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Questions? | Policy Manual | Training Information

This section provides information about the facility. The date of admission is either the date of the actual admission to this facility (Bethany) or the date her level of care was updated (Abbott). The anticipated discharge date can be used to determine a client’s length of stay. The facility's National Provider Identifier (NPI) number is entered into MMIS.

Emily was admitted to the Abbott Northwestern’s Sister Kenny Unit on the twelfth of last month and was discharged on the fifteenth of last month. She was then admitted to Bethany Covenant Home on the 15th of last month and is not expected to be discharged.

This section provides information about the client including name, date of birth and reason for admission. Emily was admitted to both the Abbott Sister Kenny Unit and Bethany Covenant Home due to Alzheimer’s disease and a broken hip.

This section is completed when a client is in a facility other than an ICF/DD. It indicates when the client’s PAS was completed, or the reason a screening did not take place, or why it was completed after admission. Emily’s PAS was completed on the eleventh of last month by Ramsey County.

This section provides information about the LTCC for a person entering an ICF/DD.

This section indicates when the client’s initial admittance to an LTCF occurred, the level of care required, the length of stay and where the client resided prior to admittance. This information is used to determine other aspects of eligibility that will be discussed in a later course of the LTC/Waiver course sequence.

On Emily’s Abbott Sister Kenny Unit DHS-1503 it indicates she was admitted on the twelfth of last month, during which time she received SNF services and was expected to stay less than 30 days. Notice that on line 31a of this DHS-1503 it indicates that Emily was actually admitted to the hospital on the second of last month but her SNF services didn’t start until the twelfth.

On Emily’s Bethany Covenant Home DHS-1503 it indicates she was admitted to Bethany Covenant Home on the 15th of last month. This DHS-1503 also shows that she had a hospital stay immediately preceding this admission.

To be valid, the form must be signed and dated by the physician or authorized person. An “authorized person” attests to the fact that the facility maintains documentation of the physician's signature in the resident’s record.

Both of Emily’s DHS-1503s were signed by the attending physician listed in the Provider Information section of the forms.