Free 45932.pdf - Indiana

PASARR CATEGORICAL DETERMINATION FOR SHORT-TERM NURSING FACILITY CARE CERTIFICATION BY PHYSICIAN FOR LONG TERM CARE SERVICES
State Form 45932 (R / 6-93) Form 450B / PASARR 2A - Section V, Part B

This form is CONFIDENTIAL according to IC 12-15-2 et seq., IC 12-10-10 et.seq., IC 12-21 and 470 IAC 1-3-1.

INSTRUCTIONS: This form MUST be completed prior to nursing facility admission for the following situations in accordance with 42 CFR 483.106 for persons identified as possibly being Mentally Ill (MI) or Mentally Retarded/Developmentally Disabled (MR/DD) on Section IV of the "PASARR LEVEL I" form. Only the PAS agency may authorize placement in a nursing facility under the conditions in Part B. This completed form must be retained with a copy of the PAS application and PASARR Level I forms on the resident's active record in the nursing facility. A copy must be retained on file by the PAS agency with the PAS application and PASARR Level I forms. A copy of this authorization must be included in the PAS case. If longer-term placement is subsequently required, a written explanation of the change in circumstances necessitating such placement must be included with the PAS case.
Name of applicant / resident Name of facility City

SECTION V - PART B

1. RESPITE SHORT-TERM (30-DAY): An individual may be admitted to a nursing facility from home (non-institutional setting) for short-term respite care not to exceed thirty (30) calendar days per quarter, with a break of at least thirty (30) days between stays of fifteen (15) or more consecutive days of respite care. Respite care is a temporary or periodic service provided to a functionally impaired individual for the purpose of relieving the regular caregiver. At the time of admission, there must be an expressed intention of leaving the nursing facility by the expiration of the approved time period. NOTE: For persons with a Developmental Disability (DD) and Mental Illness (MI), the PreAdmission Screening (PAS) agency must contact the local DD Integrated Field Services Agency or Community Mental Health Center (CMHC) prior to authorization. Nursing facility (NF) placement is to be the placement of last resort.

Signature of PAS agency

Title

Date signed (month, day, year)

Agency number

2. ADULT PROTECTIVE SERVICES (7-DAY): An endangered adult who is referred to Adult Protective Services (APS) may be admitted to a nursing facility from the community for a period not to exceed seven (7) days while a determination is made and/or alternative arrangements for longer care are made. The individual must be in need of intensive emergency intervention; i.e., the individual is determined to be in imminent danger, as certified by the signature of the APS investigator. NOTE: For DD and MI persons, the PAS agency must immediately notify the local DD Integrated Field Services Agency or CMHC. NF placement is to be the placement of last resort.
Signature of APS investigator Title Date signed (month, day, year) Agency number

Signature of PAS agency

Title

Date signed (month, day, year)

Agency number