Free 47185.FH11 - Indiana

LEVEL II: PASRR / MI MENTAL HEALTH ASSESSMENT
State Form 47185 (R5 / 4-99) / BAIS 0036

Information contained herein is CONFIDENTIAL according to IC 16-14-1.6-8.

PAS (PreAdmission Screening) New Mental Health Assessment Updated PAS RR (Resident Review):
Yearly RR Significant - Change RR

Give date of IPAS agency initial referral:

Give date returned to IPAS agency:

Send completed forms to:

Prior Level II done:

If "Yes" complete for most-recent:

Yes

No

Missed RR Name of PAS applicant or

(1) Check: PAS PAS Update (2) Give date of psychiatrist signature: NF resident:

"LOCAL IPAS AGENCY" Send completed RR CheckUnknown list with RR Case(s) to: MS21 PASRR / MI Program, Yearly RR Significant-Change RR Room W454, P.O. Box 7083 Missed RR Indianapolis, IN 46207-7083 Birthdate (month, day, year): Age: Sex: Male Female
If in NF, date of initial admission: Date of evaluation (mo., day, yr.):

Location where Level II completed (name, address, city, state, ZIP code) (home or include name of facility or hospital): Name and address of CMHC or hospital completing Level II: *

* This Level II assessment was completed by an entity which is not a nursing facility and has no direct or indirect affiliation with such facility. [P.L. 101-508, Sec. 408 (b)(1-8) and 42 CFR 483.106 (e)(3)] I. PAS location of applicant (check all that apply): At own home / residence Acute Care In hospital: Psychiatric Non-Acute Care Non-Psychiatric Respite Stay II. Significant - Change RR purpose (check all that apply): Change in mental status WITHOUT hospitalization Change in mental status WITH hospitalization In hospital (No prior Level II ) In NF (Readmitted on basis of current Level II ) Other: Private - pay: Yes Medicaid number No

In NF from home: APS Continued stay in NF beyond exempted hospital discharge Other: III. "Missed Level II": (check one) PAS Yearly RR Significant-Change RR Social Security number Medicare number

I. DRUG HISTORY The PASRR / MI assessment process must provide a comprehensive drug history, including current and immediate past use of medications with particular attention to use of medications that could mask symptoms or mimic mental illness. [42 CFR 483.134 b(2)] The psychiatrist should review the medications for appropriateness and medication interaction. LIST ALL CURRENT MEDICATIONS DOSAGE / FREQUENCY START DATE REASON FOR PSYCHOTROPIC MEDICATIONS (If Unknown, Explain)

OPTION: Please see attached medication sheet. Yes No Significant changes: SIGNIFICANT - CHANGE RR AND UPDATES ONLY: Reviewed current Level II: Yes No INAPPROPRIATE REFERRAL (Identified after assessment begun: Stop and complete Inappropriate Referral form.) PAST TWELVE MONTHS (Major Psychotropic Drugs) DOSAGE / FREQUENCY START / STOP DATES

Yes

No

REASON / PURPOSE FOR PSYCHOTROPIC MEDICATIONS

RR AND UPDATES ONLY: Medications reviewed:

Yes

No

Any changes since last Level II:

Yes

No

Page 1of 4 Pages

Name of applicant

Social Security number

Date of birth

II. PSYCHOSOCIAL REPORT The PASRR / MI assessment process must include a psychosocial evaluation of the person, including current living arrangements and medical support systems. [42 CFR 483.134 (b) (3)] CURRENT LIVING ARRANGEMENT (Brief description) What has been this persons residence for the last several years? How long has this person lived in the nursing facility? What is this persons stated preference of living arrangement? Is it feasible? Explain. Add any other pertinent details deemed appropriate.

SUPPORT SYSTEMS (Family, friendships, church, associations, etc.) What emotional support does this person have? How extensive is the support system outside the NF? Where do they live? Who actively supports the person? Explain. For PAS cases, have you contacted the persons listed? Is there a legal guardian? Is the guardianship full or limited? Include names and addresses, if available.

MEDICAL SYSTEMS Identify this persons attending physician. (Other pertinent medical professionals may be entered, as deemed necessary.)

If the psychological evaluation is not conducted by a social worker, then a social workers review and concurrence with pages 1 and 2 above is required and must be documented by a co-signature below. [42 CFR 483.134 (c)] Specify social workers credentials: LSW, LCSW, BSW, and / or MSW.
Signature of evaluator Co-signature (if needed) Professional credentials Professional credentials Date (month, day, year) Date (month, day, year) T elephone number T elephone number

III. PSYCHIATRIC HISTORY AND EVALUATION The PASRR / MI process must be a comprehensive assessment. At a minimum, this assessment must address the following areas: complete psychiatric history for the past 24 months, including all hospitalizations and / or out-patient episodes; evaluation of intellectual functioning, memory functioning, and orientation; description of current attitudes and overt behavior; affect; suicidal or homicidal ideation; paranoia; and degree of reality testing (presence and content of delusions) and hallucinations. (42 CFR 483.134) Attach copies of all available discharge summaries dated within the past 24 months. You may summarize information from records. If unavailable, note and explain. A. NAME OF TREATMENT LOCATION DATE OF ADMISSION DATE OF DISCHARGE DIAGNOSIS (Include current DSM code whenever possible) DISCHARGE SUMMARY

Is this individual currently receiving mental health services? If Yes, specify:

Yes

No

Page 2 of 4 Pages

Name of applicant

Social Security number

Date of birth

B. MENTAL STATUS EVALUATION (WNL means within normal limits. Check all box(es) that apply.) WNL VARIATIONS Appearance Poor Hygiene Attitude Guarded Motor Activity Restless / Agitated Affect Constricted Mood Depressed / Sad Speech Loud Soft Thought Process Circumstantial Thought Content Paranoid Disheveled Suspicious Tremors / Tics Stunted Anxious Rapid Aphasic Tangential Obsessional Auditory Ideations Ideations Person Remote Thin/Emaciated Inappropriate Obese Bizarre Other (Clarify below) Uncooperative Indifferent Belligerent Manipulative Other (Clarify below) Retarded Other (Clarify below) Flat Agitated Excited Other (Clarify below) Elated Labile Hostile / Angry Euphoric Other (Clarify below) Slowed Pressured Delayed Responses Slurred Other (Clarify below) Loose Concrete Flight of Ideas Delusional Other (Clarify below) Poverty of Content Preoccupied with Visual Other Intent Plans: Comments: Intent Plans: Comments: Time Passage of Time Other (Clarify below) Selective Immediate Other (Clarify below) Maladaptive Questionable Co-Dependent Self-Destructive Other (Clarify) Has very little insight Insight lacking Other (Clarify below) Below Average Retarded Other (Clarify below) Calculation Ability Other (Clarify) Attention Span Abstract Thinking

Orientation Memory Judgment Insight Intellect Cognition

Hallucinations: Suicidal: Homicidal: Place Recent Poor Impulse Control Has some insight Above Average Level of Consciousness

C. NARRATIVE DESCRIPTION Give a narrative description of this person. Include any pertinent explanations of the MS evaluation checklist, above, or other behavioral problems identified. Additional pages / reports may be attached as needed. Address positive traits, strengths and weaknesses, and emotional needs. [42 CFR 483.128 (i)] NOTE: This mental status description does not determine need for NF level of services.

This person's current or past behavior presents a danger to self or others?

Yes

No

(If "Yes", explain.)

Page 3 of 4 Pages

Name of applicant

Social Security number

Date of birth

IV. SUMMARY OF ASSESSMENT FINDINGS The Level II assessment must result in independent diagnosis(es) by the evaluator, supported by the data entered in the Level II document. When more than one (1) diagnosis is listed, list them by level of intensity with the principal / primary diagnosis first, etc. ENTER CURRENT DSM CODE + DIAGNOSIS FOR EACH IDENTIFIED MI CONDITION. AXIS I: AXIS II: AXIS III: (From medical records / NF chart)

AXIS I from chart (optional):

DEFINITION OF "MENTAL ILLNESS": An individual is considered to have mental illness if he / she has a current primary or secondary diagnosis of a major mental disorder (as defined in the current Diagnostic and Statistical Manual of Mental Disorders) limited to schizophrenic, schizoaffective, mood (bipolar and major depressive type), paranoid or delusional, panic or other severe anxiety disorder; somatoform or paranoid disorder; personality disorder; atypical psychosis or other psychotic disorder (not otherwise specified); or another mental disorder that may lead to a chronic disability; and he / she does not have a concurrent predominant (primary or principal) diagnosis of senile or presenile dementia (including Alzheimer's Disease or related disorder) or any condition determined to be mental retardation / developmental disability (MR / DD). (See Appendix C of the IPAS / PASARR program manual.) A. This individual is is not mentally ill as defined above.

DEFINITION OF "MI SPECIALIZED SERVICES": Specialized Services are defined as the implementation of an individualized plan of care developed under and supervised by a physician, provided by a physician and other qualified mental health professionals, that prescribes specific therapies and activities for the treatment of persons who are experiencing an acute episode of severe mental illness, which necessitates supervision by trained MH personnel. A nursing facility resident with mental illness who requires specialized services shall be considered to be eligible for the level of services provided in an institution for mental diseases (IMD) or an inpatient psychiatric hospital (subject to Medicaid reimbursement requirements). B. This individual is is not in need of mental health specialized services / inpatient psychiatric care (as defined above).

C. SERVICES OF LESS INTENSITY THAN SPECIALIZED SERVICES: This individual needs the following mental health services, regardless of placement. (42 CFR 483.128) CHECK ALL THAT APPLY. Medication Review Diagnosis Review / Update by NF / Hospital Psychiatric Evaluation Medication Adjustment Dementia Work-Up Outpatient MH Services Medication Monitoring MH Case Management Services Individual / Group Therapy Medication Administration Continue Current MH Services Partial Hospitalization / Day Treatment Yearly RR Required Further Evaluation of Medication Side Effects Needs Further Review - Specify: Other - Specify: None of the above-listed services required at this time Identify placement options which would meet the individual's needs. Check all viable options, regardless of current availability. NOTE: Recommendations do not constitute approval for such placement. In my opinion, if nursing facility placement is not appropriate, the following option(s) may apply. State Hospital Other - Specify: NOTE: The results of this assessment do not determine need for NF level of services. IF INDIVIDUAL IS IN NF, AVAILABLE RESIDENT ASSESSMENT / MDS WAS REVIEWED: Yes No Comments: Other Residential - Specify: Semi-Independent Living Supervised Group Living Alternative Family Living Program CMHC Residential Program:

Assessments are required under the minimum federal criteria for states to use in making preadmission screening and annual resident review determinations about admission to or continued residence in nursing facilities for individuals who have mental illness or mental retardation. (42 CFR 483.100-138)
Signature of Evaluator Credentials Date T elephone number

I certify that I have reviewed the above report and concur with the findings. [42 CFR 483.134 (d)]
Signature of Psychiatrist

Board certified Board eligible Page 4 of 4 Pages

Date

T elephone number