Fillable Printable Screen Form: Doh-695 (2/2009)
Fillable Printable Screen Form: Doh-695 (2/2009)
Screen Form: Doh-695 (2/2009)
SCREEN Form:
DOH-695 (2/2009)
CONFIDENTIALITY STATEMENT/DISCLAIMER NOTICE
All rights reserved 2006. No part of this form or the form’s instructions may be altered or re-designed without the pr ior written permission of the New York State
Department of Health. This form is offered electronically for the express use of Health Care Facilities and Care Providers only. Violators will be prosecuted. Health
Facilities and Care Providers are responsible for the secure use of this form maintaining compliance with Health Insurance Portability and Accountability Act of 1996
(HIPAA) and the Personal Privacy Protection Law, New York Public Officers Law, Article 6-A. The information contained on this form is confidential and intended
for the use of qualified SCREENERS only. If the reader of this form is not the intended recipient, or any employee or agent responsible to deliver it to the intended
recipient, you are hereby notified that any dissemination, distri bution or copying of this form is strictly prohibited. If you receive this form in error, please immediately
notify the person or facility noted in item #3.
DOH-695 (2/2009) Page 1 of 7
NEW YORK STATE DEPARTME NT OF HEALTH
SCREEN
Office of Long Term Care – Division of Residential Services
A Patient Review Instrument (PRI) or Hospital and Community PRI (H/C PRI) must be completed before beginning the SCREEN form. Refer
to the SCREEN Instructions
(
DOH-695i
)
when com
p
letin
g
the SCREEN form.
IDENTIFICATION
1. Facility Operating
Certificate Number:
4. Patient/Resident/
Person’s Name:
2. Patient/Resident/Person’s
Social Security Number:
5. Date of HC-PRI or
PRI Completion:
3. Name of Person(s)
Completing SCREEN:
6a. Date of SCREEN
Initiation:
6b. Date of SCREEN
Completion:
DIRECT REFERRAL FACTOR FOR RESIDENTIAL HEALTH CARE FACILITY (RHCF)
YES NO
7. This person has a home in the community (owns or rents a home, lives in an Adult Care Facility or with family or friends) and that resid enc e is
still available OR appropriate community based living can be arranged OR this person is eligible for an Adult Care Facility.
Guideline:If item 7 is marked YES, proceed to DIRECT REFERRAL FACTORS FOR COMMUNITY BASED ASSESSMENT (items 8 -12).
If item 7 is marked NO, explain on a separate sheet of paper and attach to this form; refer to RHCF. Proceed to REFERRAL
RECOMMENDATION (item 21).
DIRECT REFERRAL FACTORS FOR COMMUNITY BASED ASSESSMENT
Answer all items 8-12
YES NO
8. This person understands information given and opposes placement/continued stay in a Residential Health Care Facility.
9. This person is aware of the cost of necessary community services and desires to use private resources (e.g., insurance, income, savings) to
purchase care at home or in an Adult Care Facility. Evaluator specifically described all necessary community services and described privat e
resources (such as insurance coverage, savings, income or financial aid provided by a spouse, relative or friend) that may be available to pay
for such services. Medicare and Medicaid should NOT be included as private financial resources.
10. This person has an informal support system. Individuals in this system are willing and are physically and mentally capable of caring for this
person, and providing for most of his/her specific needs.
11. All ADL responses = 1 or 2 (see PRI or HC-PRI PART III, 19-22)
This person was independent in ADLs prior to most recent acute episode and shows good rate of return of physical and mental functioning. 12.
Guideline:If any direct referral factor (items 8-12) is marked YES, refer to a Certified Home Health Agency (CHHA) for a community based
assessment. Attach assessment to the SCREEN, then proceed to REFERRAL RECOMMENDATION (item 21). If all referral factors
(items 8-12) are marked NO, proceed to HOME AND CAREGIVING ARRANGEMENTS (Item 13).
HOME AND CAREGIVING ARRANGEMENTS
13. a. Estimate the total number of hours per day that the informal support(s) system is willing and able to provide supervision or assistance to this
person. a. ______
b
. Estimate the total number of hours per day that this person can be alone. b. ______
c
. Add a and b (a+b=c) ........................................................................ c. _____
YES NO
d. Does c. total 12 or more hours?
Guideline: If item 13d. is marked YES, proceed to item 16.
If item 13d. is marked NO, proceed to item 14.
DOH-695 (2/2009) Page 2 of 7
YES NO
14. Can the number of hours that this person is attended by self or informal supports be expected to increase to 12 or more hours per day within
six months?
Guideline: If item 14 is marked YES, proceed to item 16.
If item 14 is marked NO, proceed to item 15.
15. If the answer to item 14 is NO, enter reason(s) (a, b, and/or c): ______
a. This person’s physical and/or mental condition is not expected to improve to a degree that would permit increased self care within six m onths.
b. Person has no informal supports.
c. Informal supports are unable or unwilling to provide additional assistance, or person does not want care from informal supports.
Guideline: Proceed to item 16
YES NO
16. Is there a need for restorative services documented by a physician or rehabilitation specialist?
Guideline: If item 16 is marked YES, proceed to item 17.
If item 16 is marked NO, proceed to item 19.
YES NO
17. Can this person receive restorative services at home, at adult day care, or as an outpatient?
Guideline: If item 17 is marked YES, proceed to item 19.
If item 17 is marked NO, proceed to item 18.
18. If the answer to item 17 is NO, enter reason(s) (a, b and/or c): ______
a. Restorative services are not available in this person’s community.
b. Restorative services are too costly or not covered in this person’s community.
c. This person cannot access restorative services in their community.
Guideline: Proceed to item 19.
YES NO
19. Does this person have any risk factors that could cause undue risk to self or others if placed in the community?
If YES, enter reason(s) (a, b, c and/or d):_____
a. This person has a history of unpredictable behaviors and may injure self or others. This condition is not temporary.
b. Comatose (PRI or H-C PRI Part II, 17 A) or all ADL responses = 4 or 5 (PRI or H-C PRI PART III, 19-22).
c. Requires constant monitoring due to health threatening medical conditions.
d. Skilled services are needed at least one time per day and cannot be delegated to nonprofessionals or informal supports.
Guideline: Proceed to item 20.
YES NO
Based on the answer to item 19, can this person be placed safely in the community without causing undue risk to self or others? 20.
Guideline: Proceed to item 21.
DOH-695 (2/2009) Page 3 of 7
________________________________________________________________________________________________________________________
REFERRAL RECOMMENDATION
21.Based on the information obtained by the screener during the screen assessment, check the principal referral recommendation and reason.
Explain as needed:
a. RHCF:
1.( ) A community based assessment was done by a Certified Home Health Agency (CHHA), and it was determined that this person cannot be cared for
in the community. This community assessment represents this person’s current status.
2. ( ) This person does not have an available home in the community (does not own or rent a home, is not eligible for an Adult Care Facility , or cannot
live with family or friends).
3. ( ) Appropriate community based living cannot be arranged because this person cannot be adequately cared for in the community and/or is a risk to
self or others.
4. ( ) Both community based and RHCF care are being investigated. Recommendation is RHCF.
b. RHCF for Restorative Services:
1. ( ) This person cannot receive restorative services in their community.
c. Community:
1. ( ) A CHHA completed a community based assessment and determined that this person can be cared for in the community.
Guideline:If RHCF (item 21 a) or RHCF for Restorative Services (item 21 b) is chosen, proceed to item 22.
If Community (item 21 c) is chosen, proceed to item 36.
DEMENTIA DIAGNOSIS
YES NO
22.
Does this person have a dementia diagnosis (including Alzheimer’s disease) documented in the medical record?
Guideline:Proceed to item 23.
LEVEL I REVIEW FOR POSSIBLE MENTAL ILLNESS (MI)
YES NO
23.
Does this person have a serious mental illness?
Guideline:Proceed to LEVEL I Review for Possible Mental Retardation/Developmental Disability (items 24 -26)
LEVEL I REVIEW FOR POSSIBLE MENTAL RETARDATION/DEVELOPMENTAL
DISABILITY (MR/DD)
Answer ALL items 24-26.
YES NO
24. Does this person have a diagnosis or documented history of mental retardation an d/or a dev elop me nta l disability, and did the mental
retardation or developmental disability manifest itself prior to age 22, and is it likely to continue indefinitely, resulting in substantial functional
limitations in three or more areas of major life activity?
25. Has this person ever been deemed eligible for and/or received MR/DD services, or has this person been referred by an agency that serves
persons with MR/DD?
DOH-695 (2/2009) Page 4 of 7
26.
Does this person present with evidence of cognitive deficits and/or adaptive skill deficits that may indicate the presence of
mental retardation or developmental disability?
Guideline:If item 23 or any of items 24-26 are marked YES, proceed to Categorical Determinations (items 27-30).
If item 23 and all of items 24-26 are marked NO, proceed to Patient/Resident/Person Disposition (item 36).
CATEGORICAL DETERMINATIONS
Answer ALL items 27-30.
YES NO
27.
Does this person qualify for convalescent care?
28. Is this person seriously physically ill?
29. Is this person terminally ill?
30. Is this person to be admitted for a very brief and finite stay or a provisional emergency admission?
Guideline: If any of the items 27-30 are marked YES, proceed to DANGER TO SELF OR OTHERS QUALIFIERS (item 31).
If all are marked NO, proceed to LEVEL II REFERRALS (item 33).
DANGER TO SELF OR OTHERS QUALIFIERS
YES NO
31.
Based on your interview with this person (and/or available informants), and/or a review of this person’s medical record, is there any
evidence to suggest that this person is, or may have been, a danger to self or others during the past two years?
Guideline:If item 31 is marked YES, proceed to item 32.
If item 31 is marked NO, proceed to Patient/Resident/Person Disposition (item 36).
YES NO
32. Has this person been deemed a danger to self or others based on a current psychiatric evaluation by a licensed mental health
professional?
Guideline:If item 32 is marked YES, proceed to LEVEL II REFERRALS (item 33).
If item 32 is marked NO, proceed to Patient/Resident/Person Disposition (item 36).
LEVEL II REFERRALS
33. Enter the Level II Referral(s): a, b, or c ______
a. Level II mental illness evaluation by the designated mental health review entity
b. Level II evaluation by the Office of Mental Retardation and Developmental Disabilities
c. Both a and b
Guideline: Proceed to item 34.
YES NO
I, as the qualified screener, acknowledge that this Patient/Resident/Person and his/her legal representative* have received verbal and written
notification that this Patient/Resident/Person is being referred for a Level II Evaluation.
34.
Guideline:
STOP ! Do not complete items 35 through 38 until you have obtained the Level II recommendations from the designated
evaluator(s).
*Legal representative means an individual whose appointment is made and regularly reviewed by a state court or agency empowered under state law to appoint and
review such officers, and having the authority to consent to health/mental health care or treatment of an individual.
DOH-695 (2/2009) Page 5 of 7
LEVEL II RECOMMENDATIONS
YES NO
35.
Specialized services are recommended based on the Level II Evaluation(s).
Guideline: Proceed to item 36.
PATIENT/RESIDENT/PERSON DISPOSITION
36. Enter one response (a,b,c,d,e,f,g,h,i,j.): ______
a. Home g. RHCF for restorative services
b. Home with home care services h. RHCF for other services
c. Adult Care Facility i. Person died
d. Inpatient Psychiatric Carej. Other (specify)
e. OMR/DD Residential Placement
f. Adult Care Facility with home care services
Guideline: Proceed to item 37
PATIENT/RESIDENT/PERSON AND/OR LEGAL REPRESENTATIVE AND/OR HEALTH
CARE AGENT ACKNOWLEDGEMENT
37. I have had the opportunity to participate in decisions regarding the arrangements for my continuing care, and I have received verbal and written information
regarding the range of services in my community.
__________________ _______________________________________________________________________________________
Date Signature of the patient/resident/person being assessed and/or legal representative and/or health care agent
Guideline: Proceed to item 38.
QUALIFIED SCREENER
38. I have personally observed/interviewed this person and completed this SCREEN and I certify that I am a trained and qualified SCREENER and the information
contained herein is a true abstract of this person’s current condition and circumstances.
Print date, name and title of qualified SCREENER SCREENER Identification Number
(Assigned by NYSDOH)
Signature of qualified SCREENER
DOH-695 (2/2009) Page 6 of 7
NOTIFICATION OF NEED FOR LEVEL II EVALUATION
A Level I SCREEN has been completed for____________________________, on _____________. This notice serves to inform ____________________________
and his/her legal representative that a Level II Evaluation is required, due to suspected mental illness and/or mental retardation. The Level II Evaluation will be
completed by the New York State Office of Mental Health and/or Office of Mental Retardation/Developmental Disability or designee.
Print date, name and title of qualified SCREENER SCREENER Identification Number
(Assigned by NYSDOH)
_________________________________________________________
Signature of qualified SCREENER
DOH-695 (2/2009) Page 7 of 7
