Submit the completed form to the appropriate agencies, including OCCO, DDD, and/or DMHAS. Fax the form to the relevant office as specified based on the screening outcome. Ensure all sections are thoroughly filled and all required supporting documents are attached for a smooth submission process. For detailed submission guidelines, refer to the New Jersey DHS forms webpage at: https://www.state.nj.us/humanservices/doas/home/forms.html. My advice is to double-check all entries for accuracy and completeness to avoid delays and ensure compliance.

For 2024 and 2025, any significant updates to federal PASRR regulations and deadlines for submission affected by these changes will be important. Ensure your submissions are timely to avoid compliance issues.

The purpose of this form is to conduct a pre-admission screening and resident review (PASRR) for individuals applying for nursing facility admission in New Jersey. The form aims to identify individuals with mental illness, intellectual, or developmental disabilities to ensure they receive the appropriate level of care and support. Proper completion and submission of this form are crucial to comply with federal regulations and secure Medicaid reimbursement.

• 1. Name of Applicant: Enter the applicant's last name and first name.
• 2. Social Security Number: Provide the applicant's Social Security Number.
• 3. Current Location Address: Enter the address where the applicant currently resides.
• 4. County of Current Location: Specify the county of the applicant's current location.
• 5. Date of Birth: Input the applicant's date of birth.
• 6. Current Location Setting: Select the applicant's current living arrangement from the provided options.
• 7. Clinical Assessment/Authorization Status: Provide the date of current assessment or authorization and specify the referral details if applicable.
• 8. Mental Illness Screening Questions: Answer questions related to the diagnosis, impairment in functioning, and psychiatric treatment of the applicant.
• 9. Intellectual Disability/Developmental Disability Screening Questions: Answer questions regarding the applicant's intellectual or developmental disabilities and related conditions.
• 10. PASRR Level I Screening Outcome and Referral: Determine the final screening outcome and the necessary referrals based on the responses in the previous sections.

Failure to submit this form correctly may result in adverse consequences for the nursing facility and the applicant. Medicaid reimbursement may be forfeited during periods of non-compliance.

• Medicaid Reimbursement Forfeiture: The facility may lose Medicaid reimbursement for the duration of non-compliance.
• Admission Delays: Delays in processing the application could occur, affecting the applicant's admission timeline.
• Regulatory Non-Compliance: Failure to comply with federal PASRR regulations may result in penalties or other regulatory actions.

• 1. Nursing Facility Admissions: Use this form for all applicants prior to admission.
• 2. Mental Illness Detection: Screen for major mental illnesses as specified in the form.
• 3. Intellectual/Developmental Disability Identification: Identify intellectual and developmental disabilities and related conditions in applicants.
• 4. Regulatory Compliance: Ensure compliance with federal PASRR regulations.
• 5. Referral Process: Facilitate referrals to appropriate agencies for further evaluation and support.