NUMBER: MEDICAID I.D. NUMBER: REFERRAL SOURCE: (Physician’s Name; Nursing Facility; Hospital; Etc.) LEVEL I SCREEN PART A: SERIOUS MENTAL ILLNESS (SMI): YES NO 1. ( ( Does the individual, currently meet the criteria for SMI? Must have a current diagnosis of a Major Mental Disorder, which is: a. A SCHIZOPHRENIC disorder, MOOD disorder, DELUSIONAL (PARANOID) disorder, PANIC OR OTHER SEVERE ANXIETY disorder, SOMATOFORM disorder, PERSONALITY disorder, or PSYCHOTIC disorder not elsewhere .
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How to fill out the HI DHS 1178 online
The HI DHS 1178 form is a critical document used for the preadmission screening and resident review process in Hawaii. This guide provides a detailed walkthrough for completing the form online, ensuring a smooth application experience for users.
Follow the steps to successfully complete the HI DHS 1178 online.
- Press the ‘Get Form’ button to obtain the HI DHS 1178 and open it in your editing tool.
- Begin by filling in the patient’s name in the designated field, using the format Last Name, First Name, M.I.
- Input the date of birth in the mm/dd/yy format to ensure accurate record-keeping.
- Enter the social security number in the appropriate field.
- Provide the Medicaid I.D. number if applicable, ensuring all numbers are accurate.
- Identify the referral source, which may include options such as the physician's name, nursing facility, or hospital.
- Proceed to Part A, where you will assess the criteria for serious mental illness (SMI). Carefully choose 'Yes' or 'No' for each question based on the patient's current mental health diagnosis.
- In Part B, address the presence of developmental disability/intellectual disability (DD/ID) using 'Yes' or 'No' responses, following the instructions provided.
- Move to Part C to evaluate any additional conditions that may apply to the individual, marking 'Yes' or 'No' for each item listed.
- At the end of the form, review all responses for accuracy, then sign and date it as required.
- Finally, you can save your changes, download, print, or share the completed form for submission.
Complete the HI DHS 1178 online today for an efficient submission process.
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What is a Level 1 Pasrr in Hawaii?
In brief, the PASRR process requires that all applicants to Medicaid-certified nursing facilities be given a preliminary assessment to determine whether they might have SMI or ID. This is called a "Level I screen." Those individuals who test positive at Level I are then evaluated in depth, called "Level II" PASRR.
What triggers a Pasrr Level 2?
The PASRR Level II is a comprehensive evaluation required as a result of a positive Level I Screening. A Level II is necessary to confirm the indicated diagnosis noted in the Level I Screening and to determine whether placement or continued stay in a Nursing Facility is appropriate.
Who can complete a Pasrr in Florida?
PASRR should always be completed prior to admission. Appropriately credentialed nursing facility staff are able to complete the screening anywhere, including at a hospice home, an assisted living facility, or even a hospital setting.
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