The journey towards admission into a Medicaid Certified Nursing Facility is marked by a crucial step: the completion of the LTC-14 form, a document that underscores its importance through its connection to both compliance and financial implications. Officially emanating from the State of Alabama Department of Mental Health, this form serves as a fundamental Level I Screening for Mental Illness (MI), Intellectual Disability (ID), and Related Conditions (RC), ensuring that each individual's needs are meticulously evaluated. The detailed requirement for such an assessment not only adheres to regulatory standards but also caters to the nuanced care necessities of the potential resident. Bridging the gap between legal obligations and personalized healthcare, the formulation of the LTC-14 seeks to refine the admission process by forewarning against inaccuracies which might lead to Medicaid Recoupments. With clearly structured sections requesting comprehensive information ranging from personal identification to diagnostic history and present condition, the form encapsulates an ethos of precision and pragmatism. Furthermore, the document stipulates conditions under which individuals may qualify for different categories of care—be it long-term residency or short-term therapeutic interventions—thereby tailoring the screening process to fit the multifaceted spectrum of needs that prospective residents may have. Every question and checkbox within the form is a testament to a broader commitment towards ensuring that the most appropriate, safe, and beneficial placement decisions are made for individuals with MI, ID, or RC, marking the LTC-14 as not just a procedural necessity but a cornerstone of compassionate, regulatory-aligned admissions strategy.
| Question | Answer |
|---|---|
| Form Name | Form Ltc 14 |
| Form Length | 2 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 30 sec |
| Other names | OBRALIForm(LTC1 4.R11) passr screening springfield illinois form |
This Level I Screening Form must be completed prior to admission into a Medicaid Certified Nursing Facility. Failure to complete this form accurately may result in Medicaid Recoupments.
PLEASE PRINT |
State of Alabama Department of Mental Health |
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Level I Screening for Mental Illness (MI) / Intellectual Disability (ID) / Related Condition (RC) |
Page 1 of 2 |
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Use for Medicaid Certified Nursing Home (NH) Only |
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Name: ________________________________________________________ SSN: _______
________________________________________________________________________________________________________________________
Name of current residence at time of Level I submission |
Street address |
City, State, and Zip |
County |
Check Type of Residence: NF Hospital Home |
Assisted Living Facility |
Group Home Other________________________ |
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Legal Guardian, If Applicable: __________________________________________ Address: _________________________________________ ___
Note: Under OBRA ’87, any individual who willfully and knowingly causes another individual to certify a material and false statement in a resident
assessment is subject to a civil money penalty of not more than $ 5,000 with respect to each assessment.
Referral Source and Title: _____________________________________________________________________Date: ________________________
Place of Employment: _____________________________________________Fax #:_______________________Phone #:_____________________
1.Does the individual have a suspected diagnosis or history of an Intellectual Disability or a Related Condition? Yes No
1a. Specify.
ID: Intellectual Disability
Did the ID develop before age 18?
Unknown Yes No N/A
RC: Autism
Did the Autism develop before age 22?
Unknown Yes No N/A
Cerebral Palsy
Did the Cerebral Palsy develop before age 22? Unknown Yes No N/A
Epilepsy/Seizure Disorder
Did the Epilepsy/Seizure Disorder develop before age 22? Unknown Yes No N/A
Other Related Condition: ___________________________
Did the Other RC develop before age 22?
Unknown Yes No N/A
2.Does the individual have a current, suspected or history of a Major Mental
Illness as defined by the Diagnostic & Statistical Manual of Mental Disorders (DSM) current edition? Choose “No” if the person’s symptoms are situational or directly related to a medical condition. (e.g. depressive symptoms caused by hyperthyroidism, depression caused by stroke or
anxiety due to COPD, these conditions must be documented in the medical records by a physician) Yes No
2a. If yes, check the appropriate disorder below.
Schizophrenia Schizoaffective Disorder Psychotic Disorder NOS Major Depression Depressive Disorder NOS Dysthymic Disorder Bipolar Disorder Generalized Anxiety Disorder Panic Disorder
PTSD OCD Somatoform Disorder Conversion Disorder
Personality Disorders Unspecified Mental Disorder
Other Mental Disorder in the DSM ____________________________
2b. Are any of the diagnoses checked on question #2 situational or conditions that are directly related to a medical condition? Yes No
(Reminder: If the diagnoses are situational or directly related to a medical
condition, do not check these conditions on #2. However, you must ensure that this information is documented in the person’s medical
records by the physician, for example, depression related to stroke or anxiety due to COPD)
3.Has the individual’s “Medical Condition” required the administration or prescription of any
medications within the last 14 days? Yes No
3a. If yes, list psychotropic medications for the Medical Condition (Do not list PRN medications):_____________________________
______________________________________________________
4. Is there a diagnosis of Dementia, Alzheimer’s or any related organic disorders? Yes No (Note: If yes is checked, Dementia must be documented in the medical records by a physician)
4a. If yes, complete the MSE. (If unable to test due to Dementia, enter “0” as a valid MSE score; if unable to test due to any other condition, check unable to test, and leave MSE score blank)
Provide MSE Score: ____ |
Check if unable to test: |
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4b. If #4 is yes, check level of consciousness: |
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Alert |
Drowsy |
Stupor |
Coma |
N/A |
4c. If #2 & #4 are yes, which diagnosis is primary? :
Dementia Mental Illness N/A
(The primary diagnosis must be documented in the medical records as
“primary” by a physician)
5.Does the individual’s current behavior or recent history within 1 year
indicate that they are a danger to self or others? (Suicidal,
5a. If yes, explain: ____________________________________________
6.Submission of this Level I is due to one of the following:
New Nursing Facility Admission
(For current NH residents, select one of the below Significant Changes):
Medical Improvement
Medical Decline
Mental Illness Improvement
Mental Illness Decline
Behavioral Changes
Short Term to Long Term Stay (only for MI/ID/RC Categorical Convalescent Care Residents)
Mental Health Diagnosis Change (i.e. New MH diagnosis)
Previous Level I Incorrect (For NH use only)
No Level I and Determination or/and Level II and Determination upon NH admission (For NH use only)
This Level I Screening Form must be completed prior to admission into a Medicaid Certified Nursing Facility. Failure to complete this form accurately may result in Medicaid Recoupments.
PLEASE PRINT |
State of Alabama Department of Mental Health |
|
|
Level I Screening for Mental Illness (MI) / Intellectual Disability (ID) / Related Condition (RC) |
Page 2 of 2 |
|
Use for Medicaid Certified Nursing Home (NH) Only |
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7.Select Long Term Care or the applicable Short Term Care Option:
Long Term Care
Short Term Care with the intent to return to the community after:
Convalescent
For MI/ID/RC patients (1) you must have PT and/or OT orders as prescribed by a physician for 5x a week for 120 days or less (2) is not a danger to self or others and (3) must be currently in the hospital w/ a direct admission into the NH.
Respite for no more than 7 days & is not a danger to self or others (Respite is not reimbursed by Medicaid under the NH Program)
NH admission for an emergency situation requiring protective services by DHR, person can not be a danger to self or others, if admission will exceed 7 days, the OBRA office must be contacted immediately to prevent
Other Short Term Stay (If applicable, persons with MI/ID/RC must have the Level II completed prior to admission)
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IV Therapy |
Wound Care Diabetes Care Home (in community) Convalescent Care |
Other (please specify)________________________________________________________
8.Is this individual terminally ill (life expectancy of six months or less), comatose, ventilator dependent, functioning at brain stem level or diagnosed as
having Cerebella Degeneration, Advanced ALS, or Huntington’s Disease as certified by an MD? Yes No