Colorado PAS Review
PASRR Post-Admission Level I update
(For Facility Use Only)
Resident: / First Name: / Last Name:DOB: / Medicaid #: / SS#:
Is there atime limited approval? Select: / Yes No
Hospital Exemption60-Day Convalescent Hospice 30 day PACE Respite
Assessor
(person completing form):
Source of Information
(MDS, Care Conference, etc):
Facilities must retain this document in the resident’s chartRevised 11/01/2014Page 1 of 2
Colorado
PASRR STATUS CHANGE
(CMHC USE ONLY)
I. New Diagnosis of Mental Illness:
Revised 7.2.2012Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Anxiety Disorder (Severe ONLY)
Bipolar Disorder
Depression Mild or Situational
GDS Score
Major Depression
Personality Disorder
Psychotic Disorder NOS
Panic Disorder
Paranoid Disorder
Schizoaffective Disorder
Schizophrenia
Somatoform Disorder
Other: ______
None
FAX COMPLETED FORM TO MASSPRO AT: 1-855-222-3114
Revised 9-13-13Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
II. New Diagnosis of Dementia/Organic Condition:
FAX COMPLETED FORM TO MASSPRO AT: 1-855-222-3114
Revised 9-13-13Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Dementia
Alzheimer’s disease
Unknown
Other: ______
FAX COMPLETED FORM TO MASSPRO AT: 1-855-222-3114
Revised 9-13-13Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
None
FAX COMPLETED FORM TO MASSPRO AT: 1-855-222-3114
Revised 9-13-13Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Collaborative testing mechanism used to determine presence/progression
FAX COMPLETED FORM TO MASSPRO AT: 1-855-222-3114
Revised 9-13-13Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Dementia workup
Comprehensive Mental Status Exam
Other: ______
None
FAX COMPLETED FORM TO MASSPRO AT: 1-855-222-3114
Revised 9-13-13Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
III. New Discovery of Intellectual Disability ID:
FAX COMPLETED FORM TO MASSPRO AT: 1-855-222-3114
Revised 9-13-13Page 1 of 2
Colorado PAS Review
Post-Admission Level I update
(For Facility Use Only)
None No
Yes, Explain:______
(Official Document - Colorado Pre-Admission and Resident Review PASRR)Page 1 of 2
Colorado PAS Review
Post-Admission Level I update
(For Facility Use Only)
(Official Document - Colorado Pre-Admission and Resident Review PASRR)Page 1 of 2
Colorado PAS Review
PASRR Post-Admission Level I
(For Facility Use Only)
IV. Psychotropic medication prescribed on a regular basis:
-New category of meds used for non-organic condition
-Meds not on or over the Beers list
Current Medications: / Dosage: / Started: / DX:Current Medications: / Dosage: / Started: / DX:
Current Medications: / Dosage: / Started: / DX:
V. New or Worsened Serious Symptoms:
(Official Document - Colorado Pre-Admission and Resident Review PASRR)Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Self-injurious behavior
Delusions/Hallucinations
Suicidal Talk
Suicide Attempt/Gestures
Altercations
Physical Violence
Physical Threat
Psychiatric Hospitalization
Aggressive/Belligerent Behavior
Excessive Irritability
Excessive Tearfulness
None
FAX COMPLETED FORM TO MASSPRO AT: 1-855-222-3114
Revised 9-13-13Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Provide additional information if checked:
FAX COMPLETED FORM TO MASSPRO AT: 1-855-222-3114
Revised 9-13-13Page 1 of 2
Colorado
PASRR Updated Level I
(For Facility Use Only)
VI. Reason for Updated Level I
Revised 1/15/2014Page 1 of 3
Colorado
PASRR Updated Level I
(For Facility Use Only)
Admitted without required PAS (do not refer)
Incorrect or missing PAS (do not refer)
New or worsened Serious Symptoms
New diagnosis identified in Section I.
Psychiatric meds for Dementia not on or over the Beer’s list
New category of psychiatric medication
Started for non-organic condition
Expiration of time limited approval
Revised 1/15/2014Page 1 of 3
Colorado
PASRR Updated Level I
(For Facility Use Only)
VII. Have you contacted your OBRA Coordinator?
Yes. Date: ______
OBRA indicated no further action needed
OBRA has referred resident for Status Change/Level II Evaluation
No.Provide additional information if checked:
PASRR Assessors’ Signature: / Date:Revised 1/15/2014Page 1 of 3