Dhmh 4345 Form PDF Details

DHMH 4345 is a form used in the state of Maryland to report child abuse. The form is used to provide information about the alleged abuse, including the nature of the abuse, when it occurred, and who was involved. DHMH 4345 must be completed and submitted within 24 hours of discovering or suspecting child abuse. Completing this form will help ensure that all necessary information is collected and that authorities can investigate the allegations quickly and effectively.

QuestionAnswer
Form NameDhmh 4345 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other names4345 maryland form, maryland pasrr form md form, dhmh 4345 form, maryland pasrr get

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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_______________

*************************************************************************************************

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 [

]

--------------------------------------------------------------------------------------------------------------------------------------------------

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 [ ]

--------------------------------------------------------------------------------------------------------------------------------------------------

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____________

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How one can prepare maryland pasrr search stage 1

2. Soon after this section is filled out, proceed to enter the applicable information in all these - IF ALL THREE QUESTIONS ARE, Is there any presenting evidence, Is the individual being referred, Does the individual have a, Is there any history of ID or, INTELLECTUAL DISABILITY ID AND, Yes No, and Yes No.

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3. Completing Name, Yes No, Yes No, Yes No, SERIOUS MENTAL ILLNESS MI see, CATEGORICAL ADVANCE GROUP, Diagnosis Does the individual have, Level of Impairment Has the, Is the individual being admitted, Recent treatment In the past, and C Yes No Is the individual is essential for the next step, make sure to fill them out in their entirety. Don't miss any details!

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