How to Complete NJ Form LTC-26: PASRR Level I Screening Steps

NJ Form LTC-26 is New Jersey’s PASRR Level 1 screening form, and it must be completed for every person applying to a Medicaid-certified nursing facility before admission, regardless of whether Medicaid, Medicare, or private funds will pay for the stay.¹ The form flags whether the applicant may have a serious mental illness, an intellectual disability, or a related developmental condition that requires a deeper Level 2 evaluation before admission can proceed. Hospital discharge planners complete it for patients moving from a hospital to a nursing facility; nursing facility staff complete it for admissions coming from the community.

Who Needs an LTC-26 and When

Every applicant to a Medicaid-certified nursing facility in New Jersey needs a completed LTC-26 before admission, no matter their diagnosis or payer source.² That covers transfers from acute-care hospitals, admissions from private homes, and moves between nursing facilities.

The screen also applies to current residents who experience a significant change in their mental or physical condition. New Jersey’s administrative code defines a “significant change” as a major shift in the resident’s condition that will not improve without staff intervention, affects more than one area of health or functioning, and requires revision of the care plan.² A resident who develops new psychiatric symptoms or cognitive changes months after admission can trigger the same review.

Where to Get the Form

The LTC-26 is posted on the New Jersey Division of Aging Services PASRR page as both a PDF and a fillable Word document. The content is identical either way.¹ If the screen ends up positive, you will also need the LTC-29 (Notice of Referral for Level II PASRR Evaluation) from the same page.³

Demographic and Location Information

Start with the applicant’s full legal name, Social Security number, date of birth, and the county where they are currently located. Select the applicant’s current setting from the list on the form: acute-care hospital, home or apartment, residential health care facility, group home or boarding home, psychiatric hospital or unit, assisted living residence, or another setting you specify.⁴ Include the full address of the applicant’s current location. If the applicant has a legal representative such as a guardian, health care proxy, or agent under a power of attorney, record that person’s name and contact information as well; the state may need to reach them during the review.

Section II: Mental Illness Screening

Section II covers serious mental illness in three questions, and this is where most errors happen.

Question 1 asks whether the individual has a diagnosis or evidence of a major mental illness within specific diagnostic categories: schizophrenia, schizoaffective disorder, mood disorders (bipolar and major depressive type), paranoid or delusional disorder, panic or other severe anxiety disorder, somatoform disorder, personality disorder, atypical psychosis, and other psychotic disorders not otherwise specified. It also covers any other mental disorder that may lead to chronic disability.⁵ Check hospital discharge summaries and older psychiatric records carefully. A diagnosis buried in old records still counts.

Question 3 asks whether, within the last two years, the individual has had a psychiatric treatment episode more intensive than routine follow-up care. The form’s examples include inpatient psychiatric care, referral to a mental health crisis or screening center, partial-care or partial-hospitalization programs, and services from a Program of Assertive Community Treatment or Integrated Case Management Services.⁴ Review clinical progress notes and billing records covering the full 24 months, not just the current episode. The look-back window is where screeners most often come up short.

Section III: Intellectual Disability and Related Conditions

Question 4 covers intellectual disability, which the form defines as a significantly decreased level of intellectual functioning measured by a standardized test, with concurrent impairments in adaptive behavior, that manifested before age 18. Mark whether the individual has a current diagnosis or history of intellectual disability at any level: mild, moderate, severe, or profound.⁴

Question 5 asks about related conditions, meaning severe, chronic developmental disabilities that are not forms of intellectual disability but produce similar functional impairments and manifested before age 22. The form lists autism, seizure disorder, cerebral palsy, spina bifida, fetal alcohol syndrome, muscular dystrophy, deafness, and closed head injury as examples.⁴ Question 5 catches conditions that discharge planners sometimes overlook because the current admission is for something unrelated, such as a hip fracture in someone with a lifelong seizure disorder.

How Dementia Affects the Screen

Dementia does not neutralize a positive mental illness finding. If someone has a dementia diagnosis along with a listed mental illness diagnosis, mark the mental illness indicators positive. Determining whether dementia is the primary diagnosis and the mental illness secondary is a Level 2 function performed by mental health professionals during the deeper evaluation, not a decision for the Level 1 screener.⁶ When in doubt, screen positive.

Written Notice to the Applicant

When the LTC-26 identifies mental illness or an intellectual disability, developmental disability, or related condition for the first time, the screener must provide written notice to the applicant and their legal representative.⁴ This is not optional. The form has a notice section built in. Families are often caught off guard when a nursing home admission triggers a mental health or disability flag, so delivering the notice early and explaining it in plain terms prevents confusion later.

Negative Screen: What to Do

If every question in Section II and Section III is answered “No,” the screen is negative. The nursing facility can proceed with admission, and the completed LTC-26 stays in the resident’s facility record.⁴ Nothing needs to be faxed to a state agency.

Positive Screen: Where to Fax and What to Attach

If any screening question is answered “Yes,” fax copies to the appropriate state agencies. Which offices receive the form depends on what was flagged:⁴

Serious mental illness (Section II positive): Division of Mental Health and Addiction Services (DMHAS) at 609-341-2307.
Intellectual disability or related condition (Section III positive): Division of Developmental Disabilities (DDD) at 609-341-2349.
All positive screens: Also fax to the Office of Community Choice Options (OCCO), Northern Regional Office at 732-777-4681 or Southern Regional Office at 609-704-6055, matched to the applicant’s county.

If the applicant screens positive for both mental illness and an intellectual or developmental condition, fax all three agencies. Alongside the LTC-26, complete the LTC-29 referral. A mental illness referral requires a psychiatric evaluation completed by an independent or treating physician. An intellectual disability or related condition referral requires a DDD Intake Application completed by the consumer or their authorized representative.³ Submitting the LTC-26 without the LTC-29 and its required attachment means the Level 2 process cannot begin.

The 30-Day Hospital Discharge Exemption

One narrow exception lets a facility admit before the Level 2 evaluation is complete. An exempted hospital discharge applies when all three of the following are true: the individual is being admitted to a nursing facility directly from a hospital after acute inpatient care, the individual needs nursing facility services for the same condition treated in the hospital, and the attending physician certifies before admission that the individual will likely need fewer than 30 days of nursing facility care.⁷

If the resident stays beyond 30 days, the nursing facility must complete a Level 1 screening, and if it is positive the state mental health or intellectual disability authority must conduct a Level 2 resident review within 40 calendar days of the original admission date.⁷ The exemption applies only to initial nursing facility admissions. It does not cover resident reviews, readmissions, or transfers between facilities.

What a Positive Screen Sets in Motion

A positive Level 1 screen does not by itself block admission, but it does trigger a Level 2 evaluation that must be completed before clinical eligibility for nursing facility placement can be approved. The LTC-29 is explicit: clinical eligibility and admission cannot be processed until the Level 2 evaluation and determination are finished.³

DMHAS handles the Level 2 evaluation for mental illness; DDD handles it for intellectual disability and related conditions. Federal regulations require states to maintain an annual average of 7 to 9 working days between identifying the need for a Level 2 evaluation and issuing the determination.⁸ Complex cases take longer, particularly when additional psychiatric records or an in-person assessment are needed.

A Level 2 evaluation ends in one of three findings: the applicant needs nursing facility services but not specialized services, and admission can proceed; the applicant needs both nursing facility services and specialized services, which the facility must arrange or coordinate; or nursing facility placement is not appropriate, and an alternative community setting is recommended. For questions during the process, DMHAS can be reached at 1-800-382-6717 and DDD at 1-800-832-9173.³

Common Mistakes That Delay Admissions

A handful of recurring errors stall admissions for days or weeks:

Relying only on the current discharge summary and missing prior hospitalizations or outpatient episodes inside the two-year window. Pull records covering the full 24 months.
Skipping Question 5. A developmental condition can be easy to overlook when the current admission is for an unrelated problem. An applicant with cerebral palsy being admitted after a fall still needs a “Yes.”
Faxing OCCO at the wrong regional office. Match the number to the applicant’s county.
Sending the LTC-26 without the LTC-29 and its required attachment. Both forms are required for a positive screen.
Treating a dementia diagnosis as a reason to mark mental illness questions negative. If a listed mental illness diagnosis is also present, screen positive and let Level 2 sort out which is primary.

Keep the completed LTC-26, the LTC-29 if one was filed, and the resulting Level 2 determination letter in the resident’s permanent medical record. Facilities that cannot produce these documents during a survey run into compliance problems, and families may need them if they later contest a placement or services decision.

1
Division of Aging Services. Preadmission Screening and Resident Review
2
Legal Information Institute. New Jersey Admin Code 10:58A-2.10 – Pre-Admission Screening and Resident Review (PASRR) and Pre-Admission Screening (PAS)
3
New Jersey Department of Human Services. LTC-29, Notice of Referral for Level II Pre-Admission Screening and Resident Review (PASRR) Evaluation
4
New Jersey Department of Human Services. Pre-Admission Screening and Resident Review (PASRR) Level I Screen LTC-26
5
New Jersey Department of Human Services. Pre-Admission Screening and Resident Review (PASRR) Level I Screen (LTC-26)
6
PASRR Technical Assistance Center. PASRR Disabilities
7
eCFR. 42 CFR 483.106 – Basic Rule
8
PASRR Technical Assistance Center. What Are the Timing Requirements for Level I and Level II?