Fillable PASRR Level 1 Screening Section A (Texas Medicaid & Healthcare Partnership)

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PASRR Level 1 Screening Section A (Texas Medicaid & Healthcare Partnership)

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PASRR Level 1 Screening, August, 2021, V.3
Page 1 of 12
DLN Individual
A0800. Position/Title
A0400. Provider No.
A0200C. State
PASRR Level 1 Screening
A0600. Date of Assessment
A0700A. First Name A0700B. Middle Initial
A0200B. City
A0200D. ZIP Code
A0500. Vendor No.
A0300. NPI/API
A0510. County
A0700C. Last Name A0700D. Suffix
A0900B. Other Type of EntityA0900A. Type of Entity
Section A
1. Acute Care
2. Psychiatric Hospital
3. ICF/IID
4. Family Home
5. Nursing Facility
6. Physician (MD/DO)
7. Other
A0900C. Physician First Name A0900D. Physician Middle Initial
A0900E. Physician Last Name A0900F. Physician Suffix
A0100. Name
Submitter Information (NF/LA only)
A0200A. Street Address
Referring Entity Information (Screener)
A1000A. Name
A1000B. Street Address
A1000D. State
A1000E. ZIP Code A1000F. Phone Number
A1000C. City
A1100. Date of Last Physical Examination
A1200B. Signature Date
A1200A. Certification of Signature
I certify that to the best of my knowledge
this information is true and accurate.
PASRR Level 1 Screening, August, 2021, V.3
Page 2 of 12
DLN Individual
B0700A. Previous Residence Type B0700B. Other Residence Type
1. Private Home
2. ICF/IID
3. Waiver Setting
4. Nursing Facility
5. Other
6. Unknown
Personal Information (Individual being screened)
B0100A. First Name B0100B. Middle Initial
B0100C. Last Name B0100D. Suffix
B0200A. Social Security No.
B0300. Medicaid No.
B0200B. Medicare No.
B0400. Birth Date
B0500. Age at Time of Screening B0600. Gender
1. Male
2. Female
Section B
B0700C. Street Address
B0700D. City
B0700E. State B0700F. ZIP Code
Previous Residence
B0650. Individual is deceased or has been discharged?
0. Deceased
1. Discharged
B0655. Deceased/Discharged Date
B0700G. County of Residence
PASRR Level 1 Screening, August, 2021, V.3
Page 3 of 12
DLN Individual
B0800B. Other Relationship to IndividualB0800A. Relationship to Individual
1. Legally Authorized
Representative
2. Spouse
3. Child
4. Parent
5. Sibling
6. Other
B0800J. State
B0800K. ZIP Code
B0800I. City
B0800C. First Name B0800D. Middle Initial
B0800E. Last Name B0800F. Suffix
B0800H. Street Address
B0800G. Phone Number
Next of Kin
PASRR Level 1 Screening, August, 2021, V.3
Page 4 of 12
DLN Individual
PASRR Screen (Screener)
Section C
C0100. Mental Illness
0. No
1. Yes
Is there evidence or an indicator this is an individual that
has a Mental Illness?
C0200. Intellectual Disability
Is there evidence or an indicator this is an individual that
has an Intellectual Disability?
C0300. Developmental Disability
Is there evidence or indicators that this is an individual that
has a Developmental Disability (Related Condition) other
than an Intellectual Disability (e.g., Autism, Cerebral Palsy,
Spina Bifida)?
Local Authority Information (LA only)
C0500. LA - MI Vendor No.
C0600. LA - MI NPI/API No.
C0800. LA - IDD Vendor No.
C0900. LA - IDD NPI/API No.
C0400. LA - MI Provider No.
C0700. LA - IDD Provider No.
0. No
1. Yes
0. No
1. Yes
PASRR Level 1 Screening, August, 2021, V.3
Page 5 of 12
DLN Individual
Section D
Nursing Facility Choices - 1
D0100B. Vendor No.
D0100C. NPI
D0100A. Provider No.
D0100D. Facility Name
D0100E. Street Address
D0100H. ZIP Code D0100I. Phone
D0100G. State
D0100M. NF Contact Suffix
D0100K. NF Contact Middle Initial D0100J. NF Contact First Name
D0100L. NF Contact Last Name
0. No
1. Yes
0. No
1. Yes
D0100P. NF Date of Entry
D0100F. City
D0100N. NF is willing and able to serve individual
D0100O. NF Admitted the Individual
D0100Q. Comments
PASRR Level 1 Screening, August, 2021, V.3
Page 6 of 12
DLN Individual
Nursing Facility Choices - 2
D0100B. Vendor No.
D0100C. NPI
D0100A. Provider No.
D0100D. Facility Name
D0100E. Street Address
D0100H. ZIP Code D0100I. Phone
D0100G. State
D0100M. NF Contact Suffix
D0100K. NF Contact Middle Initial D0100J. NF Contact First Name
D0100L. NF Contact Last Name
0. No
1. Yes
0. No
1. Yes
D0100P. NF Date of Entry
D0100F. City
D0100N. NF is willing and able to serve individual
D0100O. NF Admitted the Individual
D0100Q. Comments
PASRR Level 1 Screening, August, 2021, V.3
Page 7 of 12
DLN Individual
Nursing Facility Choices - 3
D0100B. Vendor No.
D0100C. NPI
D0100A. Provider No.
D0100D. Facility Name
D0100E. Street Address
D0100H. ZIP Code D0100I. Phone
D0100G. State
D0100M. NF Contact Suffix
D0100K. NF Contact Middle Initial D0100J. NF Contact First Name
D0100L. NF Contact Last Name
0. No
1. Yes
0. No
1. Yes
D0100P. NF Date of Entry
D0100F. City
D0100N. NF is willing and able to serve individual
D0100O. NF Admitted the Individual
D0100Q. Comments
PASRR Level 1 Screening, August, 2021, V.3
Page 8 of 12
DLN Individual
Nursing Facility Choices - 4
D0100B. Vendor No.
D0100C. NPI
D0100A. Provider No.
D0100D. Facility Name
D0100E. Street Address
D0100H. ZIP Code D0100I. Phone
D0100G. State
D0100M. NF Contact Suffix
D0100K. NF Contact Middle Initial D0100J. NF Contact First Name
D0100L. NF Contact Last Name
0. No
1. Yes
0. No
1. Yes
D0100P. NF Date of Entry
D0100F. City
D0100N. NF is willing and able to serve individual
D0100O. NF Admitted the Individual
D0100Q. Comments
PASRR Level 1 Screening, August, 2021, V.3
Page 9 of 12
DLN Individual
D0100B. Vendor No.
D0100C. NPI
D0100A. Provider No.
Nursing Facility Choices - 5
D0100D. Facility Name
D0100E. Street Address
D0100H. ZIP Code D0100I. Phone
D0100G. State
D0100M. NF Contact Suffix
D0100K. NF Contact Middle Initial D0100J. NF Contact First Name
D0100L. NF Contact Last Name
0. No
1. Yes
0. No
1. Yes
D0100P. NF Date of Entry
D0100F. City
D0100N. NF is willing and able to serve individual
D0100O. NF Admitted the Individual
D0100Q. Comments
PASRR Level 1 Screening, August, 2021, V.3
Page 10 of 12
DLN Individual
E0400. Comments about with whom the individual would
like to live
E0200. Comments about where the individual would like to
live
D. With a lot of friends
F. Other Individual
C. With family
E. Other
G. Unknown
E0300. Living Arrangement Options Check all that apply
B. With a roommateA. By themselves
G. Unknown
F. Other Location
C. A group home D. Family home
E. Other
B. A place where there is 24 hour careA. Live alone with support
E0100. Where would this individual like to live now? Check all that apply
Section E
Alternate Placement Preferences (Screener)
PASRR Level 1 Screening, August, 2021, V.3
Page 11 of 12
DLN Individual
E0700. Name of ICF/IID Facility
E0800. Own Home/Family Home Comments
E0900. Alternate Placement Date of Entry
E0500A. Admitted to E0500B. Admitted to Other
1. Community Program
2. ICF/IID
3. Own home/family home
4. Other
E0600A. Community Program E0600B. Other Community Program
1. 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. Other
*This option cannot be selected after August
2021. Please select “6. STAR+Plus (SG 19)”
instead.
Alternate Placement Disposition
PASRR Level 1 Screening, August, 2021, V.3
Page 12 of 12
DLN Individual
F0100. 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 F
0. No
1. Yes
Admission Category (RE/LA)
F0200. Expedited Admission
Does this individual meet any of the following categories for an expedited admission into the
nursing facility?
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.
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)
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PASRR Level 1 Screening Section A (Texas Medicaid & Healthcare Partnership)

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Completed 20 September 2021

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