TX HHS Form 2333. Nursing Facility Risk Criteria Scoring Form

The TX HHS Form 2333, Nursing Facility Risk Criteria Scoring Form, is a tool used to assess an individual's risk of requiring nursing facility placement. This form helps identify individuals who may require ongoing care and support in a nursing facility setting.

This scoring form requires identifying data, including the individual's name, Medicaid number, and responder information if different from the individual. The form also includes sections for risk factors, which are identified and scored based on various criteria such as neurological diagnoses, falls, and need for hands-on guidance or physical assistance. Common scenarios of use include assessing individuals with a history of nursing facility placement, those with neurological diagnoses, or those who require ongoing care and support.

The form is designed to be used by case managers and other healthcare professionals to determine eligibility for nursing facility services. Key features include the required identifying data, risk factor scoring, and comments section for additional information. The form also includes instructions on when to continue with the eligibility process or send a denial notice. By using this form, healthcare professionals can make informed decisions about an individual's care needs and ensure they receive appropriate support and services.