DCH-3877 Form PDF Details

The Michigan Department of Community Health’s DCH 3877 form plays a pivotal role in ensuring that individuals with mental illness, mental retardation, or related conditions receive the proper mental health services when considering admission to, or residing in, nursing facilities. This comprehensive form is part of the Preadmission Screening (PAS) and Annual Resident Review (ARR), which aims to identify those in need of specialized mental health services by a detailed assessment of their condition. To ensure a thorough evaluation, the form requires information on the patient, legal representative, and agency, along with a rigorous screening completed by qualified professionals such as registered nurses, social workers, counselors, psychologists, physician's assistants, or physicians. It involves a binary (yes/no) checklist that assesses the presence of mental illness or dementia, receipt of treatment for these conditions within the last 24 months, routine prescription medication use, and presenting evidence of significant disturbances or deficits that suggest a diagnosis of mental retardation or a related condition. The form emphasizes the necessity of a meticulous review process, guided by criteria detailed in sections II and III, to determine whether an individual requires a Level II evaluation or qualifies under specific exemption criteria, thereby steering their care towards the appropriate mental health services and supports. With a structured approach to the identification and documentation of key indicators of mental health conditions, the DCH 3877 form facilitates essential communication between healthcare providers, patients, and legal representatives to ensure that the mental health needs of nursing facility residents are met in a timely and effective manner.

QuestionAnswer
Form NameDCH-3877 Form
Form Length4 pages
Fillable?Yes
Fillable fields35
Avg. time to fill out8 min 4 sec
Other namesstate of michigan 3877, michigan 3877 3878 form pdf, 3878 form 2020, state of michigan 3877 forms

Form Preview Example

Michigan Department of Community Health

PREADMISSION SCREENING (PAS) / ANNUAL RESIDENT REVIEW (ARR)

(Mental Illness / Mental Retardation / Related Conditions Identification)

Level I Screening

SECTION I – Patient, Legal Representative, and Agency Information:

PAS

ARR

Change in Condition

Patient Name (First, MI, Last)

 

Date of Birth (M,D,Y)

 

Gender

 

 

 

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

 

 

 

Address (Number and Street)

 

County of Residence

 

Social Security Number

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

ZIP Code

MEDICAID Beneficiary ID Number

MEDICARE ID Number

 

 

 

 

 

 

 

 

Does this patient have a court-appointed guardian or other legal representative?

If YES, Give Name of Legal Representative

 

 

 

 

NO

 

YES

 

 

 

 

 

 

 

 

 

 

 

County in which the Legal Representative was Appointed

Address (Number, Street, Apt. Number or Suite Number)

 

 

 

 

 

 

 

 

 

Legal Representative Telephone Number

 

City

 

 

State

ZIP Code

 

(

)

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referring Agency Name

 

Telephone Number

 

Admission Date (Actual or Proposed)

 

 

 

 

 

 

(

)

-

 

 

 

 

 

 

 

 

 

 

Nursing Facility Name (Proposed or Actual)

 

County Name

 

 

 

 

 

 

 

 

 

 

 

 

Nursing Facility Address (Number and Street)

 

City

 

 

State

ZIP Code

 

 

 

 

 

 

 

 

 

 

 

 

 

Sections II & III of this form must be completed by a registered nurse, licensed bachelor or master social worker, licensed professional counselor, psychologist, physician's assistant, or a physician.

SECTION II – Screening Criteria: All 6 items must be completed

1.

NO

YES

The person has a current diagnosis of

MENTAL ILLNESS

or

DEMENTIA. (CIRCLE ONE)

2.

NO

YES

The person has received treatment for

MENTAL ILLNESS

or

DEMENTIA within the past 24 months.

 

 

 

(CIRCLE ONE).

 

 

 

3.

NO

YES

The person has routinely received one or more prescribed antipsychotic or antidepressant medications within the last

 

 

 

14 days.

 

 

 

4.

NO

YES

There is presenting evidence of mental illness or dementia including significant disturbances in thought, conduct,

 

 

 

emotions, or judgment.

 

 

 

5.

NO

YES

The person has a diagnosis of mental retardation or a related condition, including but not limited to epilepsy, autism,

 

 

 

or cerebral palsy.

 

 

 

6.

NO

YES

There is presenting evidence of deficits in intellectual functioning or adaptive behavior which suggests that the

 

 

 

person may have mental retardation or a related condition.

 

 

Note: If you check "YES" to items 1 and/or 2, circle the word "mental illness" or “dementia."

Explain any "YES"

Note: The person screened shall be determined to require a comprehensive Level II OBRA evaluation if any of the above items are "YES" UNLESS a physician certifies on form DCH-3878 that the person meets at least one of the exemption criteria.

SECTION III – CLINICIAN’S STATEMENT: I certify to the best of my knowledge that the above information is accurate.

Clinician Signature

 

 

Date

 

Name (Typed or Printed)

 

 

 

 

 

 

 

 

 

 

 

 

Degree / License

 

 

 

 

 

 

 

 

Address (Number, Street, Apt. Number or Suite Number)

 

 

 

 

 

 

 

 

 

 

 

City

 

State

ZIP Code

 

Telephone Number

 

 

 

 

 

(

)

-

 

 

 

 

 

 

 

 

 

 

 

 

 

 

AUTHORITY:

Title XIX of the Social Security Act

 

 

The Department of Community Health is an equal opportunity employer, services,

COMPLETION:

Is Voluntary, but if NOT completed,

 

 

 

 

and programs provider.

 

Medicaid will not reimburse the nursing facility.

 

 

 

 

 

 

 

DISTRIBUTION: If any answer to questions 1 – 6 in SECTION II is "YES":

Send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and see that a copy goes to the patient or legal representative.

DCH-3877 (02/07) Previous editions are obsolete.

Mental Illness / Mental Retardation / Related Condition Identification Criteria

Instructions for DCH-3877

The DCH-3877 is used to identify prospective and current nursing facility residents who meet the criteria for possible mental illness or mental retardation, or a related condition and who may be in need of mental health services.

Sections II and III must be completed by a registered nurse, licensed bachelor or master social worker, licensed professional counselor, psychologist, physician’s assistant, or physician.

Preadmission Screening: The DCH-3877 must be completed by hospitals as part of the discharge planning process or by physicians seeking to admit an individual to a nursing facility from other than an acute care setting. Check the PAS box.

Annual resident review: The DCH-3877 must be completed by the nursing facility. Check the ARR box.

Section II – Screening Criteria – All 6 items on the form must be completed. The following provides additional explanation of the items.

1.Mental Illness: A current primary diagnosis of a mental disorder as defined in the Diagnostic and Statistical Manual of Mental Disorders, 4th Edition, Text Revised (DSM-IV-TR™).

Current Diagnosis means that a physician has established a diagnosis of a mental disorder within the past twenty-four

(24)months. Do NOT mark “YES” for an individual cited as having a diagnosis "by history" only.

2.Receipt of treatment for mental illness or dementia within the past 24 months means any of the following: inpatient psychiatric hospitalization; outpatient services such as psychotherapy, day program, or mental health case management; or referral for psychiatric consultation, evaluation, or prescription of psychopharmacological medications.

3.Antidepressant and antipsychotic medications mean any currently prescribed medication classified as an antidepressant or antipsychotic, plus Lithium Carbonate and Lithium Citrate.

4.Presenting evidence means the individual currently manifests symptoms of mental illness or dementia, which suggest the need for further evaluation to establish causal factors, diagnosis and treatment recommendations.

5.Mental Retardation / Related Condition: An individual is considered to have a severe, chronic disability that meets ALL four (4) of the following conditions:

a) It is manifested before the person reaches age 22. b) It is likely to continue indefinitely.

c) It results in substantial functional limitations in 3 or more of the following areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living.

d) It is attributable to:

mental retardation such that the person has significant subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period;

cerebral palsy, epilepsy, autism; or

any condition other than mental illness found to be closely related to mental retardation because this condition results in impairment in general intellectual functioning OR adaptive behavior similar to that of persons with mental retardation, and requires treatment or services similar to those required for these persons.

6.Presenting evidence means the individual manifests deficits in intellectual functioning or adaptive behavior, which suggests the need for further evaluation to determine presence of a developmental disability, causal factors, and treatment recommendations.

NOTE: When there is one or more "YES" answers to questions 1 – 6 under SECTION II, a Mental Illness / Mental Retardation / Related Condition Exemption Criteria Certification, DCH-3878 must be completed only if the referring agency is seeking to establish exemption criteria for a dementia, state of coma, or hospital exempted discharge.

DCH-3877 (02/07) Previous editions are obsolete.

How to Edit DCH-3877 Form Online for Free

Once you open the online PDF editor by FormsPal, it is easy to complete or alter state of michigan 3877 here. FormsPal is devoted to making sure you have the perfect experience with our tool by consistently presenting new capabilities and upgrades. With these updates, using our tool gets better than ever before! Starting is simple! Everything you should do is follow the next easy steps directly below:

Step 1: Just click on the "Get Form Button" above on this site to see our pdf editing tool. Here you will find everything that is needed to work with your document.

Step 2: With our advanced PDF tool, it is easy to do more than merely fill in blank fields. Edit away and make your docs seem great with customized text put in, or optimize the file's original input to excellence - all comes along with an ability to incorporate stunning photos and sign the document off.

Concentrate when filling in this form. Make certain each and every field is completed accurately.

1. You should complete the state of michigan 3877 accurately, thus take care while working with the parts that contain these specific blanks:

dhs 3877 completion process clarified (part 1)

2. Given that this section is finished, you need to put in the essential specifics in SECTION II Screening Criteria All, YES The person has a current, MENTAL ILLNESS, or DEMENTIA Circle One, YES The person has received, MENTAL ILLNESS, or DEMENTIA within the past months, Circle One, YES The person has routinely, days, YES There is presenting evidence, emotions or judgment, YES The person has a diagnosis of, or cerebral palsy, and YES There is presenting evidence so you can proceed to the 3rd stage.

Step number 2 of completing dhs 3877

Be extremely attentive while filling in YES There is presenting evidence and YES The person has received, since this is the part where a lot of people make mistakes.

3. The next stage is generally easy - complete all the blanks in Address, City, e Stat, ZIP Code, Telephone Number, AUTHORITY Title XIX of the Social, COMPLETION, Medicaid will not reimburse the, The Department of Community Health, DISTRIBUTION If any answer to, and DCH Previous editions are obsolete to conclude the current step.

dhs 3877 conclusion process outlined (portion 3)

Step 3: Before moving forward, you should make sure that blank fields are filled out the correct way. As soon as you are satisfied with it, press “Done." After registering a7-day free trial account here, it will be possible to download state of michigan 3877 or send it via email immediately. The PDF document will also be easily accessible in your personal account with your every modification. FormsPal guarantees protected form editing devoid of data record-keeping or any type of sharing. Feel at ease knowing that your details are secure here!