"Resident Review Required Documentation" - Kansas

Resident Review Required Documentation is a legal document that was released by the Kansas Department for Aging and Disability Services - a government authority operating within Kansas.

Form Details:

  • Released on May 1, 2018;
  • The latest edition currently provided by the Kansas Department for Aging and Disability Services;
  • Ready to use and print;
  • Easy to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Kansas Department for Aging and Disability Services.

ADVERTISEMENT
ADVERTISEMENT

Download "Resident Review Required Documentation" - Kansas

Download PDF

Fill PDF online

Rate (4.5 / 5) 15 votes
RESIDENT REVIEW REQUIRED DOCUMENTATION
A RESIDENT REVIEW is required when an individual, in a Nursing Facility, with a PASRR determination
letter that authorized a temporary stay and the persons stay requires an extended length of time or a
change in a resident’s status.
_____ Current Release of Information (ROI) dated/signed within the last year.
_____ Current Guardianship, DPOA documents (if changed since last review)
_____ Current History & Physical (H & P) (one year or less)
_____ Current Medication Administration Record (MAR)
_____ Current Care Plan
_____ Progress Notes in the last 90 days or since change of condition (Physician, Nursing, SS etc.)
_____ MDS (change of status ONLY- the most recent MDS before and after the Change of Status)
_____ Discharge summary from any State Hospital, Psych Unit or BHU since the original Level II screen
or last resident review. Documentation from nursing and/ or social services on recent functioning, status
of ADL’s and a brief summary of why the person has had a change of status or is unable to discharge to a
lower level of care.
I have attached the required documentation for the Resident Review Assessment
Name/Title___________________________________________________________date_____________
Phone/email:__________________________________________________________________________
Please send information to
KDADS.CARE@ks.gov
attention Susan. Or Fax to 785-291-3427
If you have further questions please call Susan Cunningham @ 785-291-3360
RESIDENT REVIEW REQUIRED DOCUMENTATION
A RESIDENT REVIEW is required when an individual, in a Nursing Facility, with a PASRR determination
letter that authorized a temporary stay and the persons stay requires an extended length of time or a
change in a resident’s status.
_____ Current Release of Information (ROI) dated/signed within the last year.
_____ Current Guardianship, DPOA documents (if changed since last review)
_____ Current History & Physical (H & P) (one year or less)
_____ Current Medication Administration Record (MAR)
_____ Current Care Plan
_____ Progress Notes in the last 90 days or since change of condition (Physician, Nursing, SS etc.)
_____ MDS (change of status ONLY- the most recent MDS before and after the Change of Status)
_____ Discharge summary from any State Hospital, Psych Unit or BHU since the original Level II screen
or last resident review. Documentation from nursing and/ or social services on recent functioning, status
of ADL’s and a brief summary of why the person has had a change of status or is unable to discharge to a
lower level of care.
I have attached the required documentation for the Resident Review Assessment
Name/Title___________________________________________________________date_____________
Phone/email:__________________________________________________________________________
Please send information to
KDADS.CARE@ks.gov
attention Susan. Or Fax to 785-291-3427
If you have further questions please call Susan Cunningham @ 785-291-3360
AUTHORIZATION FOR RELEASE OF PROTECTED HEALTH INFORMATION
I, ___________________________, Social Security Number: __ __ - __ __ - __ __ __ __ DOB ___/____/___
Name of client
[optional]
hereby authorize the use and/or disclosure of my individually identifiable health information as described below. I
understand that signing this form is voluntary.
Providing the information:
Receiving the information:
P
Person(s)/Organization(s)
(check all that applies)
erson(s)/Organization(s)
(check all that applies)
____
Community mental health center(s)
____ Aging and Disability Resource Center
_____________________________________
_____________________________________
name
name
____ Intermediate care facility/nursing facility/hospital
____ Kansas Department for Aging and Disability Services
_____________________________________
name
____ State Agency/Department
Other(s): name/address/phone___________________________
_____________________________________
name
____________________________________________
____ Community developmental disability organization(s)
__________________________________________________
_____________________________________
name
__________________________________________________
____ Aging and Disability Resource Center
__________________________________________________
Other(s): name/address/phone_____________________
_________________________________________________
Description of Information to be Used or Disclosed
(place a check mark or an “x” next to the item(s) to be used or disclosed)
:
___ Recent History and Physical, signed by a physician within the last 6 months ___Listing of in patient or partial psych stays
___ List of SPMI Diagnosis
___List of IDD/RC Diagnosis
___With dates and locations in the last 2 years.
___ Substantiation of increase in supportive services (30 days) in the last 2 years.
___ LEO/APS/Housing Interventions
The purpose of the Use or Disclosure: Completion of a Level II PASRR Evaluation
***Return requested documentation to: ATTN: Susan at
KDADS.CARE@KS.GOV
or FAX to (785)291-3427
The Individual or the Individual’s Representative must read or have the following read to them and initial by each item
below:
_____
I understand that I may inspect or copy the protected health information to be used or disclosed under
(Initials) this authorization. I understand I may refuse to sign the authorization. I understand that the refusal to
sign this authorization may mean that the use and/or disclosure described in this form will not be
allowed.
_____
I understand this Release is valid for one year from today’s date.
(Initials)
_____
I understand that I may revoke this Release at any time by notifying the providing organization in
(Initials) writing. It will not have an effect on actions that were taken prior to the revocation.
_____
I understand that once the uses and disclosures have been made pursuant to this authorization, the
(Initials) information released may be subject to re-disclosure by any recipient and will no longer be
protected by federal privacy laws.
_____
This will not condition treatment or payment on my providing authorization for this use or disclosure
(Initials) except to the extent the provision of health care is solely for the purpose of creating protected health
information for disclosure to a third party.
I certify that I agree to the uses and disclosures listed above and that I have received a copy of this Authorization. (Form
must be completed before signing).
______________________________________________________
_____________________________
Signature
Date
____________________________________________________
________________
_______________________________
Signature of Personal Representative (if applicable)
Date
Description of Authority
Rev. 05/2018
Page of 2