Michigan PDF Forms

Michigan PDF Forms
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Documents used along the form

The Michigan DCH-3877 form is an essential document used in the process of preadmission screening for individuals seeking admission to nursing facilities. Alongside this form, several other documents may be required to ensure a comprehensive evaluation of the individual's needs. Below is a list of forms that are often used in conjunction with the DCH-3877, along with a brief description of each.

  • DCH-3878: This form is the Mental Illness/Developmental Disability Exception Criteria Certification. It is completed by a qualified professional to certify whether a patient meets specific exemption criteria for a Level II screening based on their mental health status.
  • Michigan Promissory Note: This legal document serves as a formal agreement where the borrower commits to repay a specified amount of money to the lender under outlined terms. For more details, visit promissoryform.com/blank-michigan-promissory-note.
  • Patient Admission Consent Form: This document secures consent from the patient or their legal representative for admission to a nursing facility. It outlines the rights and responsibilities of the patient and the facility.
  • Medical History Form: This form collects detailed information about the patient’s medical background, including past illnesses, surgeries, and ongoing treatments, which is crucial for their care plan.
  • Psychiatric Evaluation Report: A comprehensive assessment conducted by a mental health professional that provides insights into the patient’s mental health history and current status, informing the care team about necessary interventions.
  • Social History Form: This document gathers information about the patient’s social background, including family dynamics, living situation, and support systems, which can affect their care and rehabilitation.
  • Medication Administration Record (MAR): This form tracks all medications administered to the patient during their stay, ensuring compliance with prescribed treatments and monitoring for potential side effects.
  • Care Plan: Developed by the nursing facility, this document outlines the individualized care and treatment goals for the patient, based on assessments and evaluations from various healthcare professionals.
  • Discharge Planning Form: This form is created to facilitate a smooth transition for the patient from the nursing facility to their next level of care, detailing follow-up appointments and ongoing support services.

Understanding these forms can significantly enhance the admission process and ensure that all necessary information is collected to provide optimal care for individuals entering nursing facilities. Each document plays a vital role in assessing the needs and circumstances of the patient, ultimately contributing to their well-being and recovery.

Michigan Dch 3877 Preview

PREADMISSION SCREENING (PAS)/ANNUAL

RESIDENT REVIEW (ARR)

(Mental Illness/Intellectual Developmental

Disability/Related Conditions Identification)

Michigan Department of Health and Human Services

Level I Screening

PAS

ARR

Change in Condition

Hospital Exempted Discharge

SECTION I – Patient, Legal Representative and Agency Information

Patient Name (First, MI, Last)

Date of Birth (MM/DD/YY)

Gender

 

 

 

 

 

 

 

 

Male

Female

 

 

 

 

 

 

Address (number, street, apt. or lot #)

County of Residence

Social Security

 

 

 

 

 

 

Number

 

 

 

 

 

 

 

 

 

City

 

 

State

Zip Code

Medicaid Beneficiary

Medicare ID Number

 

 

 

 

 

ID Number

 

 

 

 

 

 

 

 

 

 

 

Does this patient have a court-appointed guardian

If Yes, give Name of Legal Representative

 

or other legal representative?

 

 

 

 

 

No

Yes

 

 

 

 

 

 

 

 

County in which the legal representative was

Address (number, street, apt. number or suite

appointed

 

 

 

 

number)

 

 

 

 

 

 

 

 

 

Legal Representative Telephone Number

City

State

 

Zip Code

 

 

 

 

Referring Agency Name

Telephone Number

Admission Date

 

 

 

 

 

 

(actual or proposed)

 

 

 

 

 

 

Nursing Facility Name (proposed or actual)

County Name

 

 

 

 

 

 

 

 

Nursing Facility Address (number and street)

City

State

 

Zip Code

 

 

 

 

 

 

 

 

 

 

Sections II and III of this form must be completed by a registered nurse, licensed bachelor or master social worker, licensed professional counselor, psychologist, physician’s assistant, nurse practitioner or a physician.

DCH-3877 (Rev. 3-21a) Previous edition obsolete.

1

Patient Name

Date of Birth (MM/DD/YY)

SECTION II – Screening Criteria (All 6 items must be completed.)

1.

The person has a current diagnosis of Mental Illness or Dementia (Circle one or

No

Yes

 

both)

 

 

2.

The person has received treatment for Mental Illness or Dementia (within the past

No

Yes

 

24 months) (Circle one or both)

 

 

3.

The person has routinely received one or more prescribed antipsychotic or

No

Yes

 

antidepressant medications within the last 14 days.

 

 

4.

There is presenting evidence of mental illness or dementia, including significant

No

Yes

 

disturbances in thought, conduct, emotions, or judgment. Presenting evidence may

 

 

 

include, but is not limited to, suicidal ideations, hallucinations, delusions, serious

 

 

 

difficulty completing tasks, or serious difficulty interacting with others.

 

 

5.

The person has a diagnosis of an intellectual/developmental disability or a related

No

Yes

 

condition including, but not limited to, epilepsy, autism, or cerebral palsy and this

 

 

 

diagnosis manifested before the age of 22.

 

 

6.

There is presenting evidence of deficits in intellectual functioning or adaptive

No

Yes

 

behavior which suggests that the person may have an intellectual/developmental

 

 

disability or a related condition. These deficits appear to have manifested before the age of 22.

Note: If you check “Yes” to items 1 and/or 2, circle the word “Mental Illness” and/or “Dementia.”

Explain any “Yes”

Note: The person screened shall be determined to require a comprehensive Level II OBRA evaluation if any of the above items are "Yes" UNLESS a physician, nurse practitioner or physician’s assistant certifies on form DCH-3878 that the person meets at least one of the exemption criteria.

SECTION III – CLINICIAN’S STATEMENT: I certify to the best of my knowledge that the above information is accurate.

Clinician Signature

Date

Name (type or print)

 

 

 

Address (number, street, apt. number or suite

Degree/License

number)

 

 

City

State

Zip Code

Telephone Number

The Michigan Department of Health and Human Services will not exclude from participation in, deny benefits of, or discriminate against any individual or group because of race, sex, religion, age, national origin, color, height, weight, marital status, gender identification or expression, sexual orientation, partisan considerations, or a disability or genetic information that is unrelated to the person’s eligibility.

AUTHORITY: Title XIX of the Social Security Act

COMPLETION: Is voluntary, however, if NOT completed, Medicaid will not reimburse the nursing facility.

DISTRIBUTION: If any answer to items 1 – 6 in SECTION II is "Yes", send ONE copy to the local Community Mental Health Services Program (CMHSP), with a copy of form DCH-3878 if an exemption is requested. The nursing facility must retain the original in the patient record and provide a copy to the patient or legal representative.

DCH-3877 (Rev. 3-21a) Previous edition obsolete.

2

PREADMISSION SCREENING (PAS)/ANNUAL RESIDENT REVIEW (ARR)

Mental Illness/Intellectual Developmental Disability/Related Conditions Identification

Instructions for Completing Level I Screening

This form is used to identify prospective and current nursing facility residents who meet the criteria for possible mental illness or intellectual/developmental disability, or a related condition and who may be in need of mental health services.

Sections II and III must be completed by a registered nurse, licensed bachelor or master social worker, licensed professional counselor, psychologist, physician’s assistant, nurse practitioner or physician.

Preadmission Screening or Hospital Exempted Discharge: The referral source completing the Level I Screening (DCH-3877), must complete and provide a copy to the proposed nursing facility prior to admission. Check the appropriate box in the upper right-hand corner.

Annual Resident Review or Change in Condition: This form must be completed by the nursing facility.

Check the appropriate box in the upper right-hand corner.

Section II – Screening Criteria – All 6 items in this section must be completed. The following provides additional explanation of the items.

1.Mental Illness: A current primary diagnosis of a mental disorder as defined in the American Psychiatric Association Diagnostic and Statistical Manual of Mental Disorders.

Current Diagnosis means that a clinician has established a diagnosis of a mental disorder within the past 24 months. Do NOT mark “Yes” for an individual cited as having a diagnosis "by history" only.

2.Receipt of treatment for mental illness or dementia within the past 24 months means any of the following: inpatient psychiatric hospitalization; outpatient services such as psychotherapy, day program, or mental health case management; or referral for psychiatric consultation, evaluation, or prescription of psychopharmacological medications.

3.Antidepressant and antipsychotic medications mean any currently prescribed medication classified as an antidepressant or antipsychotic, plus Lithium Carbonate and Lithium Citrate.

4.Presenting evidence means the individual currently manifests symptoms of mental illness or dementia, which suggests the need for further evaluation to establish causal factors, diagnosis and treatment recommendations. Further evaluation may need to be completed if evidence of suicidal ideation, hallucinations, delusion, serious difficulty completing tasks or serious difficulty interacting with others.

5.Intellectual/Developmental Disability/Related Condition: An individual is considered to have a severe, chronic disability that meets ALL 4 of the following conditions:

a.It is manifested before the person reaches age 22.

b.It is likely to continue indefinitely.

c.It results in substantial functional limitations in 3 or more of the following areas of major life activity: self-care, understanding and use of language, learning, mobility, self-direction, and capacity for independent living.

DCH-3877 (Rev. 3-21) Previous edition obsolete.

3

d.It is attributable to:

•Intellectual/Developmental Disability such that the person has significant subaverage general intellectual functioning existing concurrently with deficits in adaptive behavior and manifested during the developmental period;

•cerebral palsy, epilepsy, autism; or

•any condition other than mental illness found to be closely related to Intellectual/ Developmental Disability because this condition results in impairment in general intellectual functioning OR adaptive behavior similar to that of persons with Intellectual/Developmental Disability and requires treatment or services similar to those required for these persons.

6.Presenting evidence means the individual manifests deficits in intellectual functioning or adaptive behavior, which suggests the need for further evaluation to determine the presence of a developmental disability, causal factors, and treatment recommendations. These deficits appear to have manifested before the age of 22.

Note: When there are one or more "Yes" answers to items 1 – 6 under SECTION II, complete form DCH-3878, Mental Illness/Intellectual/Developmental Disability/Related Condition Exemption Criteria Certification only if the referring agency is seeking to establish exemption criteria for a dementia, state of coma, or hospital exempted discharge.

DCH-3877 (Rev. 3-21a) Previous edition obsolete.

4

Similar forms

  • Form DCH-3878: This form complements the DCH-3877 by certifying exemption criteria for individuals diagnosed with dementia or in a coma. Like the DCH-3877, it is essential for determining eligibility for Medicaid services, ensuring that both forms are part of the same screening process.

  • Form MSA-3877: The predecessor to the DCH-3877, this form served a similar purpose in identifying mental illness and developmental disabilities for nursing facility admissions. The DCH-3877 replaced it to reflect updates in diagnostic criteria and procedural changes.

  • Form DCH-XYZ: Last Will and Testament Overview – For individuals planning their estates, the comprehensive Last Will and Testament resources provide essential guidance on ensuring your wishes are respected after passing.

  • Form MSA-3878: This previous version of the DCH-3878 also focused on exemption criteria for individuals with mental health issues. The updated DCH-3878 incorporates new terminology and standards, aligning with current practices in mental health assessments.

  • Level II OBRA Screening: This screening is a comprehensive evaluation required when a Level I screening, such as the DCH-3877, indicates potential mental illness or developmental disabilities. Both processes aim to ensure that individuals receive appropriate care based on their needs.

  • Patient Admission Forms: Similar to the DCH-3877, various patient admission forms are used across healthcare settings to gather essential information about an individual’s medical history and current health status. These forms help in making informed decisions regarding patient care and treatment plans.

  • Community Mental Health Services Program Documentation: Documentation from these programs often parallels the information collected in the DCH-3877, focusing on mental health assessments and service eligibility. Both are crucial for ensuring that individuals receive the necessary mental health services in a timely manner.

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Misconceptions

  • Misconception 1: The DCH-3877 form is only for new patients.

    • This form is used for both new admissions and annual reviews of current residents. It plays a crucial role in identifying mental health needs for all individuals in nursing facilities.

  • Misconception 2: Completing the DCH-3877 is optional.

    • While the form completion is voluntary, it is necessary if a nursing facility seeks reimbursement through Medicaid. Without it, facilities may not receive payment for services rendered.

  • Misconception 3: Only doctors can fill out the DCH-3877 form.

    • In fact, the form can be completed by various qualified professionals. Registered nurses, certified social workers, psychologists, physician assistants, and physicians are all authorized to fill it out.

  • Misconception 4: The DCH-3877 is outdated and no longer used.

    • Despite being revised in 2003, the DCH-3877 remains a critical tool in the assessment process for nursing facility residents. It is regularly updated to reflect current standards and practices.

  • Misconception 5: The DCH-3877 only assesses mental illness.

    • The form also evaluates developmental disabilities. It helps identify individuals who may require mental health services, ensuring they receive appropriate care and support.

Detailed Instructions for Using Michigan Dch 3877

Filling out the Michigan DCH-3877 form is an essential step in the process of identifying individuals who may require mental health services. Completing this form accurately ensures that the necessary evaluations and screenings can take place. Follow these steps to fill out the form correctly.

  1. Obtain the DCH-3877 form from the Michigan Department of Community Health website or by ordering it directly from their office.
  2. Begin with SECTION I by entering the patient's full name, date of birth, gender, and address. Include the county of residence and the patient's Social Security number.
  3. Fill in the Medicaid and Medicare ID numbers if applicable. Indicate whether the patient has a court-appointed guardian or legal representative. If yes, provide their name and contact details.
  4. Complete the referring agency's information, including the name and telephone number, along with the actual or proposed admission date and the nursing facility's name and address.
  5. Move to SECTION II and answer all six screening criteria questions. Mark "YES" or "NO" for each item, ensuring to circle "mental illness" or "dementia" as appropriate for questions one and two.
  6. If any of the answers to questions 1 through 6 are "YES," explain the reasons in the space provided.
  7. Proceed to SECTION III and have the clinician sign and date the form. The clinician must print their name and indicate their degree or license, along with their contact information.
  8. Make copies of the completed form. Send one copy to the local Community Mental Health Services Program if any answers in SECTION II are "YES." Retain the original in the patient’s record and provide a copy to the patient or their authorized representative.

Dos and Don'ts

When filling out the Michigan DCH-3877 form, it is essential to follow certain guidelines to ensure accuracy and compliance. Here’s a list of things you should and shouldn’t do:

  • Do ensure all information is complete and accurate before submission.
  • Do use clear and legible handwriting if filling out the form by hand.
  • Do check the appropriate boxes for Preadmission Screening (PAS) or Annual Resident Review (ARR).
  • Do have a qualified professional complete Sections II & III of the form.
  • Don’t leave any required fields blank; every section must be addressed.
  • Don’t provide outdated information; ensure that all medical history is current.
  • Don’t forget to sign and date the form where indicated.
  • Don’t submit the form without making a copy for your records.