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bmpT7L5HYzIc3zUrqRD6iviU6h8LFNnLvqxGJtUM3I86tznMsRgXsads7JcPTFK6CtQsn4JWZCihhQwI5ZWye3ZMvupWR3XfiVaP3kNmxbHuKYATmwiu

Resident Review of Change in Condition: Nursing Facility Notification to Missouri Department of Mental Health

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PASRR is achieving its federal purpose when all NF residents with PASRR disabilities are identified, their disability related needs are evaluated, services and supports needed are identified, and the PASRR recommended services and supports are delivered to them. Resident care plans must include the Specialized Services or Specialized Rehabilitative Services that the NF will provide as a result of the Level II recommendations made by PASRR. If the NF disagrees, it must indicate its rationale for disagreeing in the resident's medical record [CFR 483.21(a)].

PASRR Resident assessment is an ongoing process that begins before the individual moves into a Nursing Facility and continues throughout the stay. The Final Rule [CRF 483.20(k)(4)] was published in November 2016 (80 FR 42168). Under this rule, nursing facilities (NFs) must notify the state mental health authority (SMHA) or state intellectual disability authority (SIDA) promptly after a resident experiences a significant change in condition of any kind. Please keep a copy ofthis Resident Review notification form for your records.

Name (Last, First, MI):

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Date of Birth

* must provide value

M-D-Y

SSN:

* must provide value

DCN (Medicaid Number):

* must provide value

Does the individual have a legal guardian?

* must provide value

Yes

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Guardian Name

Guardian Phone

Facility Name

* must provide value

Admit Date

* must provide value

M-D-Y

Name of Facility Representative

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Email Address

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Phone

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Fax

Is the individual currently hospitalized or has been in the hospital in the last year?

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Yes

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Hospital Name

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Date of admission

M-D-Y

Is individual currently in the hospital?

Yes

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Contact Person

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Phone

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Primary cause of hospitalization

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Medical/physical care and treatment

Mental health/behavioral care and treatment

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Additional Hospital Information

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Indicate reason for DMH Notification of Change in Condition. For Residents previously identified by PASRR (Note: this is not an exhaustive list):

Resident with increased behavioral, psychiatric, or mood-related symptoms.

Resident with behavioral, psychiatric, or mood related symptoms that have not responded to ongoing treatment.

Resident with an improved medical condition - such that the residents plan of care or placement recommendations may require modifications.

Resident with significant physical change, but with behavioral, psychiatric, or mood-related symptoms, or cognitive abilities that may influence adjustment to an altered pattern of daily living.

Resident has indicated a preference (may be communicated verbally or through other forms of communication, including behavior) to leave the facility.

Resident's condition or treatment is or will be significantly different than described in the resident's most recent PASRR Level II evaluation and determination.

Change in location, such as hospitalization (medical or psych), or transfer from one nursing facility (NF) to another NF (with or without an intervening hospital stay).

Indicate reason for DMH Notification of Change in Condition. For Residents NOT previously identified by PASRR (Note: this is not an exhaustive list):

Resident with behavioral, psychiatric, or mood-related symptoms suggesting the presence of a diagnosis of mental illness as defined under 42 CFR 4893.100 (where dementia is not the primary diagnosis).

Resident whose intellectual disability as defined under 42 CFR 483.100, or related condition as defined under 42 CFR 435.1010 was not previously identified and evaluated through PASRR.

Resident transferred, admitted, or readmitted to a NF following an inpatient psychiatric stay or equally intensive treatment.

Summarize the change in condition indicated above.

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Other concerns or changes in condition not described above:

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Describe current mental health and/or developmental disability treatment and/or services.

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Individual completing the form name:

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Individual completing the form position:

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Individual completing the form date:

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M-D-Y

Please attach a copy of current medication list.

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Upload file

Please attach a copy of the most recent medical history and physical and/or medical consult reports

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Upload file

Please attach a copy of the most recent psychiatric history and physical, assessment or consult report, psychiatric inpatient admission report and/or discharge summary.

* must provide value

Upload file

Please attach a copy of the clinical notes or other necessary information.

Upload file

DMH CENTRAL OFFICE USE

PASRR Resident Review Required	______
PASRR Resident Review	______

Level 2 Evaluation	______
Level 2 Determination	______

Application Status	______
Mental Health Indicator	______
IDD Indicator	______

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