Dhmh 4345 Form – Fill Out and Use This PDF

DEPARTMENT OF HEALTH AND MENTAL HYGIENE

PREADMISSION SCREENING AND RESIDENT REVIEW (PASRR)

LEVEL I ID SCREEN FOR

MENTAL ILLNESS AND INTELLECTUAL DISABILITY OR RELATED CONDITIONS

Note: This form must be completed for all applicants to nursing facilities (NF) which participate in the Maryland Medical Assistance Program regardless of applicant’s payment source.

Last Name_________________________ First Name__________________ MI_______ Date of Birth_____________

SSN_______________________ Sex M___ F___ Actual/Requested Nursing Facility Adm Date________________

Current Location of Individual_______________________________________________________________________

Address_________________________________________________________________________________________

City/State______________________________________________________________ ZIP______________________

Contact Person___________________________ Title/Relationship___________________ Tel#_________________

A.EXEMPTED HOSPITAL DISCHARGE

1.Is the individual admitted to a NF directly from a hospital after receiving

acute inpatient care?

Yes [ ] No [ ]

2.Does the individual require NF services for the condition for which he

received care in the hospital?

Yes [ ] No [ ]

3.Has the attending physician certified before admission to the NF that

The resident is likely to require less than 30 days NF services?

Yes [ ] No [ ]

IF ALL THREE QUESTIONS ARE ANSWERED YES, FURTHER SCREENING IS NOT REQUIRED (PLEASE SIGN AND DATE BELOW). IF ANY QUESTION IS ANSWERED NO, THE REMAINDER OF THE FORM MUST BE COMPLETED AS DIRECTED.

IF THE STAY EXTENDS FOR 30 DAYS OR MORE, A NEW SCREEN AND RESIDENT REVIEW MUST BE PERFORMED WITHIN 40 DAYS OF ADMISSION.

Signature___________________________________ Title___________________________ Date_______________

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B.INTELLECTUAL DISABILITY (ID) AND RELATED CONDITIONS (see definitions)

1.Does the individual have a diagnosis of ID or related condition? If yes, specify

	diagnosis__________________________________________________	Yes [	] No [	]
2.	Is there any history of ID or related condition in the individual’s past, prior to age 22?	Yes [	] No [	]

3.Is there any presenting evidence (cognitive or behavior functions) that may indicate

	that the individual has ID or related conditions?	Yes [	] No [	]
4.	Is the individual being referred by, and deemed eligible for, services by an agency
	which serves persons with ID or related conditions?	Yes [	] No [	]

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Is the individual considered to have ID or a Related Condition? If the answer is Yes to one or more of
the above, check “Yes.” If the answers are No to all of the above, check “No.”	Yes [ ] No [ ]

_________________________________________________________________________________________________

DHMH 4345 (Rev. 6/2014)

Name______________________________________

C.SERIOUS MENTAL ILLNESS (MI) (see definitions)

1.	Diagnosis. Does the individual have a major mental disorder?
	If yes, list diagnosis and DSM Code____________________________	Yes [	] No [	]
2.	Level of Impairment. Has the disorder resulted in serious functional limitations
	in major life activities within the past 3 – 6 months (e.g., interpersonal functioning,
	concentration, persistence and pace; or adaptation to change?	Yes [	] No [	]

3.Recent treatment. In the past 2 years, has the individual had psychiatric treatment more intensive than outpatient care more than once (e.g., partial hospitalization) or inpatient hospitalization; or experienced an episode of significant disruption to the normal living situation for which supportive services were required to maintain

functioning at home or in a residential treatment environment or which resulted in
intervention by housing or law enforcement officials?	Yes [ ] No [ ]

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Is the individual considered to have a SERIOUS MENTAL ILLNESS? If the answer is Yes to
all 3 of the above, check “Yes.” If the response is No to one or more of the above, check “No.”	Yes [ ] No [ ]

__________________________________________________________________________________________________

If the individual is considered to have MI or ID or a related condition, complete Part D of this form. Otherwise, skip Part D and sign below.

D.CATEGORICAL ADVANCE GROUP DETERMINATIONS

1. Is the individual being admitted for convalescent care not to exceed 120 days due to

an acute physical illness which required hospitalization and does not meet all
criteria for an exempt hospital discharge (described in Part A)?	Yes [ ] No [ ]

2.Does the individual have a terminal illness (life expectancy of less than six months)

as certified by a physician?

Yes [ ] No [ ]

3.Does the individual have a severe physical illness, such as coma, ventilator dependence, functioning at a brain stem level or other diagnoses which result in a

level of impairment so severe that the individual could not be expected to benefit
from Specialized Services?	Yes [ ] No [ ]

4.Is this individual being provisionally admitted pending further assessment due to

an emergency situation requiring protective services? The stay will not exceed 7 days. Yes [ ] No [ ]

5. Is the individual being admitted for a stay not to exceed 14 days to provide respite? Yes [ ] No [ ]

If any answer to Part D is Yes, complete the Categorical Advance Group Determination Evaluation Report and attach. Additionally, if questions 1, 2, or 3 are checked “Yes,” or if all answers in Part D are “No,” the individual must be referred to AERS for a Level II evaluation.

__________________________________________________________________________________________________

I certify that the above information is correct to the best of my knowledge. If the initial ID screen is positive and a Level II evaluation is required, a copy of the ID screen has been provided to the applicant/resident and legal representative.

Name________________________________________ Title_________________________ Date__________________

FOR POSITIVE ID SCREENS, NOT COVERED UNDER CATEGORICAL DETERMINATIONS, Check below.

___ This applicant has been cleared by the Department for nursing facility admission.

___ This resident has been assessed for a resident review.

Local AERS Office__________________________ Contact________________________________ Date____________