The Colorado Post Admission Level 1 Passr form is a document used to assess individuals for mental health and developmental disabilities prior to admission to certain facilities. This form collects comprehensive information about the individual's medical history, current location, and mental health status. Proper completion of the Passr form is essential for determining eligibility for services and ensuring appropriate care.
The Colorado Post Admission Level 1 PASRR form plays a crucial role in the assessment and management of individuals transitioning into nursing facilities, particularly those with mental health issues or developmental disabilities. This form is designed to gather comprehensive information about the individual, including personal details such as name, date of birth, and current location, as well as their medical and psychiatric history. It requires the identification of payment methods and any relevant scores related to daily living activities, which are essential for determining the level of care needed. Sections of the form delve into the individual's mental health status, exploring diagnoses of major mental illnesses and symptoms that may indicate the need for further evaluation. Additionally, it addresses the history of psychiatric treatment, any current medications, and the presence of dementia or developmental disabilities. The form also includes critical questions about potential exemptions or special circumstances that may affect the admission process. Ultimately, the information collected through this form aids in ensuring that individuals receive the appropriate level of care tailored to their unique needs.
COLORADO LE VE L I F ORM
PRE-ADMISSION AND RESIDENT REVIEW (PASRR)
First Name:
Middle Initial:
Last Name:
Mailing Address:
City:
State:
Zip:
Phone:
Social Security #:
-
Date of Birth:
/
Gender: c Male c Female Race: c Caucasian c African American c Asian c Hispanic c Other:
Current Location: c*Medical Facility c*Psychiatric Facility c *Nursing Facility c Community c Other:
*Provide Admission Date:
Receiving Nursing Facility:
Receiving Nursing Facility Address:
Payment Method: c Medicare c Private Pay c Medicaid c Medicaid Pending c Medicaid #
c Hospice c PACE c 30 Day PACE Respite
** Provide ULTC Scores if Medicaid or Medicaid Pending:
Bathing
Dressing
Toileting
Mobility
Transfer
Eating
Supervision Behaviors
Supervision Memory/Cognition
Section I: MENTAL ILLNESS
1. Does the individual have any of the
2.
Does the individual have any of the
3. Does the individual have a diagnosis of
following Major Mental Illnesses
following mental disorders?
a mental disorder that is not listed in
(MMI)?
c No
#1 or #2? (do not list dementia here)
c Suspected: One or more of the
following diagnosis is suspected
c Yes (if yes, enter the diagnosis(es)
following diagnoses is suspected
(check all that apply)
below):
c Yes: (check all that apply)
c Personality Disorder
c Diagnosis 1:
c Schizophrenia
c Anxiety Disorder
c Diagnosis 2:
c Schizoaffective Disorder
c Panic Disorder
c Major Depression
c Depression (mild or situational)
c Psychotic/Delusional Disorder
(provide GDS Score:
)
c Bipolar Disorder (manic depression)
c Paranoid Disorder
Section II: SYMPTOMS
4. Interpersonal—Currently or within the past 6 months, has the
5. Concentration/Task related symptoms—Currently or within
individual exhibited interpersonal symptoms or behaviors [not
the past 6 months, has the individual exhibited any of the
due to a medical condition]?: c No c Yes
following symptoms or behaviors [not due to a medical
c Serious difficulty interacting with others
condition]? c No
c Yes
c Altercations, evictions, or unstable employment
c Serious difficulty completing tasks that she/he should be
c Frequently isolated or avoided others or exhibited signs
capable of completing
suggesting severe anxiety or fear of strangers
c Required assistance with tasks for which she/he should be
capable
c Substantial errors with tasks in which she/he completes
Adaptation to change —Currently or within the past 6 months, has the individual exhibited any symptoms in #6, 7 or 8 related to
adapting to change? c No (proceed to Section III) c Yes (complete 6-8)
6. c Self injurious or self
7. c Severe appetite disturbance
8.
c Other major mental health symptoms (this may include
mutilation
c Hallucinations or delusions
recent symptoms) that have emerged or worsened as a result
c Suicidal talk
c Serious loss of interest in things
of recent life changes as well as ongoing symptoms.
c History of suicide
c Excessive tearfulness
Describe symptoms:
attempt or gestures
c Excessive irritability
c Physical violence
c Physical threats (no potential for
c Physical threats (with
harm)
potential for harm)
GDS Score:
(if any areas in #7
are marked)
Masspro s 245 Winter St. s Waltham, MA 02451 s Phone: 855-222-3112 s Fax: 855-222-3114
Patient Last Name:
Patient First Name:
Section III: HISTORY OF PSYCHIATRIC TREATMENT
9. Currently or within the past 2 years , has the individual received any of the followingmental health services?
cNo
cYes (the individual has received the following service[s]): c Inpatient psychiatric hospitalization (if yes, provide
date: )
c Partial hospitalization/ day treatment (if yes, provide
date:
cResidential treatment (if yes, provide date:
c Other:
(if yes,
provide date:
10.Currently or within the past 2 years, has the individual
experienced significant life disruption because of mental health symptoms? c No c Yes (check all that apply):
c Legal intervention due to mental health symptoms
(date:)
cHousing change because of mental illness
(date:
c Suicide attempt or ideation (date[s]:
11.
Has the individual had a recent psychiatric/behavioral evaluation? c No c Yes (date:
Section IV: DEMENTIA
12.Does theindividual have a diagnosis
of dementia or Alzheimer’s disease? c No (proceed to 15) c Yes
13.If yes to #12, is corroborative testing or other information available to verify the presence
or progression of the dementia? c No c Yes (check all that apply)
c Dementia work up c Comprehensive Mental Status Exam c Other (specify):
14.If yes to12, list currently prescribed antidepressant or antipsychotic medications listed on the Beer’s List.
Medication
Dosage MG/Day
Refer to Beer’s List
Does dosage exceed Beer’s List? cNo cYes
Section V: PSYCHOTROPIC MEDICATIONS
15.Has the individual been prescribed psychoactive (mental health) medications now or within the past 6 months other than those listed in question 14? c No c Yes (list below) [use separate sheet if necessary] *Do not list medications if used for a medical diagnosis.
Diagnosis
Started
Ended
Section VI: MENTAL RETARDATION & DEVELOPMENTAL DISABILITIES
16.
Does the individual have a diagnosis of mental retardation
17.
Does the individual have any history of MR or DD? c No c Yes
(MR) or developmental disability (DD)? c No c Yes
18.
Is there presenting evidence of a cognitive or behavioral
19.
Has the individual ever received services from an agency that
impairment prior to age 22 or suspicion of MR condition that
serves people affected by MR/DD? c No
occurred prior to age 18? c No c Yes
c Yes—agency:
Section VII: EXEMPTION AND CATEGORICAL DECISIONS
(MASSPRO MUST APPROVE USE OF CATEGORIES AND EXEMPTION PRIOR TO ADMISSION)
20. Does the admission meet criteria for Hospital Exemption? c No
c Yes (meets all the following andhas a known or suspected MMI or MR/DD):
·
Admission to NF directly from hospital after
receiving acute medical care, and
Need for NF is required for the condition treated in
the hospital (specify condition:
, )
and
22.Does the admission meet the criteria for Terminal Illness? c No
c Yes (Has a known or suspected MMI or MR/DD and MD has certified in writing that the patient has 6 months or less to live. The physician signed certification must be submitted to Masspro via facsimile within 6 business hours of submission of this form)
23.Does the admission meet the criteria for Severity of Illness?
cYes (Has a known or suspected MMI or MR/DD and is ventilator dependent or comatose unresponsive)
24.Does the admission meet criteria for 60 day Convalescence? c No
c Yes (meets all the following and has a known or suspected MMI or MR/DD): c Admission to NF directly from hospital after receiving acute medical care; and c Need for NF is required for the condition treated in the hospital, and cThe attending physician has certified prior to NF admission the individual will require less than 60 calendar days of NF services.
21. Additional Comments:
Section VIII: OUTCOME
25. Are any of the following numbers marked yes or, if applicable, suspected 1, 3, 6, 7, 8, 9, 10, 14, 15, 16, 17, 18,or 19?
26. Check yes if #2 is marked yes or suspected and any areas in #4-8 are marked
27. Check yes if #4 or 5 or (any areas in) #7 are marked affirmatively and #12 is no
28. Are any of the #25-27 marked yes?
cNo (if No, NO further screening is required. Proceed to Section IX)
cYes (Screening information must be submitted to Masspro via fax at 1-855-222-3114 for a determination of whether further screening is
required).
Provide a copy of this form to the individual and, if applicable, guardian.
Does the individual have a legal guardian? c No legal guardian c Yes, legal guardian information is below:
Guardian Last Name:
Street:
Section IX: SOURCE SIGNATURE
Print Name:
Signature:
Date:
Agency/Facility:
Fax:
Section X: MASSPRO OUTCOME: MASSPRO USE ONLY
Non-Cert c
Level I Approved:
PASRR Authorization #:
c No MMI/DD
c Follow-up next qtr.
c PACE Respite
c 30 Day Exemption
c Hospice
c Convalescent Care
c Terminal
c Severity of Illness
c Provisional-Out of state Adm.
c Provisional-Emergency Adm.
Level II Referred:
c MI
c MR/DD
c Dual
Comments:
The Colorado Post Admission Level 1 PASRR form is a crucial document used to assess individuals with mental health needs prior to their admission to a nursing facility. Alongside this form, several other documents are often utilized to ensure comprehensive evaluation and care planning. Below are four key forms and documents commonly associated with the PASRR process.
These documents work together to facilitate a thorough evaluation of individuals entering nursing facilities, ensuring they receive the appropriate care and support based on their unique needs.
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Completing the Colorado Post Admission Level 1 Passr form is a straightforward process that requires careful attention to detail. This form gathers essential information about an individual’s mental health history and current needs. After filling it out, you will submit it to the appropriate agency for review.
The Colorado Post Admission Level 1 PASRR form shares similarities with the Long-Term Care Assessment form used in various states. Both documents are designed to evaluate an individual's needs for long-term care services, particularly in nursing facilities. They require detailed personal information, including demographics and medical history. Additionally, both forms assess mental health conditions and functional abilities to determine the appropriate level of care and services required by the individual.
Another comparable document is the Medicare Initial Enrollment Questionnaire. This form collects personal and health information from individuals applying for Medicare. Like the PASRR form, it requires details about the applicant's medical history, current health status, and any ongoing treatments. Both documents aim to ensure that individuals receive the necessary healthcare services based on their specific medical needs.
The Pre-Admission Screening form for nursing facilities is also similar. This form is used to assess individuals before their admission to a nursing facility, focusing on their medical and psychological needs. It gathers comprehensive information about the individual's health conditions, functional limitations, and potential need for specialized services, paralleling the objectives of the PASRR form.
The Mental Health Assessment form utilized by various healthcare providers is another relevant document. This assessment aims to evaluate an individual's mental health status and treatment history. It includes questions about symptoms, diagnoses, and treatment received, much like the mental illness sections of the PASRR form. Both documents seek to identify any mental health issues that may affect the individual's care and support needs.
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The Functional Independence Measure (FIM) is also similar in its purpose. This assessment tool measures an individual's functional abilities and limitations in daily activities. The FIM focuses on areas such as self-care, mobility, and communication, similar to the functional assessments found in the PASRR form. Both documents aim to identify the level of assistance required for individuals to maintain their independence.
The Uniform Assessment Instrument (UAI) used in some states shares similarities with the PASRR form. The UAI is designed to evaluate the needs of individuals seeking long-term care services. It collects information about the individual's health status, living situation, and support systems. Both forms aim to provide a comprehensive understanding of the individual's needs to facilitate appropriate care planning.
The Client Intake Form used by mental health providers also has similarities. This form gathers essential information about the client’s background, mental health history, and current symptoms. Like the PASRR form, it aims to create a holistic view of the individual's health needs, which can guide treatment decisions and care plans.
Lastly, the Comprehensive Geriatric Assessment (CGA) is relevant to this discussion. The CGA is a multidimensional assessment tool for older adults that evaluates medical, psychological, and functional capabilities. Similar to the PASRR form, the CGA seeks to identify the needs of older adults to develop tailored care plans. Both documents emphasize the importance of understanding the individual's overall health and well-being.
The Colorado Post Admission Level 1 PASRR form is designed to assess individuals who are being admitted to nursing facilities. Its primary purpose is to determine if the individual has a mental illness (MI) or developmental disability (DD) that requires specialized services. This assessment helps ensure that appropriate care and resources are allocated based on the individual's needs. The form collects essential information about the individual's medical history, current symptoms, and previous psychiatric treatment.
The PASRR Level 1 form must be completed by the facility or agency responsible for the individual's admission to a nursing facility. This typically includes medical facilities, psychiatric facilities, or nursing homes. The person completing the form should have access to the individual's medical and psychiatric history to provide accurate information. Additionally, the form requires input from healthcare professionals, such as physicians, to validate the individual's mental health status and any ongoing treatment.
To complete the PASRR Level 1 form, several key pieces of information are required:
Completing the form accurately is crucial for ensuring that the individual receives the appropriate level of care and services.
Once the PASRR Level 1 form is submitted, it is reviewed by Masspro, the organization responsible for overseeing PASRR determinations in Colorado. They will assess the information provided to determine if further screening is necessary. If any areas of concern are identified, such as suspected mental illness or developmental disabilities, additional evaluations may be required. The outcome of this review will dictate the next steps in the admission process, ensuring that the individual receives the appropriate care and resources based on their needs.
When filling out the Colorado Post Admission Level 1 Passr form, keep these important do's and don'ts in mind: