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Downloading a Form to Your Computer
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Note: Open the PDF file from your desktop or Adobe Acrobat Reader DC. Do not click on the downloaded file at the bottom of the browser since it will not open the PDF in Adobe Acrobat Reader DC. It will try to open the file in the browser that results in the same browser error message.
To document if an individual meets the initial screening criteria for a nursing facility diversion slot.
When to Prepare
Use this form during initial intakes if the Automated Intake (NTK) system is not available and the individual answers "Yes" to the nursing facility diversion question on Form 2110, Community Care Intake. "If the individual cannot get the help he needs at home is there a chance he would have to move to a facility? If the answer is "Yes," the screener must complete Form 2110-A in the NTK system or complete a paper form.
The original must be attached to Form 2110 and is filed in the case folder with Form 2110.
The original is kept in the case record for three years after the case is closed.
Individual's Name — Enter the individual's name: last name, first name, middle initial.
Intake No. — Enter the intake number from Form 2110. The intake number is generated when the intake is entered into the NTK system. The intake number is not applicable if the intake is completed on a paper Form 2110.
Nursing Facility Diversion Slot Questions
1. Has the individual had or will the individual have one of the following major life events? — Check the appropriate box. If Yes, check the box indicating the current crisis situation/major life event.
2. If help could be provided in the home, such as skilled nursing or medication administration, would the individual be able to stay in the home? — Check the appropriate box and provide a detailed description of the needs if the individual can stay in the home.
3. Criteria Decision
This section records the decision on whether an individual meets the criteria for a diversion slot. Answer Yes or No. If the answers to questions 1 and 2 are "Yes," then the individual meet the criteria for a diversion slot. If the answers to questions 1 or 2 are "No," then the individual does not meet the criteria for a diversion slot.
Additional Screening Information
Answer questions 4 and 5.
If the individual indicates there are no arrangements for care or that care will be ending before services can be started, explore other options and make appropriate referrals. If the individual is in a state of abuse, neglect or self-neglect in that his daily needs cannot be met, refer to Adult Protective Services.
If the individual meets the criteria for a diversion slot, the intake screener calls the Community Services Interest List (CSIL) unit staff at 1-877-438-5658 and requests the individual be placed in the Nursing Facility (NF) Diversion Slot queue.
Updates and Case Manager Comments
The case manager uses this section to update information regarding the status of the individual or during the initial contact to document more details on the individual's circumstances that qualify him for the Nursing Facility Diversion Slot.
The case manager enters information in the appropriate comments section.
Signature of Case Manager — The case manager completing the form signs the form.
Date — The case manager enters the date the form is completed and signed.