Name:

Social Security/ID number:

Current Nursing Facility:

Admission Date: Date Specialized Services Initiated:

(Initial admission and specialized services date may have been in a previous facility)

As required by 42 CFR subsection 183, and 907 KAR 1:755, PASRR evaluations ensure persons with Mental Illness, Intellectual disabilities, or Related Conditions, who meet Kentucky Medicaid’s criteria for nursing facility services, will receive those supports in the least restrictive setting. It also identifies when specialized services are indicated. Specialized services for mental illness requires the level of intensity provided in an in-patient psychiatric hospital, and are not available in a nursing facility.

Any Individuals in nursing facilities, who no longer require Nursing Facility Level of Care, must be discharged, unless that individual meets all of the following criteria:

Has an Intellectual Disability, or Related Condition;

Has resided in a nursing facility for at least thirty (30) consecutive months; and

Received, and continues to require specialized services.

Short term absences from the facility for hospitalizations, leaves, or treatments, are included in the 30-month period.

The individual, who meets this 30-month exemption, has the option to remain in the nursing facility for as long as the specialized services are needed, or they can choose to receive their services in an alternative placement. If an alternative placement is selected, the individual can remain in the facility until the alternative placement is obtained.

I understand that as a long-term resident of a nursing facility, I have the option of staying and receiving services in the facility, or leaving and receiving specialized services (active treatment) in an alternative setting. The need for specialized services has been identified through the PASRR process, and staff from the CMHC has provided me with an explanation of my placement options.

I meet the 30-month exemption per PASRR protocols, and choose:

Signature of Individual/Legal Representative Date

Person completing form	Date