Form Ltc 14 – Fill Out and Use This PDF

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 anti-depressant, anti-psychotic, and /or anti-anxiety

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: 
4b. If #4 is yes, check level of consciousness:
 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, self-injurious or combative)  Yes  No

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)