Revised Page 4 for Instruction Manual for SCREEN Form DOH-695 (2/2009)
General Instructions for Completing the SCREEN
A SCREEN form may only be completed by health care professionals who have completed the New York State Department of Health SCREEN Certification Course and have been issued a ten digit SCREENER identification number. Qualified SCREENERS in RHCFs, hospitals, Certified Home Health Agencies (CHHAs), Long Term Home Health Care Programs (LTHHCPs), other community-based agencies and independent health care professionals may complete the SCREEN form. As a qualified SCREENER, you are responsible for periodically checking the New York State Department of Health (NYSDOH) website: www.nyhealth.gov and/or the Health Provider Network (HPN) for updates to the SCREEN form and instructions. If your facility does not have a HPN account, please contact the Commerce Accounts Management Unit at 1-866-529-1890.
A SCREEN Is Needed:
- Prior to admission to a RHCF for every person, for any length of stay.
- Prior to or within 24 hours of a hospitalized patient being designated as Alternate Level of Care (ALC) and every 30 days thereafter until hospital discharge. (See 10NYCRR Section 85.8)
- As soon as possible when the ALC patient's status changes as evidenced by a change in the patient's assigned Resource Utilization Group (RUG II). (See 10NYCRR Section 85.8)
- If a RHCF resident is newly diagnosed with a mental illness and/or mental retardation/developmental disability, a new SCREEN and Level II referral must be completed within 14 calendar days (See 42 CFR 483.20(e) & 483.108(c); 42 USC 1396r(e)(7)).
- If a RHCF resident, who was previously identified as having mental illness and/or mental retardation/developmental disability, is identified as having experienced a significant change in physical and/or mental condition. A new SCREEN and Level II Evaluation must be completed within 14 calendar days. (See 42 U.S.C. Section 1396r(e)(7)(B)(iii)).
- If a resident of a RHCF, who was identified as having mental illness and/or mental retardation/developmental disability on their admission SCREEN Level I Review and met the criteria for Categorical Determination (convalescent care, seriously physically ill, terminally ill, or provisional emergency admission), requires a length of stay longer than the appropriate physician documented number of days. A SCREEN and Level II Evaluation must then be completed. (See 42 CFR, Part 483, Subpart C)
- If a resident of a RHCF, who was identified as having mental illness and/or mental retardation/developmental disability on their admission SCREEN Level I Review, and met the criteria for Categorical Determination for a brief or finite stay (requiring less than a 30 day stay), requires a length of stay longer than 30 days. A SCREEN and Level II Evaluation must be completed by the 40th day. (See 42 CFR, Part 483, Subpart C)
NOTE: The RHCF is responsible for ensuring that a copy of the resident's most recent SCREEN, which may include a Level II evaluation, accompanies the resident upon transfer to a hospital or another RHCF. (See 42 CFR 483.106) For residents who are discharged to the community with skilled services, it is suggested that, for informational purposes, a copy of the most recent SCREEN, and Level II evaluation as appropriate, be made available to the service provider.
Revised: Effective 10/1/09