Chapter 100 - (OBRA-1)

110.00 Scope and Purpose of the OBRA-1 Initial Screen

The OBRA 1 Initial Screen must be used for all persons who are 18 years old or older who are seeking admission to a nursing facility (NF). In addition, for all persons seeking developmental disability services that are funded through Medicaid, the OBRA 1 Initial Screen form is completed as the initial step in the full PAS screening process described in this manual. Entities authorized to complete the OBRA 1 Initial Screen are representatives of the:

1. Department of Healthcare and Family Services
2. Department on Aging 
3. Department of Public Health
4. Department of Human Services (Division of Developmental Disabilities, Division of Rehabilitation Services, Division of Mental Health)
5. Hospitals
6. Nursing Facilities

The purpose of the OBRA 1 Initial Screen is to determine whether there is a reasonable basis to suspect a developmental disability or mental illness and if so, to make the appropriate referrals for a full assessment of the need for services. The OBRA 1 is used as a referral document between agencies for the pre-screening process.

120.00 Individuals Who Are Exempt from OBRA 1 Screening Process

A screening assessment is not required for an individual who:

1. Is receiving or will be receiving shelter care services.
2. Transfers within the same level of care (e.g., CILA to CILA, private ICF/DD to private ICF/DD, private ICF/DD to SODC, private ICF/DD or SODC to waiver, waiver to waiver, etc.), with or without an intervening hospital stay. (It is the transferring entity's responsibility to ensure that copies of the person's most recent screening assessment accompany the transferring person).
3. Resided in a setting for a period of at least 60 days and is returning to the same setting after an absence of not more than 60 days.
4. Is receiving or will be receiving hospice services.
5. Is readmitted to a setting after a therapeutic home visit.
6. Is readmitted to a setting from a hospital to which he or she was transferred for the purpose of receiving care.

130.00 OBRA 1 Initial Screen Procedures

The OBRA-1 may be completed through interviews and reviews of documentation.

If a completed OBRA-1 is not available, the ISC agency may complete the OBRA 1 over the telephone if the ISC agency is able to obtain sufficient information to make reasonable judgments. Appropriate sources of this information might include the individual, guardian, family members, health care professionals, former service providers, etc. The ISC agency will obtain a copy of and review all relevant information that the individual brings to the screening interview and will obtain other documentation, as necessary, with appropriate Authorizations For Release of Information.

If the individual was referred to the ISC agency by any of the other authorized screening entities, the ISC agency will review the completed OBRA-1.

140.00 Instructions for Completing the OBRA-1 Initial Screen - Front Page

1. Part I. Identifying Information

    Self-explanatory. All information must be provided.

2. Part II. Reasonable Basis to Suspect a Developmental Disability

   Complete every item. Every item (1) through (5) must be answered either "yes" or "no." For Item (5), if there are other indicators of a developmental disability not previously mentioned, they must be specified in the space provided.

   1. Attend to Age of Onset: For there to be a reasonable basis to suspect a developmental disability, the condition must have manifested itself prior to the age of 18 for intellectual disability and 22 for a related condition. In other words, the condition must have been present during the developmental years.

      Example: an individual who experienced a traumatic brain injury as a child, resulting in a condition similar to intellectual disability and therefore possibly meeting criteria for a related condition, could be considered a person with a developmental disability and would be assessed by a ISC agency through the Level II screening process. If that same person experienced the same injury at the age of 22, resulting in the same condition, the individual would not be considered a person with a developmental disability.

   2. Attend to Related Conditions:
      • Cerebral palsy and epilepsy are related conditions that indicate a developmental disability. All individuals with cerebral palsy and epilepsy will be referred to the appropriate ISC agency for a Level II screening.
      • Autism and other disorders within the autism spectrum are conditions that may result in a determination of developmental disability and must always be a reason for referral to ISC entities for screening.
      • Traumatic brain injury may be a related condition. Individuals who received such an injury prior to the age of 22 should generally be referred to ISC entities.
      • Muscular dystrophy is a condition that results primarily in impaired motor activity due to muscular degeneration. It does not result in impairment of cognitive or adaptive abilities and is therefore not considered a related condition.

3. Part III. Reasonable Basis to Suspect a Mental Illness

   Every item (1) through (4) must receive a "yes" or "no" response. For Item (4), if there are other indicators of mental illness not previously mentioned, they must be specified in the space provided.

4. Signature Block

   The form must be signed and dated at the bottom, with the name and phone number provided of the organization whose employee has completed the OBRA-1.

150.00 Referral of the Completed OBRA-1

1. General Guidelines

   The OBRA-1 is completed when the front page is finished (i.e., Parts I, II, and III are filled out and information in the signature block at the bottom of the front page has been provided). The completed OBRA-1 is then referred (with any supporting documents) for completion of the pre-screening to the appropriate agency, as indicated in the following table.

   Results of Completed OBRA-1	Referred to:	Action by DD ISC Agency
   Part II indicates a reasonable basis to suspect a developmental disability (as indicated by one or more "yes" responses). Part III does not indicate a reasonable basis to suspect a mental illness. (There are no "yes" responses in Part III.)	DD ISC Agency	If no Level II is needed, use OBRA 1 Part V to document reason and to refer to MH PAS, DRS, or Aging. If referring to MH PAS, adjust Part III. If Level II is needed, perform Level II. If DD= no, document on DDPAS forms and use OBRA-1 Part V to refer to MH PAS, DRS, or Aging. If MH PAS, adjust Part III. If DD= yes, but Active Treatment= no, refer for non-waiver DD services and, if appropriate, use OBRA-1 Part V to refer to MH PAS, DRS, or Aging. If MH PAS, adjust Part III. (May refer to nursing facility if 24-hour nursing is needed.) If DD=yes and Active Treatment=yes, refer for DD waiver/ICFDD services. (May refer to nursing facility if 24-hour nursing is needed and if Categorical Need applies-see Section 400.40, or if retiring from Active Treatment, see Chapter 900.)
   Part II does not indicate a reasonable basis to suspect a developmental disability. (There are no "yes" responses in Part II.) Part III indicates a reasonable basis to suspect a mental illness (as indicated by one or more "yes" responses).	MH PAS Agency	DDD ISC agencies will use the OBRA 1 Part IV to make referrals to MH PAS agencies.
   Part II indicates a reasonable basis to suspect a developmental disability (as indicated by one or more "yes" responses) AND Part III indicates a reasonable basis to suspect a mental illness (as indicated by one or more "yes" responses).	DD ISC Agency (The initial responsibility for further screening is assigned to the DD ISC Agency.)	If no Level II is needed, use OBRA-1 Part V to document reason and to refer to MH PAS. If Level II is needed, perform Level II. If DD= no, document on DDPAS forms and use OBRA 1 Part V to refer to MH PAS. If DD= yes, but Active Treatment= no, refer for appropriate non-waiver DD services and use OBRA 1 Part V to refer to MH PAS. If DD=yes and Active Treatment=yes, refer for DD waiver/ICFDD services. (May refer to nursing facility if requiring 24-hour nursing and if Categorical Need applies-see Section 400.40, or if retiring from Active  Treatment, see Chapter 900.) Ensure that MH needs are reflected on DDPAS forms and in referrals and service planning.
   Neither Part II nor Part III has a single response marked "yes" and the individual's age is 18 years old through 59 years old.	The Division of Rehabilitation Services (DRS)	Sign the front page of the OBRA-1 and send to the appropriate DRS office.
   Neither Part II nor Part III has a single response marked "yes" and the individual's age is 60 years old or older.	The Department on Aging	Sign the front page of the OBRA-1 and send to the appropriate Aging office.

2. Additional Guidance Regarding Individuals with Dementia

   Individuals with dementia (e.g., due to Alzheimer's, Parkinson's Disease, HIV disease, Huntington's Disease, head trauma, etc.) with no known history of mental illness or developmental disability must be referred for screening to the Department on Aging (for persons who are 60 or older) or the Division of Rehabilitation Services (for persons who are 18 through 59 years old).

160.00 Instructions for Making Referrals By Completing the OBRA-1 Initial Screen-Back Page

1. Part IV (Used by DD ISC agencies for referral to MH PAS agency, when there is no "yes" in Part II.)

   Part IV is used by all screening entities to refer to the appropriate DD ISC agency or the MH PAS agency, when there is at least one "yes" indicated on the front page of the OBRA-1.  The instructions at the bottom of the front page indicate when to send the referral to the DD ISC agency and when to send the referral to the MH PAS agency.

   For DD ISC agencies, Part IV will be used when there is not a "yes" response in Part II and there is a "yes" in Part III.  In that case, the DD ISC agency will complete Part IV to make the referral to MH PAS agency and will send supporting documentation with the referral when it is sent to the MH PAS agency.

2. Part V (Used by the DD ISC agency to refer to MH PAS, DRS, or Aging, when there is a "yes" in Part II but the ISC agency determines no need for Level II DD screening.)

   Part V is used by DD ISC or by MH PAS when there is a "yes" response in Part II and/or Part III and the DD ISC agency or MH PAS agency has reviewed the individual's condition and history and has determined that the individual does not require a Level II screening by that agency. Part V is used to document the DD PAS or MH PAS finding and to refer the individual to the next appropriate screening entity.

   For DD ISC agencies, Part V will be used when there is a "yes" response in Part II, but the ISC agency has determined, after further review of the individual's condition and/or history, that there is not a reason for conducting a Level II assessment. The ISC agency will complete Part V by explaining why a Level II assessment is not needed and completing the remaining information, then sending the OBRA-1 to the next appropriate screener (i.e., MH, DRS, or Aging).

   For ISC agencies screening an individual with a history of intellectual disability, cerebral palsy, epilepsy, or autism, a Level II PAS should be considered a requirement. Two possible outcomes of a Level II screening are that the person may be determined not to be a person with a developmental disability or not to need active treatment. Such outcomes are better documented through the Level II process than through the OBRA-1 process alone.

   • If the individual is determined not to have a developmental disability, the ISC agency shall refer the individual to the MH PAS agency, DRS or Aging using Part V of the OBRA-1. With appropriate releases of information, the relevant DDPAS forms and other documentation may also be forwarded.
   • If the individual is determined to have a developmental disability but does not require active treatment for the developmental disability, the DD ISC agency may refer the individual for non-waiver DD services and may also refer the individual to the MH PAS agency, DRS or Aging using Part V of the OBRA-1. With appropriate releases of information, the relevant DD PAS forms and other documentation may also be forwarded.

170.00 Required Follow Up By DDD ISC Agencies to Referrals Via the OBRA-1 From Non-DDD Screening Entities

DD ISC agencies who receive referrals through the OBRA-1 process must always respond to the original referral source regarding the DD ISC agency's action regarding the referral. ISC agencies must respond in one of the following ways:

1. Inform the referring agency that the referral has been received and that the DD ISC agency does not expect to return the referral to the original referring agency for any further action.
2. Return the original referral to the referring agency, using the OBRA-1 Part V to document the reasons for returning the referral.