1. (a)

   1. (1) Complete the Form DHS-703 for each applicant.
   2. (2) Be sure to mark the appropriate box for application, ensure that all areas are completed, and that the applicant's degree of incapacity is reflected accurately.
   3. (3) Use the nurse’s comments section on page three (3) to provide other information related to the individual's need for nursing home care.

2. (b)

   1. (1) Complete Form DMS-787 (Pre-Admission Screening for Mental Illness/Mental Retardation, Level I Identification Screen) for all applicants.
   2. (2) If the completed form indicates that the individual has a diagnosis or other indicators of mental illness, mental retardation, or developmental disability, follow the procedures outlined under 20 CAR § 405-201 et seq.

3. (c)

   1. (1) If the completed Form DMS-787 indicates the presence of MI/MR/DD, complete the Pre- Admission Screening Annual Resident Review Client Consent form, Section III, with the applicant and/or his or her guardian or legal representative.
   2. (2) Attach the signed, dated, and witnessed consent form to the DMS-703.

4. (d)

   1. (1) If the individual has a diagnosis of dementia (including Alzheimer's disease or other related disorders), complete Form DMS-780 (Dementia Diagnosis Substantiation).
   2. (2) Attach the signed and dated form to the DHS-703.
   3. (3) Refer to the section on dementia below.

5. (e)

   1. (1) If the individual does not have a diagnosis or other indicators of mental illness and/or mental retardation/developmental disability, forward copies of the DHS-703 and the DMS-787, and if applicable, the DMS-780, to: Medical Need Determination PO Box 8059, Slot S406 Little Rock, AR 72203 501-682-6973 (Telephone) 501-683-5306 (FAX)
   2. (2) Keep a copy of all forms for the facility’s files.

   3. (3)

      1. (A) Whenever possible, the application packet should be submitted to the Office of Long- Term Care prior to the individual's admission to the nursing facility.
      2. (B) Otherwise, the packet must be submitted within forty-eight (48) hours of the individual's admission to the facility.
   4. (4) For private pay (Medicare, VA contract, private insurance, etc.) applicants who are applying for Medicaid coverage, the facility must submit the packet as soon as facility staff is made aware that the application will be made.
6. (f) If the individual does have a diagnosis or other indicators of mental illness and/or mental retardation/developmental disability follow procedures outlined in 20 CAR § 405-201 et seq.
7. (g) Send a copy of the EMS-702, Notice of Admission, Discharge, or Transfer from Nursing Home to the local county Department of Human Services office and to the Medical Need Determination Unit at the address in subdivision (e)(1) of this section.
8. (h) Ensure that an individual acting on behalf of the applicant applies or has applied for nursing home care at the department county office.

Codification Notes: "MI" means mental illness. "MR" means mental retardation. "DD" means developmental disability.