1. (a)

   1. (1) Complete the Form DMS-787 for all applicants (including private pay) to the nursing facility.
   2. (2) This is the Level I identification phase of the preadmission screening.

2. (b)

   1. (1) Determine whether there is a diagnosis or other indication of MI/MR/DD.
   2. (2) Any "Yes" answer on the Mental Retardation/Developmental Disabilities or Mental Illness sections of the DMS-787 requires referral to Level II.

3. (c)

   1. (1) If there is no indication of MI/MR/DD, then forward the Forms DMS-787 and DHS-703, and Form DMS-780 if applicable, to the Medical Needs Determination Unit, as specified in 20 CAR § 405-102(e)(1) for Medicaid applicants.
   2. (2) For private pay applicants, file the DMS-787 with the applicant's other facility records.

4. (d)

   1. (1) If the completed Form DMS-787 indicates the presence of MI/MR/DD (any "Yes" answer in the MR/DD or MI sections), the Forms DMS-787, DHS-703, and DMS-780 if applicable, and any other necessary documentation must be forwarded to Bock Associates, Inc.
   2. (2) The forms should be faxed to: Bock Associates FAX Number (501) 374-2541 Telephone Number (501) 374-2559
   3. (3) The facility should keep a copy of the packet in the applicant's file.

5. (e)

   1. (1) When there is an indication of mental illness and/or mental retardation, do not admit the applicant.
   2. (2) If there is evidence that the individual would be in danger if not immediately admitted to the nursing facility, facility staff may contact the Medical Need Determination Unit at (501) 682-8481 to discuss the situation.

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