (tube feeding, TPN)
- Suctioning
- Ventilator/respirator
- Wound care (skin must be broken)

Type of Physician-Ordered Treatment/Comment:

Meal Preparation:

Determine the amount of assistance the applicant or recipient needs to prepare a meal.
This includes planning, assembling ingredients, cooking, and setting out the food and utensils.

Comment:

Medication Management:

Determine the amount of assistance the applicant or recipient needs to safely manage their medications. Assistance may be needed due to a physical or mental disability.

Comment

Safety:

Determine if the individual exhibits any of the following risk factors:
- Vision Impairment
- Falling
- Problems with balance. Balance is moving to standing position, turning to face the opposite direction, dizziness, or unsteady gait.
After determination of preliminary score, history of institutionalization and age will be considered to determine final score.
- Institutionalization in the last 5 years - long-term care facility, mental health residence, psychiatric hospital, inpatient substance abuse, or settings for persons with intellectual disabilities.
- Aged - 75 years and over

Date of last fall:

Type of Institutionalization:

(Do not include current SNF admission)

(Blank = None Reported)

Timeframe or Date Admitted to Institution:

Comment:

Individual's DoB: ______

Individual's Age:

First and Last Name:

Position/Title:

Name of Entity:

Type of Entity:

Telephone Number:

Ext:

Fax Number:

Email Address:

Date Referral Completed:

Complete Contact Person if Level II Screening Indicated

Check if Same as Referring Individual

Telephone Number:

Ext:

Email:

Fax Number:

COMRU is currently processing Level 1 applications submitted for the date of 07-22-2024.

If the application was submitted prior to this date or corrections have been made prior to this date, the submitter will need to check the status of the application.

Client: ______ ______

Level of Care Determination by DRL Central Office (COMRU)

Application Submitted to COMRU: ______

Application Accepted: ______ | Correction: ______

Meets level of care:

Application Type: ______

Point Count

There is a mandated 18 point count for SNF placement

______	DHSS COMRU
______	Submitter

Signature:

Date:

______

If Level 2 indicated above:

Special Admissions Category: ______ | Valid: ______

Date Referred to DMH for Level 2 Screening: ______

Date Due from DMH: ______

DHSS Determination: ______

Information from COMRU: ______

Level 2 Determination (DMH)

Mental Illness: ______

Intellectual Disability: ______

Previous Level 2 Determination: ______

Previous Level 2 Screening: ______

DMH Determination: ______

Application Status: ______

Date DMH review Level 2 Screening: ______

Bock Associates

Level 2 Evaluation

______

Level 2 Determination

______

M-D-Y

All corrections have been made by the submitter
(First Request):

* must provide value

Date of Correction Requested (First):

______

All corrections have been made by the submitter
(Second Request):

* must provide value

Date of Correction Requested (Second):

______

All corrections have been made by the submitter
(Final Request):

* must provide value

Date of Correction Requested (Final):

______

The point count in Section D. Assessed Needs must not be 0.

This application has been submitted to COMRU for processing.

If the submitter needs to make an adjustment to the application, please email COMRU (COMRU@health.mo.gov) to re-open the application.

Based on the information provided by the submitter, the applicant does not meet the mandated 18 point count.

Please review the point count before submitting to COMRU.

A point count under 18 will be a "DENIAL" for SNF placement and Medicaid Reimbursement.

Label

Schizophrenia

Label

Psychotic Disorder

Label

Dysthymic Disorder

Label

Conversion Disorder

Label

Somatic Symptom Disorder

Label

Anorexia Nervosa or other eating disorders

Label

Other Mental Disorder in the DSM

Label

Schizoaffective Disorder

Label

Major Depressive Disorder

Label

Panic Disorder

Label

Personality Disorder

Label

Dissociative Identity Disorder

Label

Delusional Disorder

Label

Bipolar Disorder

Label

Obsessive-Compulsive Disorder

Label

PTSD

Label

Anxiety Disorder

Label

Mood Disorder

Label

Requested Information

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Level One Nursing Facility Pre-Admission Screening for Mental Illness, Intellectual Disability, or Related Condition

Section A. Individual Identifying Information

Section B. Individual's Contact Information

Legal Guardian or Designated Contact Person Information

Section C. Referring Individual Completing Application

Section D. Level One Screening Criteria for Serious Mental Illness

Section E. Level One Screening Criteria for Intellectual Disability or Related Condition

Section F. Special Admission Categories

Send to Physician

This section must be signed by a Physician.

It cannot be signed by a Nurse Practitioner or a Physician Assistant.

Section G. Physician's Authorization and Signature

If Level 2 screening is not indicated, provide the survey code to proposed Nursing Facility for review

Nursing Facility Level of Care Assessment

Section A. Individual's Identifying Information

Section B. Current Location/Proposed Placement

Section C. Recent Medical Incidents (I.E., CVA, Surgery, Fracture, Head Injury, ETC., and Give Dates)

A diagnosis list must be provided.

Section D. Assessed Needs

Behavioral:

Cognition:

Mobility:

Eating:

Toileting:

Bathing:

Dressing and Grooming:

Rehabilitative Services:

Treatments:

Meal Preparation:

Medication Management:

Safety:

Section E. Referring Individual Completing Application

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