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 128 March 2007 TO: Nursing Facilities Participating in MassHealth FROM: Tom Dehner, Acting Medicaid Director RE: Revision to Level I Preadmission Screening (PAS) Form—Correction This bulletin is being issued to correct the phone number listed for DMR in Nursing Facility Bulletin 127 (December 2006). There are no other changes in the information provided in that bulletin, but the complete text is reprinted here for your reference. We apologize for any inconvenience this error caused. 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 617-624-7796 or fax them at 617-624- 7557. (continued on next page) MassHealth Nursing Facility Bulletin 128 March 2007 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. MassHealth Commonwealth of Massachusetts EOHHS www.mass.gov/masshealth 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. Nursing Facility Provider Information Provider number Name Address City, ZIP code Telephone number Nursing Facility Applicant Information MassHealth ID or SSN Name Address City, ZIP code 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 disability? yes no 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 disability? yes no 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. 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 (Circle one.) Date: Time: 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 Schizophrenia Paranoia Atypical psychosis Affective Disorders 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. Inpatient 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) Comatose Ventilator dependent Terminal illness with less than six-month prognosis as certified by a physician 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). Severe brain injury ES COPD with 24-hour oxygen ES CHF with 24-hour oxygen ES Amyotrophic lateral sclerosis (ALS) ES Huntington’s chorea ES Parkinson’s disease 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 (Circle one.) Date: Time: Level I and Level II PAS must be kept permanently in the medical record. -2-