The NYS DOH-695 SCREEN form is New York State’s required pre-admission assessment for anyone being considered for a nursing home, and a certified screener — not the patient or family — fills it out. Its job is to answer two questions at once: does this person clinically need a residential health care facility (RHCF), and does the person show signs of a serious mental illness or intellectual disability that federal law says must be evaluated before admission. The form is mandated by 10 NYCRR Section 400.12 for every prospective RHCF admission.1Cornell Law Institute. New York Comp. Codes R. and Regs. Tit. 10 400.12 – Level of Care Criteria Families don’t complete the clinical portions, but understanding the process and arriving with the right paperwork prevents the delays that most often stall an admission.2New York State Department of Health. DOH-695 Instruction Manual
What the SCREEN Actually Decides
The DOH-695 does two things in one document. First, it looks at whether the person could be safely cared for at home or in a community setting instead of a nursing home. Second, it serves as New York’s federally required Level I preadmission review under 42 CFR Part 483, Subpart C — the initial check for serious mental illness, intellectual disability, or a related developmental disability.2New York State Department of Health. DOH-695 Instruction Manual The outcome controls whether the admission moves forward on its own or whether additional specialized evaluations get triggered first.
The PRI Has to Be Done First
Before the SCREEN can even start, a Patient Review Instrument (PRI) or Hospital and Community PRI must already be complete. The instruction manual states it plainly: “A Patient Review Instrument (PRI) or Hospital and Community PRI (H/C PRI) must be completed before beginning the SCREEN form.”2New York State Department of Health. DOH-695 Instruction Manual
The PRI (DOH-694) is the clinical companion form. It documents medical conditions and treatments — ventilator dependence, dialysis, wound care levels, rehabilitation needs, activities of daily living — to establish whether the person meets the medical threshold for nursing home care.3New York State Department of Health. Patient Review Instrument (PRI) It must be current: finished within the last 90 days and reflecting the person’s condition today.2New York State Department of Health. DOH-695 Instruction Manual If it’s older than that, or was done before a meaningful change in health, a new PRI has to be completed before the SCREEN can proceed.
The activities-of-daily-living data the SCREEN relies on (eating, transferring, toileting) comes from the PRI, not from any separate assessment on the SCREEN itself.4New York State Department of Health. DOH-695 SCREEN Form For families, this means the clinical work happens in two stages, and the PRI is the piece to confirm is done and current before anything else.
Who Is Allowed to Complete the Form
Only healthcare professionals who have finished the New York State Department of Health’s approved SCREEN Certification Course and been issued a 10-digit screener identification number can fill out the DOH-695.5New York State Department of Health. Revised Page 4 for Instruction Manual for SCREEN Form DOH-695 Under 10 NYCRR Section 400.11, the screener must be “a professional with demonstrated skills in assessing psychosocial situations, including but not limited to social work and discharge planning professionals.”6New York State Department of Health. SCREEN/PASRR Frequently Asked Questions In practice, that usually means registered nurses, licensed social workers, or hospital discharge planners.
Families don’t sign the clinical portions. If a loved one is going from a hospital to a nursing home, the hospital’s discharge planning team almost always initiates the SCREEN. For admissions coming from home, assisted living, or an adult care facility, the process is typically coordinated by the receiving nursing home or a local Certified Home Health Agency. If it isn’t clear who will handle it, ask the admissions coordinator at the nursing home under consideration; they arrange screenings routinely and can direct you to a certified screener.
What the Form Asks
The DOH-695 has 38 items across four components. Most items are answered yes or no, and the answers branch: the screener follows only the path relevant to that person, so the form functions as a decision tree rather than a full checklist.2New York State Department of Health. DOH-695 Instruction Manual
Component 1 (items 1–6) is identification: facility operating certificate number, patient name, Social Security number, name of the person completing the SCREEN, PRI completion date, and the dates the SCREEN was started and finished.4New York State Department of Health. DOH-695 SCREEN Form
Component 2 (items 7–21) is the heart of the assessment. It decides whether nursing home care is appropriate or whether the person could be served in the community. The screener works through the direct referral factor for RHCF care, the direct referral factors that would trigger a community-based assessment, the home and caregiving situation, whether restorative or rehabilitation services could return the person to community living, and any risk of harm to self or others. Item 21 records the referral recommendation based on everything above.4New York State Department of Health. DOH-695 SCREEN Form
Component 3 (items 22–35) is the Level I PASRR review, covering dementia diagnosis, psychiatric history, and categorical determinations. If anything here suggests a serious mental illness or intellectual disability, the screener makes a Level II referral to the appropriate state authority for specialized evaluation.2New York State Department of Health. DOH-695 Instruction Manual
Component 4 (items 36–38) records the disposition, collects the patient’s or representative’s acknowledgment, and captures the screener’s title, printed name, 10-digit identification number, and signature.6New York State Department of Health. SCREEN/PASRR Frequently Asked Questions
When a Community-Based Assessment Gets Triggered
The SCREEN doesn’t automatically approve a nursing home admission. If any of the direct referral factors for community-based assessment (items 8–12) are marked yes, the screener must refer the person to a qualified agency for a full community-based assessment before RHCF placement can proceed. Agencies authorized to conduct these assessments include Certified Home Health Agencies, Lombardi Long Term Home Health Care Programs, Community Alternative Systems Agencies, Health Homes, and Managed Long Term Care programs.6New York State Department of Health. SCREEN/PASRR Frequently Asked Questions
The community assessment evaluates whether home care, adult day programs, or other non-institutional services could meet the person’s needs safely. Once it’s finished, the result is attached to the SCREEN and the screener moves on to the referral recommendation. A finding that community care is feasible does not by itself block nursing home admission, but it becomes part of the record the Department of Health reviews.
When a Level II PASRR Evaluation Gets Triggered
If the Level I portion of the SCREEN identifies possible serious mental illness or intellectual disability, a Level II PASRR evaluation follows. This is a more intensive assessment conducted by the state mental health authority or state intellectual disability authority, and it is a federal requirement rather than an optional step.7PASRR Technical Assistance Center. When Does a Level II Evaluation Need to Be Conducted
For PASRR purposes, “serious mental illness” means a major mental disorder — schizophrenia, mood disorders, severe anxiety disorders, personality disorders, or other psychotic disorders — that results in functional limitations and that has required psychiatric treatment more intensive than outpatient care within the past two years. Dementia, including Alzheimer’s, is excluded as a primary diagnosis unless the person also has a qualifying major mental disorder.8eCFR. 42 CFR Part 483 Subpart C – Preadmission Screening and Annual Review This distinction matters because many nursing home applicants have some cognitive decline, but the Level II trigger targets serious psychiatric conditions or intellectual disability, not dementia by itself.
The Level II evaluation determines whether nursing home placement is appropriate for the person’s mental health or disability needs and what specialized services should be provided during the stay. Non-compliance with PASRR requirements can result in recoupment of Medicaid funds or a Department of Health citation.2New York State Department of Health. DOH-695 Instruction Manual
The Hospital Shortcut and Its 30-Day Trap
There is a narrow shortcut called an exempted hospital discharge (EHD). It applies when the person is admitted to a nursing facility directly from an acute hospital stay, needs nursing facility care for the same condition treated in the hospital, and a physician certifies that the stay will likely last fewer than 30 days.9PASRR Technical Assistance Center. What Is the Exempted Hospital Discharge Under an EHD, the full SCREEN and PASRR process does not have to be completed before admission.
The trap is what happens if the stay runs long. If the person is still in the facility past 30 days, the nursing home must screen them using the Level I process and refer anyone with suspected mental illness or intellectual disability for a Level II evaluation. That Level II review must be completed within 40 calendar days of the original admission date.9PASRR Technical Assistance Center. What Is the Exempted Hospital Discharge A delayed screening that surfaces a Level II need can disrupt a stay that everyone assumed was settled, so families should track that 30-day mark.
How Long the SCREEN Stays Valid
Timing matters after the form is done, too. The assessment is valid for 30 days for hospitalized individuals and 90 days for people in any other setting, including at home. If the admission doesn’t happen inside that window, the process has to start over.
What to Have Ready Before the Screener Arrives
Families don’t complete the DOH-695, but the paperwork you can produce shapes how quickly it moves. Have these on hand:
- The completed PRI or HC-PRI, confirmed as finished within the past 90 days. Without it, the SCREEN cannot begin.
- The patient’s Social Security number, needed for the identification section.
- A current list of medications and diagnoses, which helps the screener verify the PRI and evaluate specialized treatment needs.
- Hospital discharge summaries, if the person is coming from an inpatient stay.
- Psychiatric and behavioral health records, if there’s any history of mental health treatment, inpatient psychiatric care, or behavioral concerns. Missing psychiatric history is one of the more common reasons a SCREEN gets delayed or generates follow-up questions.
- Details about the home environment, available caregivers, and home accessibility, which feed the community-placement portion of Component 2.
Item 21 — the referral recommendation — is built from everything the screener records in items 7–20.6New York State Department of Health. SCREEN/PASRR Frequently Asked Questions Complete documentation on the first visit is what lets the screener reach an accurate recommendation without circling back for records that should have been ready from the start.