New Jersey DHS PASRR Level I Screening Form
This is a pre-admission screening and resident review (PASRR) Level I screening form required by the New Jersey Department of Human Services for all applicants prior to nursing facility admission. The form identifies mental illness and intellectual/developmental disabilities. Proper submission is necessary to avoid forfeiture of Medicaid reimbursement.
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How do I fill this out?
To fill out this form, begin by entering the applicant's demographic information and clinical assessment status. Complete the mental illness and intellectual/developmental disability screening sections, then submit the form to the appropriate agencies. Ensure all required fields are accurately filled to avoid delays in processing.
How to fill out the New Jersey DHS PASRR Level I Screening Form?
1
Enter the applicant's demographic information.
2
Complete the mental illness screening section.
3
Fill out the intellectual/developmental disability screening section.
4
Determine the screening outcome based on the responses.
5
Submit the form to the appropriate agencies.
Who needs the New Jersey DHS PASRR Level I Screening Form?
1
Nursing facility administrators for pre-admission screening.
2
Healthcare providers identifying mental illness in patients.
3
Organizations supporting individuals with intellectual disabilities.
4
Social workers assisting with facility admissions.
5
Applicants or their legal representatives completing required documentation.
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What are the instructions for submitting this form?
Submit the completed form to the appropriate agencies, including OCCO, DDD, and/or DMHAS. Fax the form to the relevant office as specified based on the screening outcome. Ensure all sections are thoroughly filled and all required supporting documents are attached for a smooth submission process. For detailed submission guidelines, refer to the New Jersey DHS forms webpage at: https://www.state.nj.us/humanservices/doas/home/forms.html. My advice is to double-check all entries for accuracy and completeness to avoid delays and ensure compliance.
What are the important dates for this form in 2024 and 2025?
For 2024 and 2025, any significant updates to federal PASRR regulations and deadlines for submission affected by these changes will be important. Ensure your submissions are timely to avoid compliance issues.
What is the purpose of this form?
The purpose of this form is to conduct a pre-admission screening and resident review (PASRR) for individuals applying for nursing facility admission in New Jersey. The form aims to identify individuals with mental illness, intellectual, or developmental disabilities to ensure they receive the appropriate level of care and support. Proper completion and submission of this form are crucial to comply with federal regulations and secure Medicaid reimbursement.
Tell me about this form and its components and fields line-by-line.
- 1. Name of Applicant: Enter the applicant's last name and first name.
- 2. Social Security Number: Provide the applicant's Social Security Number.
- 3. Current Location Address: Enter the address where the applicant currently resides.
- 4. County of Current Location: Specify the county of the applicant's current location.
- 5. Date of Birth: Input the applicant's date of birth.
- 6. Current Location Setting: Select the applicant's current living arrangement from the provided options.
- 7. Clinical Assessment/Authorization Status: Provide the date of current assessment or authorization and specify the referral details if applicable.
- 8. Mental Illness Screening Questions: Answer questions related to the diagnosis, impairment in functioning, and psychiatric treatment of the applicant.
- 9. Intellectual Disability/Developmental Disability Screening Questions: Answer questions regarding the applicant's intellectual or developmental disabilities and related conditions.
- 10. PASRR Level I Screening Outcome and Referral: Determine the final screening outcome and the necessary referrals based on the responses in the previous sections.
What happens if I fail to submit this form?
Failure to submit this form correctly may result in adverse consequences for the nursing facility and the applicant. Medicaid reimbursement may be forfeited during periods of non-compliance.
- Medicaid Reimbursement Forfeiture: The facility may lose Medicaid reimbursement for the duration of non-compliance.
- Admission Delays: Delays in processing the application could occur, affecting the applicant's admission timeline.
- Regulatory Non-Compliance: Failure to comply with federal PASRR regulations may result in penalties or other regulatory actions.
How do I know when to use this form?
- 1. Nursing Facility Admissions: Use this form for all applicants prior to admission.
- 2. Mental Illness Detection: Screen for major mental illnesses as specified in the form.
- 3. Intellectual/Developmental Disability Identification: Identify intellectual and developmental disabilities and related conditions in applicants.
- 4. Regulatory Compliance: Ensure compliance with federal PASRR regulations.
- 5. Referral Process: Facilitate referrals to appropriate agencies for further evaluation and support.
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What types of information do I need to fill out this form?
You will need the applicant's demographic information, clinical assessment status, and responses to mental illness and intellectual/developmental disability screening questions.
Why is this form required?
This form is required for pre-admission screening to nursing facilities in New Jersey, ensuring compliance with PASRR regulations.
Where do I submit the completed form?
Submit the form to the appropriate agencies, including OCCO, DDD, and/or DMHAS as applicable.
What happens if I don't fill out this form correctly?
Failure to complete the form correctly may result in delays or forfeiture of Medicaid reimbursement.
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