Section He-M 1302.03 - Identifying and Referring Nursing Facility Applicants with MI or DD - the Level I Screen(a) A referral agent shall conduct a level I screen for every applicant seeking admission to a Medicaid certified nursing facility to identify each applicant who is suspected of: (1) Having MI as defined in He-M 1302.02(h) ; or(2) Having DD as defined in He-M 1302.02(d) .(b) The referral agent shall use "PASSR Level 1 Review Form" (11/2012 edition) for conducting the level I screen.(c) Every applicant's medical record at the nursing facility shall contain a completed "PASSR Level 1 Review Form" (11/2012 edition) .(d) For each applicant identified in (a) above, the referral agent shall submit the following, as applicable, to the PASRR office for a level II evaluation: (1) The applicant's name and address;(2) The name and address of the referring agency and the receiving agency;(3) The applicant's date of birth;(4) The name, address, telephone number, and relationship of the applicant's nearest relative or, if applicable, legal representative;(5) The applicant's Medicaid claim number and information regarding the applicant's other insurance and resources, as available;(6) The date of admission to the referring agency and the date of transfer to the receiving agency, if available;(7) The applicant's suspected MI or DD diagnosis;(8) The applicant's physical history and current functional, mental, and physical status, including: c. Functional assessments;d. Physical disabilities; ande. Need for assistive devices;(9) The applicant's rehabilitation goals and the estimated length of stay, if applicable;(10) The physician's name;(11) Psychiatric history and consultations covering at least the past 2 years, including: a. Identification of one or more of the disorders as defined in He-M 1302.02(h) ;b. A description of how the disorder has resulted in functional limitations in major life activities within the past 3 to 6 months;c. A description of the last 2 years' psychiatric treatment history and in-patient psychiatric treatment; andd. A description of interventions from social service or law enforcement representatives relative to the MI;(12) If referred from a hospital setting, intake, history and physical, and consultation reports;(13) The written notice pursuant to (e) below; and(14) Any other information that is considered by the referral agent to be necessary to make an accurate determination pursuant to He-M 1302.06(a) .(e) For each applicant identified in (a) above, the referral agent shall give the applicant, or his or her legal guardian or legal representative, a written notice explaining that the applicant is being referred to the PASRR office for level II evaluation pursuant to He-M 1302.03(d) .N.H. Admin. Code § He-M 1302.03
#6063 eff 8-1-95; ss by #7920, INTERIM, eff 8-2-03, EXPIRED: 1-29-04
New. #8035, eff 2-7-04, EXPIRED: 2-7-12
New. #10123, INTERIM, eff 4-30-12, EXPIRES: 10-29-12; ss by #10216, eff 10-29-12