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Effective Date: 
11/2019

Documents

 

Instructions

Updated 11/2019

 

Purpose

Form 1014 is used to summarize the results of a Pre-Admission Screening and Resident Review (PASRR) Evaluation for a person seeking admission into a nursing facility who qualifies for PASRR Specialized Services.

 

When to Prepare

The Local Intellectual and Developmental Disability Authority (LIDDA) or Local Mental Health Authorities (LMHAs) must complete Form 1014 following the completion of a PASRR evaluation (PE) for all persons being admitted to a nursing facility with a positive PE.  Note: Only the entity that completes the PE must complete this form and only one form should be completed per individual.

 

Form Retention

Form 1014 must be kept in the person’s record until notified otherwise by HHSC Legal Services.

 

Detailed Instructions

Section I

Individual’s First and Last Name – Enter the person’s first and last name.

Date of PASRR Evaluation – Enter the date the evaluation was conducted.

Individual’s Medicaid Number – Enter the person’s Medicaid number.

PASRR Evaluator’s First and Last Name – Enter the evaluator’s first and last name.

PASRR Evaluator’s Title – Enter the evaluator’s job title.

PASRR Evaluator’s Phone No. – Enter the evaluator’s area code and phone number.

Name of Entity that Conducted the PASRR Evaluation – Enter the name of the entity (LIDDA or LMHA/LBHA) that conducted the evaluation.

Entity’s Phone No. – Enter the area code and phone number of the LIDDA or LMHA/LBHA PASRR Department or Unit.

PASRR Qualifying Diagnosis – Check the box for each identified qualifying diagnosis.

Documentation Used to Confirm the PASRR Qualifying Diagnosis – List all forms of documentation used to confirm the PASRR qualifying diagnosis.

Section II

When the person has a dual diagnosis, the Local Intellectual Developmental and Disability Authority will take the lead in completing this section.

The PASRR Evaluation indicated that your needs could also be met in one or more of the following settings (check all that apply): – Check all settings that apply in this section.  If Other is checked, specify in the space indicated.

Section III

Recommended ID/DD Specialized Services – Check the box for each recommended IDD specialized service identified on the PASRR evaluation, if applicable.

Section IV 

Recommended MI Specialized Services – Check the box for each recommended MI specialized service identified on the PASRR evaluation, if applicable.

Section V

Recommended Nursing Facility Specialized Services – Check the box for each recommended nursing facility specialized service identified on the PASRR evaluation, if applicable. 

Type of Durable Medical Equipment (DME) – Check the box for each type of DME recommended on the PASRR evaluation, if applicable.

Person or Legally Authorized Representative Signature and Date – The person or Legally Authorized Representative signs and dates the form to indicate they have received a copy of Form 1014.