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IOWA Level I Data Collection Tool
This document is only to be used as a data collection tool for completing the online LI screening at www.pasrr.com
First Name:
Middle Initial:
Mailing Address:
Social Security #:
Gender:
Male
Last Name:
City:
-
-
State:
__ ____
Zip:
Phone:
Medicaid Id: __________________________ Date of Birth:
Female
_/
___
/
Race/Ethnicity:
American Indian/Alaskan Native Asian
Black/African American
Hispanic/Latino White
Native Hawaiian/Pacific Islander
Does the individual need/want an interpreter to communicate with doctor/NF staff? No
Yes
County of Residence: ___________________________
Current Location:_
___________
__________
Street_
__________
City__________
_
State_______Zip: ____
Why are you here?
Individual is seeking a new admission to a NF
Individual was readmitted to a NF after a psychiatric hospitalization
Individual was readmitted to a NF after a medical hospitalization
Individual is a NF resident who has experienced a significant change in status
Individual is a NF resident whose short-term approval is expiring
Individual is a NF resident who has never had a PASRR evaluation prior to admission to this facility
Date of Admission:
_/
/
___
Reason for Admission:______________________________________________________
Who or what entity is paying for this stay:
Medicare Self Pay Medicaid Pending
Dual-Medicare covering NF
Typical living situation over the past year:
Home Alone
Hospital
Homeless/Shelter Home Setting w/natural supports
NF
Home w/paid supports
Assisted Living Facility
Other: ______________________
Admitting Nursing Facility:
Street_
__________
______________________
City__________
Medicaid
Dual-Medicaid covering NF
Date Admitting:_____/___/_____
_
State_______Zip: ____
___
MENTAL ILLNESS
1.
Does the individual have any of the
following Major Mental Illnesses
(MMI)?
No
Suspected: One or more of the following
diagnoses is suspected (check all that
apply)
Yes: (check all that apply)
Schizophrenia
Schizoaffective Disorder
Major Depression
Psychotic/Delusional Disorder
Bipolar Disorder (manic depression)
Paranoid Disorder
2.
Does the individual have any
of the following mental
disorders?
No
Suspected: One or more of the
following diagnoses is
suspected (check all that
apply)
Yes: (check all that apply)
Personality Disorder
Anxiety Disorder
Panic Disorder
Depression
(mild or situational)
3.a Does the individual have a diagnosis of a mental disorder that
is not listed in #1 or #2? (do not list dementia here)
No
Yes (if yes, list diagnosis(es) below):
Diagnosis 1: _____________
Diagnosis 2:_______________
3.b. Does the individual have a substance related disorder?
No
Yes (if yes, complete remaining questions in this section)
b.1 List substance related diagnosis(es)
Diagnosis ___________ ___ Diagnosis _________________
Diagnosis ___________ ___ Diagnosis _________________
b.2 Is NF need associated with this diagnosis? No
Yes
b.3 When did the most recent substance use occur?
☐ Less than 7 days
☐ 7–14 days
☐ 15–30 days
☐ 31 days-3 months
☐ 4-6 months ☐ 7-12 months
☐ Greater than 12 months
☐ Unknown
SYMPTOMS
1. Interpersonal– Currently or in the past, has the individual exhibited
interpersonal symptoms or behaviors [not due to a medical
condition]?: ☐ No ☐ Yes
☐ Serious difficulty interacting with others
☐ Altercations, evictions, or unstable employment
☐ Frequently isolated or avoided others or exhibited signs
2. Concentration/Task related symptoms – Currently or in the past, has
the individual exhibited any of the following symptoms or behaviors [not
due to a medical condition]? ☐ No ☐ Yes
☐ Serious difficulty completing tasks that she/he should be capable of
completing
☐ Required assistance with tasks for which s/he should be capable
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Last Name_________________________ First Name__________________________ DOB__________________
☐ Substantial errors with tasks in which she/he completes
suggesting severe anxiety or fear of strangers
If yes, how recent:
☐ Current or within past 30 Days ☐ 2-6 months ☐ 7-12 months
☐ 13-24 months
☐ 25 months-5 years
☐ Greater than 5 years
If yes, how recent:
☐ Current or within past 30 Days ☐ 2-6 months ☐ 7-12 months
☐ 13-24 months
☐ 25 months-5 years
☐ Greater than 5 years
3. Identify whether the individual exhibited any of the following symptoms or behaviors currently or in the past relating to adapting to change:
No
Yes
3a. ☐ Self-injurious or self-mutilation
3b☐ Severe appetite disturbance
3c. ☐ Other major mental health symptoms (this
may include recent symptoms that have
☐ Suicidal talk
☐ Hallucinations or delusions
emerged or worsened as a result of recent life
☐ History of suicide attempt or gestures
☐ Serious loss of interest in things
changes as well as ongoing symptoms. Describe
☐ Physical violence
☐ Excessive tearfulness
Symptoms:
☐ Physical threats (with potential for harm)
☐ Excessive irritability
☐ Physical threats (no potential for
harm)
If yes, how recent:
If yes, how recent:
If yes, how recent:
☐ Current or within past 30 Days
☐ Current or within past 30 Days
☐ Current or within past 30 Days
☐ 2-6 months
☐ 7-12 months
☐ 2-6 months
☐ 7-12 months
☐ 2-6 months
☐ 7-12 months
☐
13-24
months
☐ 25 months-5 years
☐ 13-24 months ☐ 25 months-5 years
☐ 13-24 months ☐ 25 months-5 years
☐
Greater
than
5
years
☐ Greater than 5 years
☐ Greater than 5 years
HISTORY/DEMEMTIA
1. Currently or in the past, has the individual received any of the following
mental health services?
No
Yes (the individual has received the following service[s]):
Inpatient psychiatric hospitalization(if yes, provide date:
)
Partial hospitalization/day treatment(if yes, provide date:
)
Residential treatment (if yes, provide date:
)
Other:_____________________(if yes, provide date:___________)
If yes, how recent:
☐ Current or within past 30 Days
☐ 13-24 months
☐ Greater than 5 years
2. Currently or in the past, has the individual experienced significant
life disruption because of mental health symptoms?
No
Yes
(check all that apply):
Legal intervention due to mental health symptoms (date:
)
Housing change because of mental illness(date:
)
Suicide attempt or ideation (date[s]________________________)
Current Homelessness
Homelessness within the past 6 months but not current
Other:_______________ (date:__________________________)
If yes, how recent:
☐ Current or within past 30 Days ☐ 2-6 months ☐ 7-12 months
☐ 13-24 months
☐ 25 months-5 years
☐ Greater than 5 years
☐ 2-6 months ☐ 7-12 months
☐ 25 months-5 years
3. Has the individual had a recent psychiatric/behavioral evaluation?
4. Does the individual have a primary diagnosis of
dementia or Alzheimer’s disease?
No
Yes
Yes, the individual has dementia, but it is not primary
No
Yes (date:
)
5. If yes, is corroborative testing or other information available to verify the presence
or progression of the dementia? No Yes (check all that apply):
Dementia work up Comprehensive Mental Status Exam
Other (specify):
______________________________________________________________
PSYCHOTROPIC MEDICATIONS
1. Has the individual been prescribed psychoactive (mental health) medications now or within the past 6 months?
[use separate sheet if necessary] Do not list medications used for medical diagnoses
Medication
Dosage MG/Day
1. Does the individual have a diagnosis of intellectual disability
(ID)?
No
Yes
3. Is there evidence of a cognitive or developmental impairment that
occurred prior to age 18?
No
Yes
Diagnosis
No
Yes (list below)
Discontinued
ID/DD
2. Does the individual have presenting evidence of intellectual
disability (ID) that has not been diagnosed?
No
Yes
4. Has the individual ever received services from an agency that
serves people with ID?
No
Yes – agency:_____________________________
©20 11 , 2 014 As ce nd M ana ge me nt I n no vat io ns L LC . Al l r ig ht s re se rve d.
Rev. 7.1.13
Last Name_________________________ First Name__________________________ DOB__________________
5. Does the individual have a diagnosis which affects intellectual or
adaptive functioning? No
5a.
Yes – (specify) Autism  Epilepsy  Blindness
Cerebral Palsy
 Closed Head Injury
 Deaf
 Other:____________
5b. Did this condition develop prior to age 22?
No
Yes
6. Are there substantial functional limitations NOT due to medical
condition, dementia or mental illness?
No
Yes ( Specify)  Mobility
 Self-Care
 Self-Direction  Learning
 Understanding/Use of Language
 Capacity for living independently
EXEMPTIONS AND CATEGORICAL DECISIONS –TO BE ELIGIBLE FOR SHORT TERM EXEMPTION OR CATEGORICAL DESCISION, THE
INDIVIDUAL MUST BE PSYCHIATRICALLY AND BEHAVIORALLY STABLE.
No
Yes, meets all the criteria for a 60 day Categorical Decision
1. Does the admission meet criteria for Hospital Convalescence?
Yes, meets all the criteria for a 30 day Exempted Hospital Discharge
PRACTITIONER CERTIFICTIONREQUIRED
Admission to NF directly from hospital after receiving acute medical care AND Need for NF is required for the condition treated in the hospital;
Specify diagnosis(es)_____________________________________________________________________________________________ AND
The attending physician has certified prior to NF admission the individual will require less than 30 calendar days of NF services OR the attending
physician has certified prior to NF admission the individual will require less than 60 calendar days of NF services.
2. Does the admission meet criteria for provision emergency or provisional delirium?
No
Yes, meets the following criteria:
Provisional Emergency: Emergency protective services situation necessitating NF care for no greater than 7 calendar days.
Explain emergency: ________________________________________________________________________________________________
Provisional Delirium: Delirium affected the ability to accurately diagnose. Records supporting delirium must accompany the screening.
3. Does the individual meet one of the following criteria for Respite admission for up to 30 calendar days:
No
Yes, meets the following
criteria: The individual requires respite care for up to 30 calendar days to provide relief to the family or caregiver.
4.Does the individual meet one of the following criteria for categorical NF approval as a result of terminal state or severe illness?
No
Yes, meets the following criteria:
PRACTITIONER CERTIFICATION REQUIRED
Terminal Illness: Prognosis if life expectancy of < 6 months along with nursing care supervision needs associated with the condition.
Severe Illness: Coma, ventilator dependent, brain-stem functioning, progressed ALS, progressed Huntington’s etc. so severe that the
individual would be unable to participate in a program of specialized care associated with his/her MI and/or ID/RC. (documentation of
the individual’s medical status must accompany this screen)
5. Does the individual have co-occurring dementia and Intellectual disability/Developmental Disability:
No
Yes If so, is the dementia progressed to the extent that the individual could not benefit from ID/DD services? No
Yes
(if yes, corroborative documentation will be required)
Guardianship & Physician Information (Required only for individuals with known or suspected Level II conditions)
Legal Representative Name:______________________________ Phone:__________________ Fax:___________________________
Street___________________________________________ City_____________________ State___________ Zip_________________
Primary Physician’s Name:______________________________ Phone:__________________ Fax:___________________________
Street___________________________________________ City______________________ State___________ Zip________________
©20 11 , 2 014 As ce nd M ana ge me nt I n no vat io ns L LC . Al l r ig ht s re se rve d.
Rev. 7.1.13