Colorado
PASRR Resident Review/Status Change
(Authorized CMHC Use Only)
PATIENT: / First Name: / Last Name:DOB / Medicaid # (or PP) / SS#:
Payment Method: / Medicaid Medicaid Pending Other (PP/Medicare) Hospice PACE 30 day PACE Respite
PASRR Evaluator:
Nursing Facility:
Source of Information:
MDS, Routine Assessment, etc.
Trigger for Status Change
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC Use Only)
New or worsened Serious Symptoms
New diagnosis of MMI (and/or depression)
Psychiatric meds for Dementia over the Beer’s list
New category of psychiatric medication started
Significant improvement in condition
Expiration of time limited approval
Colorado
PASRR STATUS CHANGE
(CMHC USE ONLY)
I. 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
Delusional Disorder NOS
Depressive Disorder (any depressions other than major depression)
Major Depression
Personality Disorder
Psychotic Disorder NOS
Panic Disorder
Paranoid Disorder
Schizoaffective Disorder
Schizophrenia
Somatoform Disorder
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)
II. Diagnosis of Organic Conditions:
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
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)
III. Psychotropic medication prescribed on a regular basis for non-organic condition; or for Dementia-related diagnosisthat is not on or is over the Beers limit
Current Medications: / Dosage: / Started: / DX:Current Medications: / Dosage: / Started: / DX:
Current Medications: / Dosage: / Started: / DX:
IV. Change in behavior or mental status that is not due to organic or physical/medical conditions. (check all that apply) Some examples are:
Deterioration in mental status that has not been reversed by NF staff interventions:
Signed form must be retained in clinical record
Revised 06/2014DRAFT DOCUMENT JUNE 2014Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Confusion
Delusions
Depressed Mood
Disorganized Thinking
Easily Distracted
Excessive Feelings of Worthlessness/Guilt
Grandiose Feelings/Statements
Hallucinations
Hopelessness
Irritability
Lack of Interest/Pleasure
Low Self-Esteem
Memory/Concentration Difficulties
Mood Swings (Highs/Lows)
Paranoia
Pressured Speech
Suicidal Thoughts
Signed form must be retained in clinical record
Revised 06/2014DRAFT DOCUMENT JUNE 2014Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Change in ADLs not accounted for by physical/medical condition:
Signed form must be retained in clinical record
Revised 06/2014DRAFT DOCUMENT JUNE 2014Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Bathing/Hygiene
Communication Difficulties
Difficulty with Dressing
Difficulty with Mobility
Fatigue/Loss of Energy
Incontinence (B/B)
Significant Increase or Decrease in Weight/Appetite
Sleep Disturbances
Other:
Signed form must be retained in clinical record
Revised 06/2014DRAFT DOCUMENT JUNE 2014Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Behavioral changes not accounted for by organic condition:
Signed form must be retained in clinical record
Revised 06/2014DRAFT DOCUMENT JUNE 2014Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Bizarre Behavior
Impaired Decision Making
Impaired/Poor Judgment
Inappropriate Sexual Behavior
Psych Hospitalization
Intrusiveness
Physical Abuse to Others/Self
Poor Impulse Control
Psychomotor Agitation/Retardation
Resistive to Care
Verbal Abuse
Other:
Signed form must be retained in clinical record
Revised 06/2014DRAFT DOCUMENT JUNE 2014Page 1 of 2
Colorado
PASRR Resident Review/Status Change
(Authorized CMHC/PASRR Evaluator)
Other: (list)V. OUTCOME:
Approved, no MMI (no Level II required)
Approved with follow up next quarter (does not require Level II)
Status Change, Approved MMI(does not require new Level II)
Refer for Level II (Level II attached to this document)
REASON FOR OUTCOME AND ANY IDENTIFIED NON-COMPLIANCE:
OBRA INDICATED COMPLIANCE
OBRA INDICATED NON-COMPLIANCE DUE TO:Status ChangePAS
If non-compliant, PASRRCompliance/Effective Date:
CMHC/PASRREvaluator: / Date:Signed form must be retained in clinical record
Revised 06/2014DRAFT DOCUMENT JUNE 2014Page 1 of 2