Fillable PASRR Evaluation Section A DLN Individual Submitter Information (Texas Medicaid & Healthcare Partnership)

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PASRR Evaluation Section A DLN Individual Submitter Information (Texas Medicaid & Healthcare Partnership)

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PASRR Evaluation, September, 2017 V.5
Page 1 of 32
DLN Individual
PASRR Evaluation
A0700. LA - IDD Provider No. A0800. IDD Vendor No.
A1100D. Suffix
A0400. Provider No. A0500. Vendor No.
A0300. NPI/API
A0100. Name
A0900. LA - IDD NPI/API
A0200A. Street Address
A0200B. City
A0200C. State A0200D. ZIP Code
A1100A. First Name A1100B. Middle Initial
A1100C. Last Name
A1200. Evaluator Position/Title IDD Assessment
A1300A. Type of Credential for Evaluator - IDD Assessment
Submitter Information
Evaluation Information
A0600. Type of Evaluation(s)
IDD Information
A1000. Date of IDD Assessment
A1300B. Other Type of Credential for IDD Evaluator
1. IDD only
2. MI only
3. IDD and MI
1. Qualified Intellectual Disability Professional (QIDP)
2. Qualified Developmental Disability Professional (QDDP)
3. Registered Nurse (RN)
4. Licensed Clinical Social Worker (LCSW)
5. Licensed Professional Counselor (LPC)
6. Licensed Marriage and Family Therapist (LMFT)
7. Licensed Psychologist
8. Advanced Practice Nurse (APN)
9. Physician (MD or DO)
10. Other
Section A
PASRR Evaluation, September, 2017 V.5
Page 2 of 32
DLN Individual
A2300F. County A2300G. Phone Number
A2300D. State
A1400. LA - MI Provider No. A1500. LA - MI Vendor No.
A1600. LA - MI NPI/API
A1800A. First Name A1800B. Middle Initial
A1800C. Last Name A1800D. Suffix
A1900. Evaluator Position/Title MI Assessment
A2000A. Type of Credential for Evaluator - MI Assessment
MI Information
A1700. Date of MI Assessment
1. Qualified Mental Health Professional (QMHP)
2. Registered Nurse (RN)
3. Licensed Clinical Social Worker (LCSW)
4. Licensed Professional Counselor (LPC)
5. Licensed Marriage and Family Therapist (LMFT)
6. Licensed Psychologist
7. Advanced Practice Nurse (APN)
8. Physician (MD or DO)
9. Other
A2100. Type of Setting
Setting of Assessment
A2000B. Other Type of Credential for MI Evaluator
1. Acute Care
2. Psychiatric Hospital
3. Intermediate care facility for individuals with an intellectual disability or related conditions (ICF/IID)
4. Own Home/Family Home
5. Nursing Facility
6. Other
A2200. Other Type of Setting
A2300A. Name
A2300B. Street Address
A2300C. City
A2300E. ZIP Code
PASRR Evaluation, September, 2017 V.5
Page 3 of 32
DLN Individual
A3300B. Other Relationship to Individual
A3300G. Phone Number
A3300C. First Name A3300D. Middle Initial
A3300E. Last Name A3300F. Suffix
A3300A. Relationship to Individual
Personal Information
A2400A. First Name A2400B. Middle Initial
A2400C. Last Name A2400D. Suffix
A2500A. Social Security No. A2500B. Medicare No.
A2600. Medicaid No. A2700. Birth Date
A2800. Age at Time of Screening A2900. Gender
A3000. Height (in inches) A3100. Weight (in pounds)
A3200A. Previous Residence Type
1. Private Home
2. ICF/IID
3. Waiver Setting
4. Nursing Facility
5. Other
A3200C. Street Address
A3200D. City
A3200E. State A3200F. ZIP Code
1. Legally Authorized Representative
2. Spouse
3. Child
4. Parent
5. Sibling
6. Other
A3200B. Other Residence Type
Previous Residence
Next of Kin
A3200G. County of Residence A3200H. Did the individual live with others?
0. No
1. Yes
PASRR Evaluation, September, 2017 V.5
Page 4 of 32
DLN Individual
A3500D. Middle Initial
A3400G. Phone Number
A3500A. Relationship to Individual
1. Spouse
2. Child
3. Parent
4. Sibling
5. Other
A3400B. Other Relationship to Individual
A3400H. Street Address
A3400I. City
A3400J. State A3400K. ZIP Code
A3400C. First Name A3400D. Middle Initial
A3400E. Last Name A3400F. Suffix
A3400A. Relationship to Individual
A3500H. Street Address
A3500I. City
A3500J. State A3500K. ZIP Code
A3500C. First Name
A3500E. Last Name A3500F. Suffix
A3500G. Phone Number
1. Spouse
2. Child
3. Parent
4. Sibling
5. Other
A3500B. Other Relationship to Individual
A3400. Additional Contact Information - 2
A3400. Additional Contact Information - 1
A3300H. Street Address
A3300I. City
A3300J. State A3300K. ZIP Code
PASRR Evaluation, September, 2017 V.5
Page 5 of 32
DLN Individual
B0400M. Other
areas
B0300. Has the individual experienced intervention by law enforcement, protective services agencies or
other housing officials in the last two years? (i.e. evicted, arrested, charged or convicted of a crime)
B0100. To your knowledge, does the individual have an Intellectual Disability which manifested before
the age of 18? (e.g. Mental Retardation)
B0200. To your knowledge, does the individual have a Developmental Disability other than an Intellectual
Disability that manifested before the age of 22? (e.g. autism, cerebral palsy, spina bifida)
TO BE COMPLETED FOR INDIVIDUALS SUSPECTED OF HAVING INTELLECTUAL DISABILITY OR DEVELOPMENT DISABLITIES
B0050. I am completing the IDD section
Determination for PASRR Eligibility (IDD)
Specialized Services Determination/Recommendations
B0400A. Self-monitoring of nutritional support
B0400. Does this individual need assistance in any of the following areas? Check all that apply:
B0400B. Self-monitoring and coordinating medical treatments
B0400C. Self-help with ADLs such as toileting, grooming, dressing and eating
B0400D. Sensorimotor development with ambulation, positioning, transferring, or hand eye coordination to the extent that a
prosthetic, orthotic, corrective or mechanical support devices could improve independent functioning
B0400E. Social development to include social/recreational activities or relationships with others
B0400F. Academic/educational development, including functional learning skills
B0400G. Expressing interests, emotions, making judgments, or making independent decisions
B0400H. Independent living skills such as cleaning, shopping in the community, money management, laundry, accessibility within
the community
B0400I. Vocational development, including current vocational skills
B0400J. Additional adaptive medical equipment or adaptive aids to improve independent functioning
B0400K. Speech and language (communication) development, such as expressive language (verbal and nonverbal), receptive
language (verbal and nonverbal)
B0400L. Other
B0400N. None of the above apply
0. No
1. Yes
0. No
1. Yes
0. No
1. Yes
2. Unknown
Section B
If Type of Assessment is IDD and MI and the answer to B0100 and B0200 is No, skip to Section C.
PASRR Evaluation, September, 2017 V.5
Page 6 of 32
DLN Individual
1. Alternate Placement Services
2. Determination of Intellectual Disability
(DMR)*
3. Vocational Training*
4. Service Coordination (SC)
5. Employment Assistance
6. Supported Employment
7. Day Habilitation
8. Independent Living Skills Training
9. Behavioral Support
* This option was redefined and cannot be selected after
6/24/2016
B0500. Recommended Services Provided / Coordinated by Local Authority
PASRR Evaluation, September, 2017 V.5
Page 7 of 32
DLN Individual
1. Specialized Physical Therapy (PT)
2. Specialized Occupational Therapy (OT)
3. Specialized Speech Therapy (ST)
4. Customized Manual Wheelchair (CMWC)
5. Durable Medical Equipment (DME)
B0600. Recommended Services Provided/Coordinated by Nursing Facility
PASRR Evaluation, September, 2017 V.5
Page 8 of 32
DLN Individual
C0400. Functional Limitation Check all that apply:
C0400I. Co-Occurring Substance Abuse
Determination for PASRR Eligibility (MI)
Section C
TO BE COMPLETED FOR INDIVIDUALS SUSPECTED OF HAVING MENTAL ILLNESS
C0050. I am completing the MI section
C0300C. Paranoid Disorder
C0300D. Somatoform Disorder
C0300E. Other Psychotic Disorder
C0300F. Schizoaffective Disorder
C0300G. Panic or Other Severe Anxiety Disorder
C0300H. Personality Disorder
C0300I. Any other disorder that may lead to a chronic disability diagnosable under the current DSM
C0300J. None of the above apply
C0400A. Appetite Disturbance
C0400B. Sleep Disturbance
C0400C. Personal Hygiene
C0400D. Impaired Social Interaction
C0400E. Threatening or Aggressive Behavior
C0400F. Danger to Self or Others
C0400G. Employment Difficulties
C0400K. None of the above apply
C0400H. Housing Difficulties
C0200. Severe Dementia Symptoms
Are the individual's Dementia symptoms so severe that they cannot be expected to benefit from PASRR
Specialized Services?
C0300B. Mood Disorder (Bipolar Disorder, Major Depression or other mood disorder)
C0100. Primary Diagnosis of Dementia
Does this individual have a PRIMARY diagnosis of Dementia?
0. No
1. Yes
2. Unknown
0. No
1. Yes
C0300. Mental Illness Check all that apply:
C0300A. Schizophrenia
C0400J. Criminal Justice Involvement
PASRR Evaluation, September, 2017 V.5
Page 9 of 32
DLN Individual
C0800. Based on the QMHP assessment, does this individual meet the PASRR definition of mental illness?
C0900M. Other
Areas
Specialized Services Determination/Recommendations
C0900. Does the individual need assistance in any of the following areas? Check all that apply
C0900A. Self-monitoring of health status
C0900B. Self-administering of medical treatment
C0900C. Self-scheduling of medical treatment
C0900D. Self-monitoring of medications
C0900E. Self-monitoring of nutritional status
C0900F. Self-help with ADLs such as appropriate dressing and appropriate grooming
C0900G. Independent living such as supported housing
C0900H. Management of money
C0900I. Vocational development, including current vocational skills
C0900J. Psychological evaluation – for individuals who are suspected of having mental illness, but no diagnosis is available
C0900K. Discharge Planning – assessment, planning, facilitation of discharge (may only be delivered within 180 days or less,
before planned discharge)
C0900L. Other
C0900N. None of the above apply
0. No
1. Yes
C0700. Intervention by law enforcement
Has this individual experienced intervention by law enforcement, protective services agencies or other
housing officials in the last two years due to mental illness? (i.e., evicted, arrested, charged or convicted
of a crime)
C0600. Disruption to normal living situation
Has this individual experienced a significant disruption to their normal living situation requiring supportive
services (e.g. residential or respite services) in the last two years due to mental illness?
C0500. Inpatient Psychiatric Treatment
Has this individual experienced a psychiatric treatment more intensive than outpatient care more than
once in the past 2 years?
0. No
1. Yes
2. Unknown
0. No
1. Yes
2. Unknown
0. No
1. Yes
2. Unknown
Recent Occurrences
PASRR Evaluation, September, 2017 V.5
Page 10 of 32
DLN Individual
C1000. Recommended Services Provided/Coordinated by Local Authority
1. Group Skills Training
2. Individual Skills Training
3. Intensive Case Management (This service is also subject
to the <180 day stay requirement)
4. Medication Training & Support Services (Group)
5. Medication Training & Support Services (Individual)
6. Medication Training Group
7. Medication Training Individual
8. Psychiatric Diagnostic Interview Examination
9. Psychosocial Rehabilitative Services (Group)
10. Psychosocial Rehabilitative Services (Individual)
11. Routine Case Management (This service is also subject
to the <180 day stay requirement)
12. Skills Training & Development (Group)
13. Skills Training & Development (Individual)
PASRR Evaluation, September, 2017 V.5
Page 11 of 32
DLN Individual
Evaluation of History and Physical Information
Section D
Nursing Facility Level of Care Assessment
D0100B.
Physical/Mental Diagnosis Description
D0100C. Date of
Onset, if known
D0100D.
Primary
Diagnosis
D0100A.
Physical/Mental
Diagnosis Code
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200. Medications - 1
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 2
D0200D.
Reason for
antipsychotic
PASRR Evaluation, September, 2017 V.5
Page 12 of 32
DLN Individual
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200. Medications - 3
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 4
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 5
D0200D.
Reason for
antipsychotic
PASRR Evaluation, September, 2017 V.5
Page 13 of 32
DLN Individual
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200. Medications - 6
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 7
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 8
D0200D.
Reason for
antipsychotic
PASRR Evaluation, September, 2017 V.5
Page 14 of 32
DLN Individual
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200. Medications - 9
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 10
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 11
D0200D.
Reason for
antipsychotic
PASRR Evaluation, September, 2017 V.5
Page 15 of 32
DLN Individual
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200. Medications - 12
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 13
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 14
D0200D.
Reason for
antipsychotic
PASRR Evaluation, September, 2017 V.5
Page 16 of 32
DLN Individual
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200. Medications - 15
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200. Medications - 16
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 17
D0200D.
Reason for
antipsychotic
D0200D.
Reason for
antipsychotic
PASRR Evaluation, September, 2017 V.5
Page 17 of 32
DLN Individual
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200. Medications - 18
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 19
D0200B.
Any known side effects for this individual
D0200C.
Check if
antipsychotic
D0200A.
Current Medications
D0200D.
Reason for
antipsychotic
D0200. Medications - 20
D0300.
Medication
Allergies
D0300. Medication Allergies
D0200D.
Reason for
antipsychotic
PASRR Evaluation, September, 2017 V.5
Page 18 of 32
DLN Individual
D1900. Does this individual receive any treatments by injection?
D1800. Does this individual have any Special Ports/Central Lines/PICC ?
0. No
1. Yes
2. Unknown
D1700A. Does this individual require Oxygen Therapy?
0. No
1. Yes
D1700B. If yes, how often?
1. Less than once a week
2. 1 to 6 times a week
3. Once a day
4. Twice a day
5. 3 - 11 times a day
6. 6 - 23 hours
7. 24-hour continuous
0. No
1. Yes
2. Unknown
D1600. Does this individual require a ventilator or respirator to breathe at least one time every day?
D1400A. Does this individual have a tracheostomy?
D1400B. If Yes, do they require care for their tracheostomy at least one time every day?
D1500. Does this individual require a ventilator or respirator on a continuous basis to breathe?
0. No
1. Yes
0. No
1. Yes
0. No
1. Yes
0. No
1. Yes
D1300. Does this individual have an internal defibrillator?
D1200. Does this individual require pacemaker monitoring?
D1100. Is this individual on hospice?
0. No
1. Yes
0. No
1. Yes
2. Unknown
0. No
1. Yes
2. Unknown
D0900. Does the NF supervision and structure mitigate danger to self or others?
D0600. Is this individual a danger to himself/herself? D0700. Is this individual a danger to others?
D0800. Is this individual known to demonstrate self-injurious behaviors?
0. No
1. Yes
0. No
1. Yes
0. No
1. Yes
0. No
1. Yes
2. Unknown
D1000. Is there a physician certification that the individual is expected to live less than 6
months in the individual’s chart?
0. No
1. Yes
D0400. Number of hospitalizations in the last 90 days
D0500. Number of emergency room visits in the last 90 days (include all emergency room visits)
Between 00-90
Between 00-90
PASRR Evaluation, September, 2017 V.5
Page 19 of 32
DLN Individual
D2000C. Number of Ulcers
D2000A. Does this individual have a pressure ulcer (bed sore or decubitus ulcer)?
D2000B. If Yes, is it staged as:
0. No
1. Yes
2. Unknown
1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
5. Unstageable
6. SDTI (suspected deep tissue injury)
Between 00-99
D2500A. Is the individual oriented to person?
D2500C. Is the individual oriented to time?
D2500B. Is the individual oriented to place?
0. No
1. Yes
2. Unknown
0. No
1. Yes
2. Unknown
0. No
1. Yes
2. Unknown
D2400B. If No, at what developmental level is the individual functioning?
D2300B. If Yes, indicate the appropriate answer for type of memory loss:
D2400A. Is this individual's developmental level normal for their chronological age?
1. Short Term
2. Long Term
3. Unspecified
0. No
1. Yes
1. < 1 Infant
2. 1 - 2 Toddler
3. 3 - 5 Pre-School
4. 6 - 10 School age
5. 11 - 15 Young Adolescence
6. 16 - 20 Older Adolescence
7. Unknown or unable to assess
D2300A. Does this individual experience memory loss?
0. No
1. Yes
D2100A. Does this individual have any other ulcers, wounds, or skin issues?
D2100B. If Yes, is it staged as:
D2200. Is this individual in a coma (persistent vegetative state or no discernible consciousness)?
0. No
1. Yes
2. Unknown
1. Stage 1
2. Stage 2
3. Stage 3
4. Stage 4
5. Unstageable
6. SDTI (suspected deep tissue injury)
0. No
1. Yes
PASRR Evaluation, September, 2017 V.5
Page 20 of 32
DLN Individual
D2600A. Indwelling catheter
D2600. Is there any documentation that indicates that the individual has an appliance assisting with bladder or bowel function?
Check all that apply:
D2600B. External catheter
D2600C. Ostomy
D2600D. Intermittent catherization
D2600E. None of the above
D2600F. Unknown
PASRR Evaluation, September, 2017 V.5
Page 21 of 32
DLN Individual
E0100D. Medication(s)
E0100B. In how many of the falls listed above was the individual physically restrained prior to the fall?
Evaluation of History and Physical Information
E0100A. Enter the number of times this individual has fallen in the last 90 days.
E0100C. Environmental (e.g. debris, slick or wet floors, lighting)
E0100E. Major Change in Medical Condition (e.g. Myocardial Infarction (MI/Heart Attack),
Cerebrovascular Accident (CVA/Stroke), Syncope (Fainting))
E0100F. Poor Balance/Weakness
E0100G. Confusion/Disorientation
E0100H. Assault by Resident or Staff
E0200. Does this individual have a history of medication error, non-compliance with a self-medication
regimen or drug seeking?
E0300. Which option best describes this individual’s speech pattern?
E0400. Which option best describes this individual’s ability to express ideas and wants?
E0500. Which option best describes this individual’s ability to understand others?
Section E
Between 000-999
Between 000-999
Between 000-999
Between 000-999
Between 000-999
Between 000-999
Between 000-999
Between 000-999
0. No
1. Yes
2. Unknown
1. Clear speech - distinct intelligible words
2. Unclear speech - slurred or mumbled words
3. No speech - absence of spoken words
1. Understood
2. Usually understood - difficulty communicating
some words or finishing thoughts but is able if
prompted or given time
3. Sometimes understood - ability is limited to
making concrete requests
4. Rarely/never understood
1. Understands - clear comprehension
2. Usually understands - misses some part/
intent of message but comprehends most
conversation
3. Sometimes understands - responds
adequately to simple, direct communication
only
4. Rarely/never understands
Consider both verbal and non-verbal expressions
Understanding verbal content, however able, with a hearing aid or device if applicable
PASRR Evaluation, September, 2017 V.5
Page 22 of 32
DLN Individual
E1000B. If Yes, how severe is the pain?
E1000C. If Yes, what frequency is the pain occurring?
E1100. Does this individual require assistance with eating and drinking?
E1200A. How does this individual eat?
E1200B. How much food is eaten by mouth?
E1200C. Does this individual require a mechanically altered diet?
E1300. Which option best describes the individual's functioning around urination?
E1000A. Is there an indication that the individual currently has issues with pain?
0. No
1. Yes
1 – Mild
2 – Moderate
3 – Severe
4 – Very severe, horrible
5 – Unable to answer
1 – Almost constantly
2 – Frequently
3 – Occasionally
4 – Rarely
5 – Unable to answer
0. No
1. Yes
1. By mouth
2. By tube inserted in nose
3. By tube inserted into abdomen
4. By tube inserted into artery
1. 75% or more
2. 50-74%
3. 49% or less
E1200D. Is this individual on a therapeutic diet?
0. No
1. Yes
0. No
1. Yes
1. Always continent
2. Occasionally incontinent
3. Frequently incontinent
4. Always incontinent
E0600. Does this individual have an impaired mental status?
E0700. Does this individual have a hearing impairment?
E0800. Does this individual have a vision impairment?
E0900. Does the individual typically reject attempts at evaluations and assistance that are
necessary to achieve goals for health and well being?
0. No
1. Yes
2. Unknown
0. No
1. Yes
0. No
1. Yes
0. No
1. Yes
2. Unknown
PASRR Evaluation, September, 2017 V.5
Page 23 of 32
DLN Individual
E1400. Activities of Daily Living (ADL)
Instructions for Rule of 3
* When an activity occurs three times at any one given level, code that level.
* When an activity occurs three times at multiple levels, code the most dependent, exceptions are total dependence (4), activity must
require full assist every time, and activity did not occur (8), activity must not have occurred at all. Example, three times extensive
assistance (3) and three times limited assistance (2), code extensive assistance (3).
* When an activity occurs at various levels, but not three times at any given level, apply the following:
- When there is a combination of full caregiver performance, and extensive assistance, code extensive assistance.
- When there is a combination of full caregiver performance, weight bearing assistance and/or non-weight bearing assistance code
limited assistance (2).
If none of the above are met, code supervision.
1. ADL Self-Performance
Code for individual's performance of ADL's - not including setup. If the ADL activity occurred 3 or more times at various levels of
assistance, code the most dependent - except for total dependence, which requires full staff performance every time
0. Independent - no help or staff oversight at any time
1. Supervision - oversight, encouragement or cueing
2. Limited assistance - resident highly involved in activity; staff provide guided maneuvering of limbs or other non-weight-bearing
assistance
3. Extensive assistance - resident involved in activity, staff provide weight-bearing support
4. Total dependence - full staff performance every time during entire 7-day period
7. Activity occurred only once or twice - activity did occur but only once or twice
8. Activity did not occur - activity did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the
entire 7-day period
2. ADL Support Provided
Code for most support provided; code regardless of individual's self performance classification
0. No setup or physical help from staff
1. Setup help only
2. One person physical assist
3. Two+ persons physical assist
8. ADL activity itself did not occur or family and/or non-facility staff provided care 100% of the time for that activity over the entire 7-day
period
PASRR Evaluation, September, 2017 V.5
Page 24 of 32
DLN Individual
E1400E.1. Self Performance
E. Locomotion Off Unit Or In Home - how resident moves to or returns from distant areas in his/her home (e.g. areas
set aside for dining, activities or treatments). If facility has only one floor, how individual moves to and from distant
areas on the floor. If in wheelchair, self-sufficiency once in chair
E1400A.2. Support
A. Bed mobility - how individual moves to and from lying position, turns side to side, and positions body while in
bed or alternate sleep furniture
E1400B.2. Support
B. Walk in room - how resident walks between locations in his/her room
E1400C.1. Self Performance
C. Walk in hallway - how individual walks in hallway
E1400C.2. Support
C. Walk in hallway - how individual walks in hallway
E1400D.1. Self Performance
D. Locomotion On Unit Or In Room - how individual moves between locations in his/her room and adjacent
corridor on same floor. If in wheelchair, self-sufficiency once in chair
E1400D.2. Support
D. Locomotion On Unit Or In Room - how individual moves between locations in his/her room and adjacent
corridor on same floor. If in wheelchair, self-sufficiency once in chair
E1400E.2. Support
E. Locomotion Off Unit Or In Home - how resident moves to or returns from distant areas in his/her home (e.g. areas
set aside for dining, activities or treatments). If facility has only one floor, how individual moves to and from distant
areas on the floor. If in wheelchair, self-sufficiency once in chair
E1400A.1. Self Performance
A. Bed mobility - how individual moves to and from lying position, turns side to side, and positions body while in
bed or alternate sleep furniture
E1400F.1. Self Performance
F. Dressing - how individual puts on, fastens and takes off all items of clothing, including donning/removing a
prosthesis or TED hose. Dressing includes putting on and changing pajamas and housedresses
E1400F.2. Support
F. Dressing - how individual puts on, fastens and takes off all items of clothing, including donning/removing a
prosthesis or TED hose. Dressing includes putting on and changing pajamas and housedresses
E1400B.1. Self Performance
B. Walk in room - how resident walks between locations in his/her room
PASRR Evaluation, September, 2017 V.5
Page 25 of 32
DLN Individual
E1400H.2. Support
Toilet use - how individual uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self
after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of
bedpan, urinal or bedside commode, catheter bag or ostomy bag
E1400J.2. Support
Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position
(excludes to/from bath/toilet)
E1400G.2. Support
Eating - how individual eats and drinks, regardless of skill. Do not include eating/drinking during medication pass.
Includes intake of nourishment by other means (e.g. tube feeding, total parenteral nutrition, IV fluids administered
for nutrition or hydration).
E1400H.1. Self Performance
Toilet use - how individual uses the toilet room, commode, bedpan, or urinal; transfers on/off toilet; cleanses self
after elimination; changes pad; manages ostomy or catheter; and adjusts clothes. Do not include emptying of
bedpan, urinal or bedside commode, catheter bag or ostomy bag
E1400I.2. Support
Medication management - level of assistance the individual needs to take prescribed medications
E1400I.1. Self Performance
Medication management - level of assistance the individual needs to take prescribed medications
E1400J.1. Self Performance
Transfer - how resident moves between surfaces including to or from: bed, chair, wheelchair, standing position
(excludes to/from bath/toilet)
E1400G.1. Self Performance
Eating - how individual eats and drinks, regardless of skill. Do not include eating/drinking during medication pass.
Includes intake of nourishment by other means (e.g. tube feeding, total parenteral nutrition, IV fluids administered
for nutrition or hydration).
E1500A. Is placement in an NF appropriate for this individual at this time?
E1500B. Explanation of findings to support that the individual
meets or does not meet a nursing facility level of care. Include
any additional information to support why this individual does or
does not require the level of care provided in a Nursing Facility.
0. No
1. Yes
PASRR Evaluation, September, 2017 V.5
Page 26 of 32
DLN Individual
F0200A. Has this individual received information regarding the services and support alternatives to the nursing
facility admission (for Preadmission Screening) or continuation of the nursing facility stay (for Resident Review)?
F0200B. Does this individual/LAR expect to return to live in the community either following a short term stay in
the nursing facility or at some point in the future?
Return to Community Living
F0200. Information And Expectations
F0400. Did this individual receive community-based services? Check all that apply
F0400A. Adult Foster Care
F0400B. Community Attendant Services
F0400C. Community Based Alternative Program (CBA)
F0400D. Community Living Assistance and Support Services (CLASS)
F0400E. Consumer Manages Personal Assistance Services (CMPAS)
F0400F. Day Activity and Health Services
F0400G. Deaf Blind with Multiple Disabilities (DBMD)
F0400H. Emergency Response Services
F0400I. Home and Community Based Services (HCS)
F0400J. In Home and Family Support Services
F0400K. Medically Dependent Children's Program (MDCP)
F0400L. Primary Home Care
F0300A. Has this individual been employed in the past 12 months?
F0300. Employment
F0300B. If Yes, what was the occupation?
F0400M. Psychological Rehabilitation
F0400N. STAR+Plus
Section F
0. No
1. Yes
2. Unknown
0. No
1. Yes
0. No
1. Yes
0. No
1. Yes
F0100. Did the individual or LAR participate in this assessment discussion?
F0400O. Substance Use Treatment Services
PASRR Evaluation, September, 2017 V.5
Page 27 of 32
DLN Individual
F0400S. Unknown
F0400T. Other
F0400U. Other
community-
based services
F0500. Would this individual like to live somewhere other than a Nursing Facility?
F0600. Where would this individual like to live now? Check all that apply
F0600A. Live alone with support
F0600B. A place where there is 24 hour care
F0600C. A group home
F0600D. Family home
F0600E. Other
F0600F. Other
Location
F0600G. Unknown
F0700. Community-based Program Check all that apply
F0700B. Adult Foster Care
F0700C. Community Attendant Services
F0700D. Community Based Alternative Program (CBA)
F0700E. Community Living Assistance and Support Services (CLASS)
F0700F. Consumer Manages Personal Assistance Services (CMPAS)
F0400R. None of the above
0. No
1. Yes
2. Unknown
F0700A. Is this individual interested in enrolling in a community-based program?
0. No
1. Yes
F0400P. Texas Home Living (TxHmL)
F0400Q. Youth Empowerment Services (YES) Waiver
PASRR Evaluation, September, 2017 V.5
Page 28 of 32
DLN Individual
F0700N. Psychological Rehabilitation
F0700O. STAR+Plus
F0700Q. Texas Home Living (TxHmL)
F0700R. Youth Empowerment Services (YES) Waiver
F0700S. None of the above
F0700T. Unknown
F0700U. Other
F0700V. Other
community-
based services
F0700M. Primary Home Care
F0700L. Medically Dependent Children's Program (MDCP)
F0700P. Substance Use Treatment Services
F0800. What challenges or barriers has the individual indicated that could impede the opportunity to return to return to the
community? Check all that apply
F0800A. Care needs are likely greater than support available in community
F0800B. Accessible housing limited
F0800C. Limited or no family/friend support available
F0800D. Limited income to support community living
F0800E. Guardian/family likely not to support community living
F0800F. Interest list slot not available at this time
F0700K. In Home and Family Support Services
F0700H. Deaf Blind with Multiple Disabilities (DBMD)
F0700I. Emergency Response Services
F0700J. Home and Community Based Services (HCS)
F0700G. Day Activity and Health Services
PASRR Evaluation, September, 2017 V.5
Page 29 of 32
DLN Individual
F0800L. Describe
the individual's
strengths, available
supports, and
barriers to living in
the community
F0900C. In an institutional setting
F0900D. NF
F0900E. ICF/IID
F0900F. Other
F0900G. Other
Location
F0900. This individual's needs can be met in: Check all that apply
F0900A. An appropriate community setting
F0900B. List
settings and
supports required
to enable
community
placement in the
space below
F0800I. Other
F0800J. Other
challenges/
barriers
F0800K. No challenges/barriers
F0800H. Affordable housing limited
F0800G. Lost house during NF stay
PASRR Evaluation, September, 2017 V.5
Page 30 of 32
DLN Individual
F1000A.
Program
F1000B.
Other Program
F1000C.
Phone Number
F1000D.
Date of Referral
F1000E.
Referral
Comments
F1000. Referrals - 2
F1000A.
Program
F1000B.
Other Program
F1000C.
Phone Number
F1000D.
Date of Referral
F1000E.
Referral
Comments
F1000. Referrals - 3
F1000. Referrals
F1000A.
Program
F1000B.
Other Program
F1000C.
Phone Number
F1000D.
Date of Referral
1. Adult Foster Care
2. Community Attendant Services
3. Community Based Alternative Program (CBA)
4. Community Living Assistance and Support Services
(CLASS)
5. Consumer Manages Personal Assistance Services
(CMPAS)
6. Day Activity and Health Services (DAHS)
7. Deaf Blind with Multiple Disabilities (DBMD)
8. Emergency Response Services
9. Home and Community Based Services (HCS)
10. In Home and Family Support Services
11. Medically Dependent Children’s Program (MDCP)
12. Primary Home Care
13. Psychological Rehabilitation
14. Star Plus
15. Substance Use Treatment Services
16. Texas Home Living (TxHmL)
17. Youth Empowerment Services (YES) Waiver
18. None of the above
19. Other
F1000. Referrals - 1
F1000E.
Referral
Comments
PASRR Evaluation, September, 2017 V.5
Page 31 of 32
DLN Individual
F1000A.
Program
F1000B.
Other Program
F1000C.
Phone Number
F1000D.
Date of Referral
F1000E.
Referral
Comments
F1000. Referrals - 5
F1000A.
Program
F1000B.
Other Program
F1000C.
Phone Number
F1000D.
Date of Referral
F1000. Referrals - 4
F1000E.
Referral
Comments
PASRR Evaluation, September, 2017 V.5
Page 32 of 32
DLN Individual
H0100C. ActionH0100A. PTID H0100B. Status
Authorization (System Use Only - Do Not Complete)
H0200A. PTID H0200B. Status H0200C. Action
Coach Pending More Info
Coach Review
Invalid/Complete
LA Action Required
PCS Processed/Complete
Pending More Info
Processed/Complete
SAS Request Pending
Submit to SAS
Submitted to PCS
Coach Pending More Info
Coach Review
Invalid/Complete
LA Action Required
PCS Processed/Complete
Pending More Info
Processed/Complete
Submitted to PCS
Submit to SAS
Coach Pending More Info
Coach Review
Invalid/Complete
LA Action Required
PCS Processed/Complete
Pending More Info
Processed/Complete
Submitted to PCS
Submit to SAS
Coach Pending More Info
Coach Review
Invalid/Complete
LA Action Required
PCS Processed/Complete
Pending More Info
Processed/Complete
SAS Request Pending
Submitted to PCS
Submit to SAS
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PASRR Evaluation Section A DLN Individual Submitter Information (Texas Medicaid & Healthcare Partnership)

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Completed 20 September 2021

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