ADW PAS

State of West Virginia Medicaid

Aged and Disabled Waiver
Pre-Admission Screening (PAS)

PAS ID:
PAS Type:
PAS Status:
In Use By:
Offline Checkout:
Offline Checkout:

Create By:
Create Date:
Submit By:
Submit Date:

Referral From

Facility/Agency/Person making referral FROM

Contact Person First Name

Contact Person Last Name

Address 1

Address 2

City

State

Zip Code

Fax Number

Fax Extension

Phone Number

Phone Extension

Referral To

Facility/Agency/Person making referral TO

Contact Person First Name

Contact Person Last Name

Address 1

Address 2

City

State

Zip Code

Fax Number

Fax Extension

Phone Number

Phone Extension

Reason for Screening

Reason for Screening

If Other, explain

Member Demographic Information

1a. First Name

1b. Middle Name

1c. Last Name

1d. Suffix

2. Gender

Male Female

3. Medicaid Number

4. Medicare Number

5a. Address 1

Address 2

5b. City

5c. State

5d. Zip Code

7. County

8. Social Security Number

9. Date of Birth

10. Age

11. Phone Number

Spouse Demographic Information

Is Applicant/Member Married?

12a. Spouse First Name

12b. Spouse Middle Name

12c. Spouse Last Name

12d. Spouse Suffix

13e. Spouse County

13a. Spouse Address 1

Spouse Address 2

13b. Spouse City

13c. Spouse State

13d. Spouse Zip Code

Additional Demographic Information

6. Private Insurance:

Yes No

Private Insurance Specify

14. Current living arrangements

Include formal and informal support (i.e. family, friends, other services.)

14. Current living arrangements

Provider Information

15ab. Provider Name

15c. Provider Address 1

Provider Address 2

15d. Provider City

15e. Provider State

15f. Provider Zip Code

15g. Provider County

Waiver

16. Medicaid Waiver Recipient:

Yes No

16a. Medicaid Waiver Types:

Aged/Disabled I/DD TBI

17. Has the option of Medicaid Waiver been explained to the Applicant/Member?:

Yes No

Release of Information

18. For the purposes of determining need for appropriate services, the applicant/member or representative indicated below has signed to authorize release of any medical information by the physician to the Department of Health and Human Resources or its representative.

Yes No

Signature - Applicant/Member or Person acting on their Behalf

Relationship

Date

Checking this box certifies that the person indicated above has signed the completed PAS and a copy of this document containing the above-named Applicant/Member's signature (or their representative) is on file in the applicant/member's record

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Advanced Directive

19. Does the Member have an Advanced Directive?

Yes No

f. Living Will

Add Representative

Medical Assessment Details

20. Health Assessment Details - Include infectious diseases, nutritional needs, prior treatments, degenerative conditions, recent hospitalization(s), and/or surgery(ies) with date(s) and date of most recent office visit. (Attach most recent Discharge Summary and Physical, if available)

20. Health Assessment Details - Include infectious diseases, nutritional needs, prior treatments, degenerative conditions, recent hospitalization(s), and/or surgery(ies) with date(s) and date of most recent office visit. (Attach most recent Discharge Summary and Physical, if available)

Vital Signs

21. Normal Vital Signs for Member

a. Height

(inches or cm)

b. Weight

(pounds or kg)

c. Blood Pressure (mmHg)

/

d. Temperature

(°F/°C)

e. Pulse

f. Respiratory Rate

Normal Vital Signs Comments

Normal Vital Signs Comments

Abnormalities

22. Check if Abnormal:

a. Eyes

b. Ears

c. Nose

d. Throat

e. Mouth

f. Neck

g. Breasts

h. Lungs

i. Heart

j. Arteries

k. Veins

l. Lymph System

m. Extremities

n. Abdomen

o. Hernia(s)

p. Genitalia Male

q. Gynecological

r. Ano-Rectal

s. Musculo Skeletal

t. Skin

u. Nervous System

v. Allergies

Abnormal Eyes Description and Treatment

Abnormal Eyes Description and Treatment

xxx

Abnormal Ears Description and Treatment

Abnormal Ears Description and Treatment

xxx

Abnormal Nose Description and Treatment

Abnormal Nose Description and Treatment

xxx

Abnormal Throat Description and Treatment

Abnormal Throat Description and Treatment

xxx

Abnormal Mouth Description and Treatment

Abnormal Mouth Description and Treatment

xxx

Abnormal Neck Description and Treatment

Abnormal Neck Description and Treatment

xxx

Abnormal Breasts Description and Treatment

Abnormal Breasts Description and Treatment

xxx

Abnormal Lungs Description and Treatment

Abnormal Lungs Description and Treatment

xxx

Abnormal Heart Description and Treatment

Abnormal Heart Description and Treatment

xxx

Abnormal Arteries Description and Treatment

Abnormal Arteries Description and Treatment

xxx

Abnormal Veins Description and Treatment

Abnormal Veins Description and Treatment

xxx

Abnormal Lymph System Description and Treatment

Abnormal Lymph System Description and Treatment

xxx

Abnormal Extremities Description and Treatment

Abnormal Extremities Description and Treatment

xxx

Abnormal Abdomen Description and Treatment

Abnormal Abdomen Description and Treatment

xxx

Abnormal Hernia(s) Description and Treatment

Abnormal Hernia(s) Description and Treatment

xxx

Abnormal Genitalia Male Description and Treatment

Abnormal Genitalia Male Description and Treatment

xxx

Abnormal Gynecological Description and Treatment

Abnormal Gynecological Description and Treatment

xxx

Abnormal Ano-Rectal Description and Treatment

Abnormal Ano-Rectal Description and Treatment

xxx

Abnormal Musculo Skeletal Description and Treatment

Abnormal Musculo Skeletal Description and Treatment

xxx

Abnormal Skin Description and Treatment

Abnormal Skin Description and Treatment

xxx

Abnormal Nervous System Description and Treatment

Abnormal Nervous System Description and Treatment

xxx

Abnormal Allergies: Please Specify

Abnormal Allergies: Please Specify

xxx

Abnormal Allergies Description and Treatment

Abnormal Allergies Description and Treatment

xxx

Medical Conditions/Symptoms

23. Medical Conditions/Symptoms (Grade as 0 = None, 1 = Mild, 2= Moderate and 3 = Severe)

a. Angina-Rest

b. Angina-Exertion

c. Dyspnea

d. Significant Arthritis

e. Paralysis

f. Dysphagia

g. Aphasia

h. Pain

i. Diabetes

j. Contracture(s)

k. Mental Disorder(s)

l. Other (Specify)

Specify Other Conditions/Symptoms

Specify Other Conditions/Symptoms

Describe Medical Conditions/Symptoms

Describe Medical Conditions/Symptoms

Decubitus Information

24. Does the Member have a decubitus?

Yes No

24g. Decubitus Comments

24g. Decubitus Comments

Vacate Ability

25. In the event of an emergency, the Member can vacate the building (select one):

Home Functional Ability

26. Indicate the Member's functional ability in the home for each item with the level number 1, 2, 3, or 4. Nursing care plan must reflect functional abilities of the client in the home.

a. Eating (not a meal Prep)

b. Bathing

c. Dressing

d. Grooming

e. Continent/Bladder

f. Continent/Bowel

g. Orientation

h. Transferring

i. Walking

j. Wheeling

k. Vision

l. Hearing

m. Communication

n. Describe Functional Ability in the Home

n. Describe Functional Ability in the Home

Care Needs

27. Professional and technical care needs (check all that apply):

a. Physical Therapy

b. Speech Therapy

c. Occupational Therapy

d. Inhalation Therapy

e. Continuous Oxygen

f. Ostomy

g. Suctioning

h. Tracheostomy

i. Ventilator

j. Dialysis

k. Parenteral Fluids

l. Sterile Dressings

m. Irrigations

n. Special Skin Care

0. Other

Specify 'Other' Professional and Technical Care

Specify 'Other' Professional and Technical Care

Describe Professional and Technical Care Needs

Describe Professional and Technical Care Needs

Medications

28. Member is capable of administering his/her own medications

28.1. Comments

28.1. Comments

29. Is this Member on any Medications?

Yes No

32. Has the Member received any psychotropic medications on a regular basis within the last two years?

Yes No

33. Was this medication used to treat a neurological disorder?

Yes No

Checking this box certifies that a Medication List will be attached to this PAS form.

Medication List Attachment(s)

File attachments not available when browser is offline

Add Medication

Current MI/MR Diagnosis

30. Current Diagnosis (check all that apply)

a. None

b. Mental Retardation

c. Autism

d. Seizure Disorder

e. Cerebral Palsy

f. Other Developmental Disabilities

g. Schizophrenic Disorder

h. Paranoid Disorder

i. Major Affective Disorder

j. Schizoaffective Disorder

k. Affective Bipolar Disorder

l. Tardive Dyskinesia

m. Major Depression

n. Other Related Conditions

Seizure Disorder (30d) - Specify Age at Onset:

Specify Other Developmental Disabilities (30f):

Specify Other Related Conditions (30n):

Current Diagnosis Comments

Current Diagnosis Comments

PASRR Level II Date

MI/MR Agencies

Has the Member ever received services from an agency serving persons with intellectual/developmental disabilities and/or mental illness

Yes No

MI/MR Clinical and Psychosocial

34. Clinical and Psychosocial - Please check any of the following behaviors which the Member has exhibited in the past two years:

a. Substance Abuse

b. Combative

c. Withdrawn/Depressed

d. Hallucinations

e. Delusional

f. Disoriented

g. Bizarre Behavior

h. Bangs Head

i. Sets Fires

j. Displays Inappropriate Social Behavior

k. Seriously Impaired Judgment

l. Suicidal Thoughts, Ideations/Gestures

m. Cannot Communicate Basic Needs

n. Talks About His/Her Worthlessness

o. Unable to Understand Simple Commands

p. Physically Dangerous to Self and Others, if Unsupervised

q. Verbally Abusive

r. Demonstrates Severe Challenging Behaviors

s. Specialized Training Needs

t. Sexually Aggressive

Does the Member have Alzheimer's, multi-infarct, senile dementia, or related condition?

Yes No

Other Clinical or Psychosocial Conditions:

Physician Recommendation

35. Prognosis

Other:

36. Rehabilitative Potential

37. Diagnosis:

a. Primary:

Add Secondary Diagnosis

d. Other medical conditions requiring services:

d. Other medical conditions requiring services:

Diagnosis Comments:

Diagnosis Comments

Date Assessment Completed:

Overall Comments

PAS Overall Comments:

PAS Overall Comments:

ADW PAS 1.2.0.1