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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 Rev. 7.1.13 © 2011, 2014 Ascend Management Innovations LLC . All rights reserved. 840 Crescent Centre Drive , Suite 400 / Franklin, TN 37067 / www.ascendami.com 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