Chapter 514 - Nursing Facility Services - DHHR - State of West ...

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DATE: ________________________________________NAME: ________________________________________26. Indicate individual=s functional ability in the home for each item with the level number 1, 2, 3, 4, or 5. Nursingcare plan must reflect functional abilities of the client in the home.ItemLevel 1 Level 2 Level 3 Level 4a.__ Eating (nota meal Prep)b.__ Bathingc.__ Dressingd.__ Groominge.__Cont./Bladderf. __Cont./Bowelg.__ Orientationh.__Transferringi.__ Walkingj.__ Wheelingk.__ Visionl.__ Hearingm.__CommunicationSelf/PromptingSelf/PromptingSelf/PromptingSelf/PromptingContinentContinentOrientedIndependentIndependentNo WheelchairNot ImpairedNot ImpairedNot ImpairedPhysical AssistancePhysical AssistancePhysical AssistancePhysical AssistanceOccas. Incontinent*Occas. Incontinent**less than 3 per wk.Intermittent DisorientedSupervised/Assistive DeviseSupervised/Assistive DeviseWheels IndependentlyImpaired /CorrectableImpaired/CorrectableImpaired/UnderstandableTotal FeedTotal CareTotal CareTotal CareIncontinentIncontinentTotally DisorientedOne Person AssistanceOne Person AssistanceSituational Assistance(Doors, etc.)Impaired/Not CorrectableImpaired/Not CorrectableUnderstandable with AidsTube FedCatheterColostomyComatose (Level 5)Two Person Assist.Two Person Assist.Total AssistanceBlindDeafInappropriate/None27. Professional and technical care needs (check all that apply).a. Physical Therapy f. Ostomy k. Parenteral Fluidsb. Speech Therapy g. Suctioning l. Sterile Dressingsc. Occupational Therapy h. Tracheostomy m. Irrigationsd. Inhalation Therapy i. Ventilator n. Special Skin Caree. Continuous Oxygen j. Dialysis o. Other __________________28. Individual is capable of administering his/her own medications (check only one).a. Yes b. With Prompting/Supervision c. No Comment:__________________29. CurrentMedicationsDosage/Route Frequency ReasonPrescribedDiagnosisPAS-2000 Page 3 of 6 Effective 11-1-01Revised: 11/2001
III. MI/MR ASSESSMENTDATE: ____________________________________NAME: ___________________________________30. Current Diagnoses (Check all that apply)a. None g. Schizophrenic Disorderb. Mental Retardation h. Paranoid Disorderc. Autism i. Major Affective Disorderd. Seizure Disorder (Age at onset: _________) j. Schizoaffective Disordere. Cerebral Palsy k. Affective Bipolar Disorderf. Other Developmental l. Tardive DyskinesiaDisabilities (Specify: _______________)m. Major Depressionn. Other related conditions(Specify:_______________________)Date of last PASARR Level II Evaluation______________31. Has an individual ever received services from an agency serving persons with mental retardation/developmentaldisability and/or mental illness? □ Yes □ No If yes, specify agencyName______________________________Admission Date ______________________Address________________________________________________Discharge Date __________________________________________32. Has the individual received any of the following medications on a regular basis within the last two years?□Yes □ No33. Was this medication used to treat a neurological disorder? □Yes □ No□ Chlorpromazine □ Thorazine □ Perphenazine □ Trilafon □ Haloperidol □ Haldol□ Promazine □ Sparine □ Fluphenazine □ Prolixin □ Molindone □ Moban□ Trifupromazine □ Vesprin □ Fluphenazine HCl □ Permitil □ Loxapine □ Loxitane□ Thioidazine □ Mellaril □ Trifluphenazine □ Stelazine □ Clozapine □ Clozaril□ Mesoridazine □ Serentil □ Chlorprothixene □ Taractan □ Procholorperazine□ Actiphenazine □ Tindal □ Thiothixene □ Navane □ CompazineMedication Dosage/Route Frequency Reason Prescribed Diagnosis34. Clinical and Psychosocial Data - Please check any of the following behaviors which the individual has exhibitedin the past two years.a. Substance Abuse (Identify_____________) k. Seriously Impaired Judgmentb. Combative l. Suicidal Thoughts, Ideations/Gesturesc. Withdrawn/Depressed m. Cannot Communicate Basic Needsd. Hallucinations n. Talks About His/Her Worthlessnesse. Delusional o. Unable to Understand Simple Commandsf. Disoriented p. Physically Dangerous to Self and Others,g. Bizarre Behavior if Unsupervisedh. Bangs Head q. Verbally Abusivei. Sets Fires r. Demonstrates Severe Challenging Behaviorsj. Displays Inappropriate Social Behavior s. Specialized Training Needst. Sexually AggressiveDoes the individual have Alzheimer’s, multi-infarct, senile dementia, or related condition? □ Yes □ NoOther (Specify) ____________________________________________________________________________________PAS-2000 Page 4 of 6 Effective 11-1-01Revised: 11/2001
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CHAPTER 514 - COVERED SERVICES, LIM
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514.4.11 Services Provided by Outsi
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514.10.4 Podiatry Services ........
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514.13.47 Field Audit .............
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in the balance as part of the proce
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Minimum Data Set (MDS) - a core set
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eimbursement and annually thereafte
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A change in ownership of a nursing
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The Commissioner, in his or her dis
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514.3.2 Civil Money Penalty (CMP)A
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Employment of an individual with on
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514.4.7 Administrative PoliciesThe
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The agreement / contract must clear
Page 27 and 28: Where residents are in a nursing fa
Page 29 and 30: 514.5.10 Food and Dietary DirectorI
Page 31 and 32: #27: Individual has skilled needs i
Page 33 and 34: evaluator. All Level II evaluators
Page 35 and 36: It is the responsibility of the nur
Page 37 and 38: abuse and controlled drugs as ident
Page 39 and 40: 514.8.1 Nursing ServicesCovered ser
Page 41 and 42: Upon transfer to another nursing fa
Page 43 and 44: 514.9.2 Transfer and Discharge Poli
Page 45 and 46: the resident’s physical condition
Page 47 and 48: 514.9.10 Conveyance Upon DischargeU
Page 49 and 50: 514.10.6 Emergency Ambulance Transp
Page 51 and 52: 514.10.8 Documentation Requirements
Page 53 and 54: certification must include document
Page 55 and 56: It is not mandatory for providers t
Page 57 and 58: ownership and control has occurred
Page 59 and 60: The standard hours PPD, by bed grou
Page 61 and 62: The Model Nursing Facility Standard
Page 63 and 64: Starting with its total costs, incl
Page 65 and 66: eimbursable. For example: if a faci
Page 67 and 68: 514.13.37 Cost AdjustmentReported f
Page 69 and 70: If it has been determined that a fa
Page 71 and 72: CHAPTER 514NURSING FACILITY SERVICE
Page 73 and 74: Changes in Ownership, either in par
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Page 77: II. MEDICAL ASSESSMENTDate ________
Page 81 and 82: V. ELIGIBILITY DETERMINATION DATE:
Page 83 and 84: West Virginia Department of Health
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