Commonwealth of Massachusetts
Executive Office of Health and Human Services
Office of Medicaid
600 Washington Street Boston, MA 02111 www.mass.gov/masshealth

MassHealth
Nursing Facility Bulletin 127
December 2006

TO:
FROM:
RE:

Nursing Facilities Participating in MassHealth
Beth Waldman, Medicaid Director ^
Revision to Level I Preadmission Screening (PAS) Form

Revision to Level 1 PAS Form

MassHealth is updating the Level 1 Preadmission Screening (PAS) form to facilitate communication among nursing-facility providers, MassHealth, the Department of Mental Retardation (DMR), and the Department of Mental Health (DMH). Effective December 15, 2006, MassHealth will accept only the revised form. Please discard any previous forms. The nursing facility must complete the Level I PAS before all admissions, regardless of payment source. If the Level I PAS indicates a need for Level II PAS, the nursing facility must make a referral to DMR for individuals with mental retardation and/or a developmental disability. For individuals with mental illness, a referral to Health and Education Services (HES)—the contract agent for DMH—must be made.

Completing the Form

A nurse or social worker employed by the nursing facility and licensed by the appropriate Massachusetts Board of Registration must complete the Level I PAS.

Contacting DMR and DMH If the Level I PAS indicates the need for a Level II PAS, the nursing
facility must contact DMR or DMH/HES before admission to request the Level II PAS. DMR can be reached at 800-649-9378 and HES at 978-745-2440, x125.
To report an admission with mental retardation or developmental disability, the nursing facility must notify DMR on the day of admission and fax Page 1 of the Level I PAS to DMR. You can call DMR at 617-624-7794 or fax them at 617-624-7557.
(continued on next page)

MassHealth
Nursing Facility Bulletin 127
December 2006
Page 2
Obtaining the PAS Form     A copy of the Level I PAS is attached. You may photocopy the form as
needed. To obtain supplies of the form, mail or fax a written request to the following address or fax number.
MassHealth
ATTN: Forms Distribution P.O. Box 9118 Hingham, MA 02043 Fax: 617-988-8974

Questions

If you have any questions about the information in this bulletin, please contact MassHealth Customer Service at 1-800-841-2900, e-mail your inquiry to providersupport@mahealth.net, or fax your inquiry to 617-988-8974.

Level I Preadmission Screening (PAS)

This form must be completed by the nursing facility for all individuals who, regardless of payment source, are admitted to a nursing facility. This form must be kept permanently in the resident’s medical record. A licensed nurse or licensed social worker employed by the nursing facility must complete both sides of this form before the applicant’s admission, as mandated by the federal Omnibus Budget Reconciliation Act (OBRA) of 1987.

Provider number	MassHealth ID or SSN	
Name	Name	
Address	Address	
City, ZIP code	City, ZIP code	
Telephone number	Date of birth	Gender
 m     f	
Section 1: PAS for Mental Retardation or Developmental Disability

► 1. Does the nursing-facility applicant have a documented diagnosis or treatment history of mental retardation or developmental	
► 2. Has the nursing-facility applicant received services for mental retardation or developmental disability from an agency that serves
individuals with mental retardation and/or developmental disability?	□ yes   □ no	
► 3. Does the nursing-facility applicant exhibit any evidence that may indicate mental retardation or developmental	
If you answered no to all questions in Section 1, skip Section 2 and proceed to Section 3.	
Section 2: Convalescent Care (following an acute inpatient hospital stay)

► Is the nursing-facility applicant seeking admission for convalescent care as certifi ed by a physician not to exceed 30 days directly	
following an acute-inpatient-hospital stay?		□ yes   □ no	
Section 3: Level I Determination for Mental Retardation or Developmental Disability

Check all that apply.	
□  Level II PAS is not indicated because there is no diagnosis or evidence of mental retardation or developmental disability.	
□  Level II PAS is not indicated because the applicant is seeking admission for convalescent care as certifi ed by a physician not to exceed 30 days directly following an acute-inpatient-hospital stay.	
D Level II PAS is indicated and must be completed before admission. Date of completion:	
□  Approved by DMR for nursing-facility admission. (The DMR approval letter must be in the medical record.)	
Date of nursing-facility admission:	
Related diagnoses and comments:	
Signature:                                                 RN, LPN, LSW Date:                             Time:
(Circle one.)	
Note: You must notify DMR only when MR/DD is indicated.	
► Did you call and notify DMR on the day of admission?	□ yes (date)                                       □ no	
► Did you fax this page within 48 hours to DMR?	□ yes (date)                                       □ no	

PAS-1 (Rev. 12/06)	Please complete other side.

Name of Applicant:
Section 4: PAS for Mental Illness

► 1. Does the nursing-facility applicant have a documented diagnosis or treatment history of any of the following major mental disorders? Check all that apply.	
Psychoses                             Affective Disorders	
□ □ □	Schizophrenia Paranoia Atypical psychosis		□ □ □	Schizo-affective disorder
Bipolar disorder (formerly manic depression)
Unipolar depression more than 10 years (date of diagnosis:	)	
Severe Anxiety and Somatoform Disorders (All must apply for Level II PAS referral.)	
□ □ □	Two years’ duration with documented symptoms in the last six months
Inpatient psychiatric treatment for anxiety disorder
Psychoactive medication(s) administered for anxiety disorder (date of diagnosis:                                )	
► 2. Has the nursing-facility applicant ever received any of the following treatments for unipolar depression?	
a.	npatient or outpatient psychiatric treatment		.□ yes	□ no	
b.	Electroconvulsive therapy		.□ yes	□ no	
c.	Psychoactive medications		.□ yes	□ no	
► 3. Does the nursing-facility applicant exhibit any evidence of a major mental illness?		.□ yes	□ no	
If you answered no to all questions in Section 4, skip Section 5 and proceed to Section 6.	
Section 5: Primary Diagnoses/Conditions

► Does the nursing-facility applicant have any of the following diagnoses or conditions or meet any of the following descriptions? (Note: End Stage (ES) is defi ned as severe, debilitating, and bed-bound or bed-to-chair). Check all that apply.	
□ Alzheimer’s disease or other dementia (requires supporting documentation)	□ Severe brain injury	

	□ ES COPD with 24-hour oxygen	
□ Comatose	□ ES CHF with 24-hour oxygen	
□ Ventilator dependent	□ ES Amyotrophic lateral sclerosis (ALS)	
□ Terminal illness with less than six-month prognosis as certifi ed by a physician	□ ES Huntington’s chorea	

	□ ES Parkinson’s disease	
□ Unipolar depression, less than 10 years’ duration (date of diagnosis:                                                            )	
□ Convalescent care as certifi ed by a physician not to exceed 30 days directly following an acute inpatient hospital stay (this does not include a psychiatric hospitalization).	
Section 6: Level I Determination for Mental Illness

Check all that apply.							
□ □ □ □	Level II PAS is not indicated because there is no diagnosis as listed or evidence of mental illness as noted in Section 4.
Level II PAS is not indicated because the applicant has one of the diagnoses or conditions in Section 5.
Level II PAS is indicated and must be completed before admission. Date of completion:
Approved by Health and Education Services (HES) on behalf of the Department of Mental Health for nursing-facility admission.
(The HES approval letter must be in the medical record.)	
Comments:							
List psychoactive medication(s) and dosage:						
									
Signature:			RN, LPN, LSW	Date:		Time:		
				(Circle one.)					
			Level I and Level II pas must be kept permanently in the medical record.	
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