Free None - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Mental Health and Substance Abuse Services F-20822 (Rev. 08/2008)

STATE OF WISCONSIN RE: WI Stats. 50.04(2r), WI Stats. (as), WI Stats. 51.437(4m)(L)

County of Responsibility

COUNTY REVIEW OF NURSING HOME, IMD OR ICF / MR REFERRALS
Instructions: Personally identifiable information collected on this form is confidential and will be used for identification purposes only. The completion of this form does not constitute placement and specialized services determinations under the PASARR program or establish MA eligibility. The Division of Quality Assurance is not to assign a Title XIX Care Level for a nursing home resident until all admission requirements are met, including the approval to admit a person who has a developmental disability or mental illness to a nursing home, IMD or ICF / MR from the county of responsibility. A copy of this form must be attached to the F-22256, Request for Title XIX Care Level Determination form submitted by the facility. The County Agency shall send the form to the facility to which admission was requested. A copy shall be sent to the DMHSAS Bureau of Prevention Treatment and Recovery, 1 W. Wilson St., Room 433, PO Box 7851, Madison, WI 53707-7851. Name Current Permanent Address (Street, City, State, Zip Code) Current Type or Residence Own home or apartment RCAC Hospital Name - Facility Being Recommended Birthdate (mm/dd/yyyy) Social Security Number

With relative ICF / MR

CBRF or Adult Family Home Other (e.g., jail, homeless) Address - Facility (Street, City, State, Zip Code)

Check ALL the boxes below that apply to the individual. The client has a : Mental illness Developmental disability due to a brain injury Brain injury that occurred prior to 22nd birthday Brain injury that occurred after 22nd birthday

Developmental disability not due to brain injury

Recommendation regarding institutional placement: (Check the appropriate box.) NURSING FACILITY - ADMISSION RECOMMENDED (Check the applicable boxes below.) A short exemption from Level II Screening applies. (Note: Short-term exemptions may not be used consecutively to extend the time in a facility without a PASARR Level II Screen.) Hospital Discharge Exemption - 30 day maximum Pending Alternate Placement - 30 day maximum Emergency Placement - 7 day maximum Respite Care - 30 days per year maximum The person needs nursing facility placement. Level II Screen required. County has received a recently completed Level II Screen summary from the PASARR evaluation team. Person needs a Level II Screen by area PASARR evaluation team. nd Person has a brain injury that occurred after 22 birthday and does not have an additional developmental disability or an accompanying mental illness requiring a PASARR Level II Screen. Admission to a licensed nursing home that is not Medicaid certified. (Note: PASARR only applies to Medicaid certified nursing facilities.) ICF / MR (FDD) ADMISSION RECOMMENDED The county believes that the person does not have mental illness or developmental disability as defined in s. 51.01, Stats., and therefore, county approval is not necessary. Miscellaneous Comments (Check all that apply.) If the request for the county approval had been made prior to admission, the approval would be been granted. Questions regarding county of responsibility exist and a residency determination from DHS may be requested. ADMISSION NOT RECOMMENDED for the following reasons(s):

OTHER COMMENTS

SIGNATURE - County Staff Person Completing This Form

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