Fill in a Valid Colorado Post Admission Level 1 Passr Template Access Your Colorado Post Admission Level 1 Passr Now

Fill in a Valid Colorado Post Admission Level 1 Passr Template

The Colorado Post Admission Level 1 PASRR form is a critical document used to assess individuals seeking admission to nursing facilities. This form collects essential information regarding the individual's mental health status, treatment history, and current needs. Timely completion and submission are vital to ensure appropriate care and compliance with state regulations.

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The Colorado Post Admission Level 1 PASRR form is an essential document designed to assess the needs of individuals seeking admission to nursing facilities, particularly those with mental health issues or developmental disabilities. This form gathers vital information about the individual’s personal details, including name, contact information, and social security number, while also capturing their current living situation and payment method. Importantly, it delves into the individual’s mental health history, documenting any diagnoses of major mental illnesses and symptoms they may be experiencing. Sections of the form focus on the individual’s psychiatric treatment history, including any past hospitalizations or legal interventions related to mental health. Additionally, it addresses the presence of dementia and the use of psychotropic medications, ensuring a comprehensive review of the individual’s mental health status. The form also includes critical questions aimed at determining whether the admission meets specific criteria for exemptions or categorical decisions, which can significantly impact the care and services provided. Completing this form accurately and thoroughly is crucial for ensuring that individuals receive the appropriate level of care tailored to their unique circumstances.

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COLORADO LE VE L I F ORM

PRE-ADMISSION AND RESIDENT REVIEW (PASRR)

First Name:

 

 

Middle Initial:

 

 

Last Name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mailing Address:

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

 

 

 

 

 

 

 

 

 

State:

Zip:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Phone:

 

 

Social Security #:

 

-

 

 

 

 

-

 

 

 

Date of Birth:

/

 

 

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Gender: c Male c Female Race: c Caucasian c African American c Asian c Hispanic c Other:

 

 

 

 

 

 

 

Current Location: c*Medical Facility c*Psychiatric Facility c *Nursing Facility c Community c Other:

*Provide Admission Date:

 

 

 

 

 

 

 

 

 

 

Receiving Nursing Facility:

 

 

 

 

 

 

 

 

 

 

Receiving Nursing Facility Address:

 

 

 

 

 

 

 

 

 

 

 

 

City:

 

 

 

State:

 

Zip:

 

 

 

 

 

 

Payment Method: c Medicare c Private Pay c Medicaid c Medicaid Pending c Medicaid #

 

 

 

 

 

 

 

 

 

c Hospice c PACE c 30 Day PACE Respite

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

** Provide ULTC Scores if Medicaid or Medicaid Pending:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Bathing

 

Dressing

 

 

 

Toileting

 

 

Mobility

 

 

 

Transfer

 

 

 

 

 

 

 

 

 

 

 

Eating

Supervision Behaviors

 

Supervision Memory/Cognition

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section I: MENTAL ILLNESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

1. Does the individual have any of the

 

2.

Does the individual have any of the

 

3. Does the individual have a diagnosis of

following Major Mental Illnesses

 

 

following mental disorders?

 

 

 

 

 

 

 

 

a mental disorder that is not listed in

(MMI)?

 

 

 

 

 

 

c No

 

 

 

 

 

 

 

 

 

 

 

 

#1 or #2? (do not list dementia here)

c No

 

 

 

 

 

 

c Suspected: One or more of the

 

 

 

c No

 

 

 

 

 

 

 

 

 

c Suspected: One or more of the

 

 

 

 

following diagnosis is suspected

 

 

 

c Yes (if yes, enter the diagnosis(es)

 

following diagnoses is suspected

 

 

 

 

(check all that apply)

 

 

 

 

 

 

 

 

below):

 

 

 

 

 

 

 

 

 

 

(check all that apply)

 

 

 

 

 

 

c Yes: (check all that apply)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c Yes: (check all that apply)

 

 

 

c Personality Disorder

 

 

 

 

 

 

 

 

c Diagnosis 1:

 

 

 

 

 

 

 

 

 

c Schizophrenia

 

 

 

 

 

 

c Anxiety Disorder

 

 

 

 

 

 

 

 

 

 

 

c Diagnosis 2:

 

 

 

 

 

 

 

 

 

c Schizoaffective Disorder

 

 

 

c Panic Disorder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c Major Depression

 

 

 

 

 

 

c Depression (mild or situational)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c Psychotic/Delusional Disorder

 

 

 

 

(provide GDS Score:

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c Bipolar Disorder (manic depression)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c Paranoid Disorder

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Section II: SYMPTOMS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

4. Interpersonal—Currently or within the past 6 months, has the

 

5. Concentration/Task related symptoms—Currently or within

individual exhibited interpersonal symptoms or behaviors [not

 

 

the past 6 months, has the individual exhibited any of the

due to a medical condition]?: c No c Yes

 

 

 

 

 

 

 

 

 

 

 

following symptoms or behaviors [not due to a medical

c Serious difficulty interacting with others

 

 

 

 

 

 

 

 

 

 

condition]? c No

c Yes

 

 

 

 

 

 

 

 

 

c Altercations, evictions, or unstable employment

 

 

c Serious difficulty completing tasks that she/he should be

c Frequently isolated or avoided others or exhibited signs

 

 

capable of completing

 

 

 

 

 

 

 

 

 

 

suggesting severe anxiety or fear of strangers

 

 

c Required assistance with tasks for which she/he should be

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

capable

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c Substantial errors with tasks in which she/he completes

 

 

 

 

 

 

Adaptation to change —Currently or within the past 6 months, has the individual exhibited any symptoms in #6, 7 or 8 related to

adapting to change? c No (proceed to Section III) c Yes (complete 6-8)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6. c Self injurious or self

7. c Severe appetite disturbance

 

8.

c Other major mental health symptoms (this may include

mutilation

c Hallucinations or delusions

 

 

 

 

recent symptoms) that have emerged or worsened as a result

c Suicidal talk

c Serious loss of interest in things

 

 

 

 

of recent life changes as well as ongoing symptoms.

c History of suicide

c Excessive tearfulness

 

 

 

 

 

 

 

 

Describe symptoms:

 

 

 

 

 

 

 

 

 

attempt or gestures

c Excessive irritability

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c Physical violence

c Physical threats (no potential for

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

c Physical threats (with

harm)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

potential for harm)

GDS Score:

 

 

 

(if any areas in #7

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

are marked)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Masspro s 245 Winter St. s Waltham, MA 02451 s Phone: 855-222-3112 s Fax: 855-222-3114

The attending physician has certified prior to NF admission the individual will require less than 30 calendar days of NF services and the individual’s symptoms or behaviors are stable.
Physician Name:
Physician Phone: Physician License #:

 

COLORADO LE VE L I F ORM

 

PRE-ADMISSION AND RESIDENT REVIEW (PASRR)

Patient Last Name:

 

Patient First Name:

 

Section III: HISTORY OF PSYCHIATRIC TREATMENT

9. Currently or within the past 2 years , has the individual received any of the followingmental health services?

cNo

cYes (the individual has received the following service[s]): c Inpatient psychiatric hospitalization (if yes, provide

date: )

c Partial hospitalization/ day treatment (if yes, provide

date:

 

)

 

 

 

 

cResidential treatment (if yes, provide date:

 

)

c Other:

 

 

 

(if yes,

 

provide date:

 

 

)

 

 

 

10.Currently or within the past 2 years, has the individual

experienced significant life disruption because of mental health symptoms? c No c Yes (check all that apply):

c Legal intervention due to mental health symptoms

(date:)

cHousing change because of mental illness

(date:

 

)

 

 

 

 

c Suicide attempt or ideation (date[s]:

)

c Other:

 

(date:

 

 

)

 

11.

Has the individual had a recent psychiatric/behavioral evaluation? c No c Yes (date:

 

)

Section IV: DEMENTIA

12.Does theindividual have a diagnosis

of dementia or Alzheimer’s disease? c No (proceed to 15) c Yes

13.If yes to #12, is corroborative testing or other information available to verify the presence

or progression of the dementia? c No c Yes (check all that apply)

c Dementia work up c Comprehensive Mental Status Exam c Other (specify):

14.If yes to12, list currently prescribed antidepressant or antipsychotic medications listed on the Beer’s List.

 

 

 

 

 

 

Medication

Dosage MG/Day

Refer to Beer’s List

 

 

 

 

Does dosage exceed Beer’s List? cNo cYes

 

 

 

 

 

 

 

 

 

Does dosage exceed Beer’s List? cNo cYes

 

 

 

 

 

 

 

 

 

Does dosage exceed Beer’s List? cNo cYes

 

 

 

 

 

Section V: PSYCHOTROPIC MEDICATIONS

15.Has the individual been prescribed psychoactive (mental health) medications now or within the past 6 months other than those listed in question 14? c No c Yes (list below) [use separate sheet if necessary] *Do not list medications if used for a medical diagnosis.

Medication

Dosage MG/Day

Diagnosis

Started

Ended

Section VI: MENTAL RETARDATION & DEVELOPMENTAL DISABILITIES

16.

Does the individual have a diagnosis of mental retardation

17.

Does the individual have any history of MR or DD? c No c Yes

 

(MR) or developmental disability (DD)? c No c Yes

 

 

 

 

 

 

 

 

18.

Is there presenting evidence of a cognitive or behavioral

19.

Has the individual ever received services from an agency that

 

impairment prior to age 22 or suspicion of MR condition that

 

serves people affected by MR/DD? c No

 

occurred prior to age 18? c No c Yes

 

c Yes—agency:

 

 

 

 

 

 

Section VII: EXEMPTION AND CATEGORICAL DECISIONS

(MASSPRO MUST APPROVE USE OF CATEGORIES AND EXEMPTION PRIOR TO ADMISSION)

20. Does the admission meet criteria for Hospital Exemption? c No

c Yes (meets all the following andhas a known or suspected MMI or MR/DD):

·

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 condition:

 

, )

 

and

 

·

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

22.Does the admission meet the criteria for Terminal Illness? c No

c Yes (Has a known or suspected MMI or MR/DD and MD has certified in writing that the patient has 6 months or less to live. The physician signed certification must be submitted to Masspro via facsimile within 6 business hours of submission of this form)

23.Does the admission meet the criteria for Severity of Illness?

cNo

cYes (Has a known or suspected MMI or MR/DD and is ventilator dependent or comatose unresponsive)

24.Does the admission meet criteria for 60 day Convalescence? c No

c Yes (meets all the following and has a known or suspected MMI or MR/DD): c Admission to NF directly from hospital after receiving acute medical care; and c Need for NF is required for the condition treated in the hospital, and cThe attending physician has certified prior to NF admission the individual will require less than 60 calendar days of NF services.

21. Additional Comments:

Masspro s 245 Winter St. s Waltham, MA 02451 s Phone: 855-222-3112 s Fax: 855-222-3114

c No c Yes
c No c Yes
c No c Yes

COLORADO LE VE L I F ORM

PRE-ADMISSION AND RESIDENT REVIEW (PASRR)

Patient Last Name:

 

Patient First Name:

Section VIII: OUTCOME

25. Are any of the following numbers marked yes or, if applicable, suspected 1, 3, 6, 7, 8, 9, 10, 14, 15, 16, 17, 18,or 19?

26. Check yes if #2 is marked yes or suspected and any areas in #4-8 are marked

27. Check yes if #4 or 5 or (any areas in) #7 are marked affirmatively and #12 is no

28. Are any of the #25-27 marked yes?

cNo (if No, NO further screening is required. Proceed to Section IX)

cYes (Screening information must be submitted to Masspro via fax at 1-855-222-3114 for a determination of whether further screening is

required).

Provide a copy of this form to the individual and, if applicable, guardian.

Does the individual have a legal guardian? c No legal guardian c Yes, legal guardian information is below:

Guardian Last Name:

 

 

 

First Name:

 

 

 

Street:

 

 

City:

 

 

 

State:

 

Zip:

 

Section IX: SOURCE SIGNATURE

Print Name:

Signature:

Date:

/

/

 

 

 

 

 

Agency/Facility:

Phone:

Fax:

 

 

 

 

 

 

 

Section X: MASSPRO OUTCOME: MASSPRO USE ONLY

Date:

Non-Cert c

Level I Approved:

PASRR Authorization #:

 

 

 

c No MMI/DD

 

 

 

 

 

 

c Follow-up next qtr.

c PACE Respite

 

c 30 Day Exemption

c Hospice

 

 

c Convalescent Care

 

c Terminal

c Severity of Illness

 

 

 

 

 

 

 

c Provisional-Out of state Adm.

 

 

 

c Provisional-Emergency Adm.

Level II Referred:

 

c MI

c MR/DD

c Dual

 

 

Comments:

Masspro s 245 Winter St. s Waltham, MA 02451 s Phone: 855-222-3112 s Fax: 855-222-3114

Get PDF Form

Form Properties

Fact Name Details
Form Purpose The Colorado Level I PASRR form is used for pre-admission and resident review for individuals with suspected mental illness or developmental disabilities.
Governing Law This form is governed by federal law under the Nursing Home Reform Act and Colorado state regulations regarding mental health services.
Submission Requirements The completed form must be submitted to Masspro for review and determination of further screening needs.
Sections Included The form consists of multiple sections, including mental illness assessment, psychiatric treatment history, and dementia evaluation.
Payment Methods Individuals can indicate their payment method, which includes options like Medicare, Medicaid, and private pay.
Symptoms Assessment Section II assesses various symptoms related to mental health, such as interpersonal difficulties and concentration issues.
Outcome Determination The form includes an outcome section where specific criteria are checked to determine if further screening is necessary.
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