Form 2360, Negative PASRR Evaluation Letter

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Effective Date
06/2019
2360.pdf (40.94 KB)
2360-s.pdf (1.79 MB)

 

Instructions        

Updated: 6/2019

 

Purpose

Form 2360 is for local intellectual and developmental disability authorities (LIDDAs), local mental health authorities (LMHAs) and local behavioral health authorities (LBHAs) to inform an individual seeking admission into a nursing facility (NF) of the results of their preadmission screening and resident review (PASRR) evaluation (PE) when the results are negative. This letter standardizes the language determining a negative PE and communicates who conducted the PE. Additionally, the letter contains instructions on how the individual can appeal the determination, the time frame to do so, who to contact, an attached “Fair Hearing Request” form, and mailing address. 

Procedure

After completing a PE, the PE evaluator will complete the form letter, including their agency information.

If the PE evaluator completed the intellectual and/or developmental disability (IDD) sections of the PE, then the evaluator will only complete the LIDDA section of the form letter and mail it to the individual.

If the PE evaluator completed the mental illness (MI) sections of the PE, then the evaluator will only complete the LMHA\LBHA section of the form letter and mail it to the individual.

Note: When an individual is evaluated for both IDD and MI, they should receive two letters.

After entering the information in the letter, the PE evaluator will add their agency logo or letterhead to indicate the letter is being sent by the LIDDA/LMHA/LHA.

When to Prepare

Complete this form letter when the results of the PE do not confirm an IDD or MI diagnosis and the individual is PASRR negative.

Form Retention

A copy of the form letter is permanently retained in the individual’s record. Do not send copies to state office.

Detailed Instructions

This form has a custom logo upload functionality. To embed the custom logo into the form, follow these steps:

  1. Fill out all the form fields.
  2. Click on the upper left-hand image box and upload the logo. Only JPG and PNG files are supported.
  3. In the menu bar go to File > Print.
  4. In the Printer section select "Adobe PDF" or "Print to PDF" option.
  5. Click "Print" and this will prompt you to save the filled-out PDF to your computer.
  6. At this point, the PDF will be flattened and you will no longer have the option to edit the form.

Click to insert your logo – Insert the LIDDA/LMHA/LBHA logo or letterhead to indicate the letter is being sent by the agency.

Date – Enter the date the letter is generated. 

Dear – Enter the name of the individual the letter is being mailed to.

You had a PE on – Enter the date the PE was conducted.

PE conducted by – Check the appropriate box based on the local authority that conducted the evaluation.  

A local mental health authority (LMHA) or local behavioral health authority (LBHA) Name – Enter the LMHA/LBHA’s name.

Evaluator Name – Enter the name of the person who completed the PE.

Evaluator Position/Title-MI Assessment – Enter the title of the person who completed the PE.

Area Code and Phone No. – Enter the evaluator’s area code and phone number.            

A local intellectual and developmental disability authority (LIDDA) Name – Enter the LIDDA’s name.

Evaluator Name – Enter the name of the person who completed the PE.

Evaluator Position/Title-IDD Assessment – Enter the title of the person who completed the PE.

Area Code and Phone No. – Enter the evaluator’s area code and phone number.

Based on the PE completed, it was determined that you are not eligible for PASRR specialized services because you do not have – Select the appropriate box based on the type of PE that was conducted.

Page 2

You may lose you right to appeal this decision if your request is not received by – Enter the date, which is 90 days from the date of the letter on Page 1. This provides the individual a deadline for requesting a fair hearing.

Signature – The evaluator must sign his/her name once the form is printed.

Evaluator Name – Enter the name of the person who completed the PE.

Evaluator’s Position/Title – Enter the title/position of the person who completed the PE.