Fhsc 18 Form Nevada PDF Details

The Fhsc 18 Nevada form plays a crucial role within the Nevada Medicaid and Nevada Check Up Programs operated by First Health Services Corporation, serving as a primary tool for Level I Identification Screening in accordance with the Pre-Admission Screening and Resident Review (PASRR). This comprehensive form is designed to ensure that individuals seeking admission into Medicaid-funded nursing facilities or requiring specialized services due to mental illness (MI), mental retardation (MR), related conditions (RC), or dementia are appropriately evaluated. The sections within the form cover extensive ground, including mental illness screening and interventions, determinations for mental retardation and related conditions, dementia assessment, and categorical determinations for conditions such as terminal illness and severe physical illness. Moreover, the form assesses the need for exempted hospital discharge and time-limited categorical determinations, crucial steps in facilitating the right care pathways. The confidentiality underscored by this process ensures sensitive patient information is handled with the utmost care, maintaining dignity and respect for the individuals and their families navigating these complex systems.

QuestionAnswer
Form NameFhsc 18 Form Nevada
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesRequestor, PASRR, NF, IIE

Form Preview Example

 

 

 

 

 

 

 

 

 

Nevada Medicaid and Nevada Check Up Programs

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Health Services Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEVEL I IDENTIFICATION SCREENING (for PASRR)

 

"CONFIDENTIAL"

 

 

 

 

 

 

 

 

 

 

 

PHONE: 1-800-525-2395

 

FAX:

1-866-480-9903

 

 

 

 

 

 

 

 

 

 

DATE SUBMITTED to FHSC:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

INITIAL___ UPDATE___

 

 

 

 

 

 

 

 

 

 

 

**PLEASE TYPE OR PRINT**

 

 

 

 

 

 

 

 

 

 

 

 

 

Patient Name:

 

 

 

 

 

 

 

 

SS #:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home Address:

 

 

 

 

 

 

 

 

Medicaid Billing #:

 

 

 

 

 

 

Sex:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOB:

 

 

 

Pmt. Source:

 

Marital Status:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Known Diagnoses: _____________________________________________

 

Original Admit Date:

 

 

 

Admit Date:

 

 

 

 

Legal Representative:

 

 

 

 

 

 

 

 

Admitting Facility:

 

 

 

 

 

 

 

 

 

 

 

Provider ID#:

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

 

 

Requesting Facility:

 

 

 

 

 

 

 

Contact Name:

 

 

 

 

 

 

 

 

 

 

Address:

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

 

 

 

Fax:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Telephone:

 

 

 

 

 

 

 

Fax:

 

 

Patient's Current Location

Home

 

Acute In-Patient

 

ER

 

 

Requestor:

 

 

 

 

 

 

 

 

 

 

 

Acute ObservBed

 

NF____

Rehab Hosp/Unit___ Other_____

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I: MENTAL ILLNESS (MI) SCREENING

3.B. Concentration/task limitations within past 6 months and due to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MI (exclude problems with medical basis):

 

 

 

 

 

 

1.A. Psychiatric Diagnoses

 

 

 

 

 

 

 

F

O

N Serious difficulty completing age related tasks.

 

 

Severe Anxiety/Panic Disorder

 

 

Psychotic disorder

 

F

O

N Serious loss of interest in things.

 

 

 

 

 

 

 

 

Bipolar Disorder

 

 

 

Somatoform disorder

 

F

O

N Serious difficulty maintaining concentration/attention.

 

 

Delusional Disorder

 

 

 

Schizophrenia

 

F

O

N Numerous errors in completing tasks which he/she

 

 

Schizoaffective disorder

 

 

Eating disorder (specify)

 

 

 

 

 

should be physically capable of accomplishing.

 

 

Major depression

 

 

 

 

 

 

 

F

O

N Requires assistance with tasks for which he/she

 

 

Personality disorder

(specify)

 

 

 

 

 

 

 

 

should be physically capable of accomplishing.

 

 

Other :

 

 

 

 

 

 

 

F

O

N Other:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Notes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1.B. Psychiatric Meds

 

 

Diagnosis/Purpose

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

3.C. Significant problems adapting to typical changes within past 6

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

months and due to MI (exclude problems with medical basis):

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

N

Requires mental health intervention due to

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

increased symptoms.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY: Meets diagnosis criteria for chronicity?

 

Y

N

Requires judicial intervention due to symptoms.

 

 

 

 

 

 

 

 

 

Y

 

 

N

 

 

 

 

Y

N

Symptoms have increased as a result of adaptation

2.A. Psychiatric treatment more intense than outpatient received in past 2 years: (MORE THAN ONCE)

 

 

 

difficulties.

 

 

 

 

 

 

 

 

 

 

 

 

inpatient psych. hosp.(dates)

 

 

 

 

 

Y

N

Serious agitation or withdrawal due to adaptation

 

 

 

 

 

 

partial hosp./day treatment(dates)

 

 

 

 

 

 

difficulties.

 

 

 

 

 

 

 

 

 

 

 

 

other(dates)

 

 

 

 

 

 

 

 

Y

N

Other

 

 

 

 

 

 

 

 

 

 

 

2.B. Intervention to prevent hospitalization: (give dates)

 

Notes:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

supportive living due to MI(dates)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

housing intervention due to MI(dates)

FHSC USE ONLY:

 

 

MI Decision:

 

 

 

 

 

 

legal intervention due to MI(dates)

 

 

 

Meets criteria for disability?

 

 

Meets criteria for SMI:

 

 

suicide attempt(dates)

 

 

 

 

 

 

Y

 

N

 

 

 

Y

 

N

 

 

 

 

 

 

other

 

 

 

 

 

 

SECTION II: MENTAL RETARDATION (MR) AND RELATED

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY: Meets criteria for duration?

 

 

 

 

 

CONDITIONS (RC) SCREENING

 

 

 

 

 

 

 

 

 

Y

 

 

N

 

 

 

1.A. MR diagnosis:

 

N

 

Y (specify)

 

 

 

 

 

 

3. Role limitations in past 6 months due to MI: (excluding medical problems)

B. Undiagnosed but suspected MR:

 

N

 

Y

 

 

N/A

Indicate: "F" Frequently, "O"

Occasionally, or "N" Never

C. History of receipt of MR services:

 

N

 

Y

 

 

 

 

3. A. Interpersonal Functioning (exclude problems w/medical basis)

 

(if yes, specify):

 

 

 

 

 

 

 

 

 

 

 

F O N

Altercations

F

O

N

Social isolation/avoidance

2. Occurrence before age 18:

 

 

N

Y

 

 

 

 

F O N

Evictions

F

O

N

Excessive irritability

 

(if yes, specify age):

 

 

 

 

 

 

 

 

 

 

F O N Fear of strangers

F

O

N

Easily upset/anxious

2.A. Related conditions which impair intellectual functioning or adaptive

F O N Suicidal talk

F

O

N

Hallucinations

 

behavior.

 

 

Blindness

 

Deafness

 

 

 

 

 

 

F O N Illogical comments

F O N

Serious communication

 

 

Cerebral Palsy

 

Autism

Epilepsy

 

 

 

 

F O N

Other

 

 

 

difficulties

 

 

Closed head injury

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

F

O

N

Other

B. Substantial functional limitations in 3 or more of the following:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Self-care

 

Mobility

 

Learning

 

 

 

 

Notes:

 

 

 

 

 

 

 

 

 

 

 

 

Self-direction

 

Capability for independent living

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Understanding/use of language

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Was the condition manifested before age 22?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

N

 

 

Y (specify)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY: Meets criteria for MR/RC?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MR Decision:

 

 

Y

 

N

 

 

 

 

 

 

 

Name and Professional Title of Person Completing Form: ___________________________ Date Completed:

 

 

 

Page 1 of 2

FHSC-18

Aug-03

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOP HERE IF NO INDICATORS OF MI, MR OR RC

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Nevada Medicaid and Check Up Program

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

First Health Services Corporation

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

LEVEL I IDENTIFICATION SCREENING (for PASRR)

 

"CONFIDENTIAL"

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOP HERE - IF NO INDICATORS OF MI, MR OR RC

 

SECTION VI: OTHER CATEGORICAL DETERMINATIONS(non-limited)

 

 

 

 

OTHERWISE CONTINUE

 

 

 

 

IIF.

 

Terminal Illness: Physician has certified life expectancy of less

SECTION III: DEMENTIA

(complete for both MI & MR/RC)

 

 

 

than 6 months. (Submit copy of certification).

A. Does the individual have a primary diagnosis of Dementia or

 

IIG.

 

Severe Physical Illness limited to:

 

 

 

Alzheimer's Disease?

 

 

 

 

 

 

 

 

 

 

 

 

Coma, Ventilator Dependence, functioning at a brain stem level

 

 

 

Y

 

N (specify)

 

 

 

 

 

 

 

 

 

 

 

 

or a diagnosis of Parkinson's, Chronic Obstructive Pulmonary

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B. Does the individual have any other organic disorders?

 

 

 

 

 

 

Disease, Huntington's disease, Amyotrophic lateral sclerosis

 

 

 

Y

 

N (specify)

 

 

 

 

 

 

 

 

 

 

 

 

or congestive heart failure which result in a level of

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

C. Is there evidence of undiagnosed Dementia or other organic

 

 

 

impairment so severe that the individual could not be expected

mental disorders?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

to benefit from specialized services.

 

 

 

Y

N

disoriented to time

Y

N

disoriented to situation

 

 

 

 

 

 

 

 

 

 

 

Y

N disoriented to place

Y

N

pervasive, significant confusion

FHSC USE ONLY:

 

 

 

 

 

 

Y N severe ST memory

Y N paranoid ideation

 

 

 

 

Meets Other Categorical Determination criteria?

 

 

deficit

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Y

 

N

 

 

 

 

 

D. Is there evidence of affective symptoms which might be confused

 

SECTION VII: REQUESTING PROVIDER TO COMPLETE

with Dementia?

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Information (required if indicators of MI, MR/RC):

Y

N

frequent tearfulness

Y

N

severe sleep disturbance

 

 

 

Legal representative's name and address:

Y

N

frequent anxiety

Y

N

severe appetite disturbance

 

 

 

 

 

 

 

 

 

 

 

E. Can the requstor provide any corroborative information to affirm that the

 

 

 

 

 

 

 

 

 

 

dementing condition exists and is the primary diagnosis?

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Dementia work-up

 

 

Thorough mental status exam

 

 

 

 

 

 

 

 

 

 

 

____ Medical/functional history prior to onset of dementia

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Other

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Primary physician's name and address:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

STOP - If Dementia is primary to MI.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

CONTINUE - for all MR/RC or non-primary dementia with MI.

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY: Meets dementia criteria?

 

 

Y

 

 

N

 

 

 

 

 

 

 

 

 

 

 

SECTION IV: EXEMPTED HOSPITAL DISCHARGE (EHD)*

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

A. Does the individual meet all of the following criteria?

 

 

 

 

 

 

Additional supporting documentation is attached/submitted.

 

 

 

Admission to a NF directly from a hospital after receiving

 

 

 

Physician's certification stating a less than 30 day nursing facility

 

 

 

acute in-patient care at the hospital; and

 

 

 

 

 

 

stay is needed to justify EHD is attached/submiited.

 

 

 

Requires NF services for the condition he/she received care in

 

 

Physician's certification for a less than six (6) month life

 

 

 

the hospital; and

 

 

 

 

 

 

 

 

 

 

 

 

expectancy for terminal illness is attached/submitted.

 

 

 

The attending physician has certified prior to NF

 

 

 

 

 

 

 

 

 

 

 

 

 

 

admission that the individual will require less than 30 days

 

Date Form Completed:

 

 

 

 

 

 

 

 

 

NF services. (Submit copy)

 

 

 

 

 

 

 

 

Name and Professional Title of Person Completing form:

* Individuals meeting all above criteria are exempt from PASRR II

 

 

 

 

 

 

 

 

 

 

 

screening for 30 days. The receiving facility must submit a Level I

FHSC OFFICE USE ONLY:

 

 

 

 

 

by the 25th day to request PASRR Level II, when it is apparent

 

SUMMARY and DETERMINATION

 

 

 

the stay will exceed 30 days.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC USE ONLY:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has indicators of MI, MR/RC

 

 

No indicators of MI,

Meets EHD criteria?

 

Y

 

 

N

 

 

 

 

 

 

 

 

 

 

 

MR/RC

Limitation Date:

 

 

 

 

 

 

 

 

 

 

 

 

Level I Identification Determination:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

PASRR LEVEL II CATEGORICAL DETERMINATIONS

 

 

 

IA - Exempted Hospital Discharge

 

 

 

SECTION V: Time-Limited* CATEGORICAL DETERMINATIONS

 

 

 

IA - Qualifies for Categorical Determination

IIE. The following categories indicate the individual requires NF services

 

 

IA - Requires PASRR Level II Individual Evaluation

and does not require specialized services for the time specified.

 

 

 

IB - Has Dementia, Alzheimer's, Organic Brain Syndrome

A. _____ Convalescent care from an acute physical illness which

 

 

 

IC - Not MI, MR/RC or Demented

 

 

 

 

required hospitalization and does not meet all criteria for an EHD.

 

 

 

 

 

 

 

 

 

 

B.

 

 

Emergency protective service situation for MI or MR/RC

 

PASRR Level II Categorical Determination:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

individual - placement in NF not to exceed 7 days.

 

 

 

 

 

 

PAS (applicant to NF)

 

 

RR (resident in NF)

C.

 

 

Delirium precludes the ability to accurately diagnose. Facility

 

 

 

 

 

 

 

 

 

 

 

must obtain PASRR Level II as soon as the delirium clears.

 

 

 

IIE - Time Limited Approval Limitation Date: ________

D.

 

 

Respite is needed for in-home caregivers to whom the MI,

 

 

 

IIF - Terminal Illness

 

 

 

 

 

 

MR/RC individual will return.

 

 

 

 

 

 

 

 

 

 

 

 

IIG - Severe Physical Illness

 

 

 

*If any of the above are checked, receiving facility must submit a

 

 

 

 

 

 

 

 

 

 

 

new Level I to request PASRR Level II ten (10) days prior to the

 

Referral Needed for PASRR Level II Individual Evaluation:

limitation date listed below for resident's whose stay is anticipated

 

 

Referred for MI

Date Referred:

 

 

to exceed that date.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Referred for MR/RC

Date Referred:

 

 

FHSC USE ONLY: Meets IIE Categorical Determination Criteria?

 

 

 

Dual Referral MI and MR/RC

Date:

A.

 

 

Y

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

B.

Appropriate for NF

 

Y

 

 

N

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Limited to: ____________________

 

 

 

 

 

Date Completed

FHSC Reviewer's Name/Signature

Note: Limitations for Convalescent care = 45 days, Emergency Protective Services = 7 days,

 

 

 

 

 

 

 

 

 

 

Delirium = 30 days, and Respite = 30 days.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FHSC-18

 

Jul 2003

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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