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Elizabeth M. Whitehorn, Director

Provider Notice issued 07/31/08

HFS 3864, Screening Verification Form

To:​

Nursing Facility Providers​

​Date: ​July 31, 2008
​Re: HFS 3864, Screening Verification Form​

On July 1, l996, the Department implemented federal law requiring universal preadmission screening for certain individuals seeking admission to a nursing facility participating in the Medical Assistance Program.  Universal preadmission screening was implemented to provide prospective residents choice of available options and to determine their need for nursing facility services. 

While preadmission screening for individuals who transfer from one nursing facility to another is not required, a transferring facility is responsible for ensuring that copies of the resident's most recent screening assessment accompany the transferring resident.  The Department recognizes that having screening documentation accompany the resident to the admitting facility is not always possible for various reasons.

In an effort to assist nursing facilities in obtaining screening information when a prospective resident is being admitted from another nursing facility, the Department of Healthcare and Family Services (HFS), in conjunction with the Department on Aging (DoA) and the long-term care provider associations, has developed the attached form that may be used in the event a copy of the screening is not provided to the admitting facility.

Form HFS 3864, Screening Verification Form, is completed by the admitting facility and submitted to the DoA Case Coordination Unit (CCU) in the area where the admitting facility is located.  The CCU will verify through a DoA database that a screening was completed on the resident.  Prior to completing Form HFS 3864, the admitting facility must make every effort to obtain a copy of the screening assessment from the discharging facility.

Form HFS 3864 should be maintained in a facility record that is available in the event the Department of Public Health surveyors ask for verification of a screening.

Please contact the Bureau of Long Term Care at 217-524-7245 if you have any questions.

Theresa A. Eagleson, Administrator

Division of Medical Programs