DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN Division Of

department of health services state of wisconsin division of long term care f-20980 (08/2008) assessment / supplement to the long

DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN
Division of Long Term Care
F-20980 (08/2008)
ASSESSMENT / SUPPLEMENT TO THE
LONG TERM CARE FUNCTIONAL SCREEN
1.
General Instructions
The Assessment/Supplement was developed as a means to collect
sufficient information to meet the requirements for a complete
assessment in the various Medicaid waivers. It was designed to be used
in conjunction with the Wisconsin Adult Long Term Care Functional
Screen in the initial application process. It is not required for
program recertification. While the Assessment/Supplement may be used
across several Medicaid waiver programs, the individual programs
continue to have unique documentation requirements.
a.
For CIP II/ COP-W, the Assessment/Supplement, when used in
conjunction with the automated Long Term Care Functional Screen,
meets the requirements for the COP Assessment, the COP Functional
Screen, the narrative and the Health Form in the initial
determination of eligibility for the COP-W and CIP II Medicaid
Waiver programs. A completed Assessment/Supplement must accompany
the Long Term Care Functional Screen for all new applications
submitted for approval. This form may be altered in appearance or
formatted for electronic use but all data elements must be
included in any locally developed version. Note: Locally generated
versions of this form may not be used without prior approval.
b.
For CIP 1A and CIP 1B applicants, the Assessment/Supplement, when
used in conjunction with the automated Long Term Care Functional
Screen, meets the requirement for the CIP Assessment, the COP
Functional screen and the LOC form (OQA-2256, Request for Title
XIX Care Level Determination) in the initial determination of
eligibility for CIP 1A and CIP 1B. A completed
Assessment/Supplement or another approved assessment document must
accompany the Long Term Care Functional Screen for all new
applications submitted.
For CIP 1A and CIP 1B, the Assessment/Supplement does not replace the
Service Plan Narrative. The narrative continues to be a required
component of the service plan packet. The content of the narrative
provides a detailed explanation of how the services included on the
Individual Service Plan will be implemented to meet all of the
applicant’s needs that were identified in the assessment process. It
is expected that the assessment will continue to be a person-centered
process, focused on the applicant’s preferences and conducted in a
manner that encourages active applicant participation.
2.
Content and Completeness
All of the elements should be considered as required information.
Specific questions that do not apply to the individual applicant may
be noted as “Not Applicable.” In all other elements the assessor
should include enough information to present a clear, current picture
of the applicant and his/her needs, current supports/services and
preferences. As is the case with the other required documentation in
the application packet, submission of an incomplete
Assessment/Supplement may delay the eligibility determination.
3. Signature Requirements
a. For CIP II/COP-W, the Assessment/Supplement must be signed by both
the care manager and a registered nurse. If the RN signature cannot be
obtained, a completed and signed F-20810 (Medicaid Waiver Program
Health Form) must accompany the application.
b. For CIP 1A and CIP 1B, the Assessment/Supplement must be signed by
the Support and Service Coordinator. The RN signature is not required.
general applicant information
County/Waiver Agency
 
Date of Assessment
 
Name – Applicant (Last, First, MI)
 ,    
Date of Birth
 
Telephone Number
 
Address
 
City / State / Zip Code
 
Marital Status
Married Widowed Divorced Single Separated
Social Security Number
 
Medicaid Number
 
Medicare Number
 
Other Insurance
 
Others in Household
 
CONTACT INFORMATION
1 – Name – (Last, First)
 ,  
Relationship
 
Telephone Number
 
Address
 
2 – Name – (Last, First)
 ,  
Relationship
 
Telephone Number
 
Address
 
3 – Name – (Last, First)
 ,  
Relationship
 
Telephone Number
 
Address
 
Other Contact(s)
Guardian: Person Estate Both POA – HC—Activated? Yes No POA Rep Payee
Other role—specify:
 
Name – (Last, First)
 ,  
Telephone Number
 
Name – (Last, First)
 ,  
Telephone Number
 
HSRS Target Group
Developmental Disability Physical Disability
Severe & Persistent Mental Illness Adults and Elderly
Alcohol or Other Drug Abuse
Living Arrangement
Own Home/Apartment Home of Relative/Other Person
Licensed/Certified AFH / CBRF / RCAC
Other—specify:
 
Referral Source
Self Relative/Family Physician/Hospital/Clinic
Prior Agency Contact
APS/EA Referral County Waiting List
Other—specify:
 
Other—specify:
 
SECTION 1: PERSONAL / SOCIAL
A - Social History
1. Personal/Family History (birthplace, parents, siblings, children,
etc.)
 
2. Relevant Ethnic/Cultural Information (plan/service implications)
 
3. Education/Work/Employment History
 
4. Previous Living Arrangements
 
B – Formal/Informal Supports
Who are the persons or agencies providing support/assistance now?
(family, friends, paid providers, etc.)
Identify formal/informal supports. Note stability/reliability of the
support provided. Are they the person’s preferred providers?
Attach additional documentation if necessary
Name
Relationship
Support Provided (who, what, when, stable/reliable)
Preferred Provider (Why/why not?)
1
 
 
 
 
2
 
 
 
 
3
 
 
 
 
4
 
 
 
 
5
 
 
 
 
Other Relevant Provider Information (others involved, concerns/gaps in
services identified)
 
SECTION 2: PERSONAL HEALTH AND SAFETY
A – Physical Health
List diagnoses, prescribed medication(s), treatment, and prescribing
physician/practitioner. Medications include prescribed
over-the-counter remedies. The assessor should note where his/her
observations or the reports of others that know the applicant well
contradict any self-reported health information. All health
information reported (diagnoses, prescription medication, etc) must be
verified. Attach additional documentation if necessary
Diagnosis
Medication/Treatment
Physician/Practitioner
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
 
List additional prescription and over-the-counter medications, if any.
(If necessary, attach additional documentation.)
 
1. Generally, how would you describe your health?
 
2. How is your (indicate response, e.g., “fine,” “so-so,” “not so
good,” etc.; last exam date; need for follow-up):
*
Vision
 
Has/needs glasses/contacts
Last exam:
 
Needs exam
*
Hearing
 
Has/needs hearing aid: L R Both
Last exam:
 
Needs exam
*
Teeth
 
Has/needs dentures: U L Both
Last exam:
 
Needs exam
*
Appetite
 
If other than “good, OK,” etc., explain:
 
*
Nutrition
 
Special diet? Yes No If yes, specify:
 
3. Do you currently have problems with (check and complete if response
is yes; if no, go to the next item):
Breathing? Short of breath—specify when:
 
Uses oxygen—specify when:
 
Dizziness/Balance/Falls? Last episode/fall occurred:
 
How often in the last 12 months?
 
Incontinence? Yes No Bladder Bowel Both Frequency:
 
Uses pads/briefs? Yes No
 
4. When did you last see a doctor?
 
How often do you see your doctor:
 
5. Who else do you see for health care and why? (dentist, specialist,
therapist, chiropractor, etc.)
 
6. Has your health changed recently? Yes No If yes, what changed and
when?
 
What did the change require? (e.g., ER/clinic visit, hospital stay,
new medication)
 
If hospitalized, date admitted:
 
Length of stay:
 
Nursing home admission? Date:
 
Length of stay:
 
7. Other significant medical history (surgery/injury/accident/major
illness, etc.)
 
8. Additional notes/relevant information
 
B – Activities of Daily Living (ADLs)
NOTE: The numbered elements of Sections B, C, D, and E below
correspond to the ADL, IADL, Communication/Cognition and
Behavior/Mental Health sections of the LTC-FS. In each element, the
assessor must first indicate the numerical screen code from the LTC-FS
for the corresponding daily activity. (The automated version of this
document will auto-fill the numerical codes.)
In a) of each element, the assessor must indicate the applicant rating
on the LTC-FS and note the person’s level of satisfaction with any
assistance now in place.
In b) of each element, the assessor must document any additional
services, equipment or supports the applicant requires or requests and
the applicant’s preference.
1. Bathing
Screen Code: 0 1 2
a.
Describe bathing assistance currently in place or note ability to
bathe independently. Indicate type of assistance (adaptive
equipment, hands-on/standby assist, etc.) and consumer
satisfaction with current level of help.
 
b.
Is additional bathing assistance or adaptive equipment
requested/indicated? Describe type and consumer preference(s).
 
2. Dressing
Screen Code: 0 1 2
a.
Describe assistance with dressing currently in place or note
ability to dress independently. Indicate type of assistance
(hands-on, cueing/prompting, adaptive equipment, etc.) and
consumer satisfaction with current level of help.
 
b.
Is additional dressing assistance or adaptive equipment
requested/indicated? Describe type and consumer preference(s).
 
3. Eating
Screen Code: 0 1 2
a. Describe assistance with eating currently in place or note ability
to eat independently. Indicate type of assistance (feeding, set-up,
adaptive utensils, etc.) and consumer satisfaction with current level
of help.
 
b. Is additional assistance with eating or adaptive equipment
requested/indicated? Describe type and consumer preference(s).
 
4. Mobility
Screen Code: 0 1 2
a. Describe assistance with mobility currently in place or note
independence in mobility. Indicate type (cane, walker, wheelchair,
attendant, etc.) and consumer satisfaction with current level of help.
 
b. Is additional assistance with mobility or adaptive equipment
requested/indicated? Describe type and consumer preference(s).
 
5. Toileting
Screen Code: 0 1 2
a. Describe toileting assistance currently in place or note ability to
toilet independently. Indicate type (commode, transfer assist, raised
seat, incontinence pads/briefs, catheter, etc.) and consumer
satisfaction with current level of help.
 
b. Is additional toileting assistance or adaptive equipment
requested/indicated? Describe type and consumer preference(s).
 
6. Transferring
Screen Code: 0 1 2
a. Describe transfer assistance currently in place or ability to
transfer independently. Indicate type (with assist of one/two,
transfer board, etc.) and consumer satisfaction with current level of
help.
 
b. Is additional transfer assistance or adaptive equipment
requested/indicated? Describe type and consumer preference(s).
 
C – Instrumental Activities of Daily Living (ADLs)
1. Meal Preparation
Screen Code: 0 1 2 3
a. Describe meal preparation assistance currently in place or note
ability to prepare meals independently. Indicate type (shopping, home
delivered, prepared by another person, etc.), frequency, and consumer
satisfaction with current level of help.
 
b. Is additional meal preparation assistance or adaptive equipment
requested/indicated? Describe type and consumer preference(s).
 
2. Medication Management
Screen Code: 0 1 2a 2b
a. Describe medication management assistance currently in place or
note ability to manage medication independently. Indicate type (set up
in med box, compu-med, or set up by another person, etc.), frequency,
and consumer satisfaction with current level of help.
 
b. Is additional medication management assistance or adaptive
equipment requested/indicated? Describe type and consumer
preference(s).
 
3. Money Management
Screen Code: 0 1 2
a. Describe money management assistance currently in place or note
ability to manage money independently. Indicate type of assistance
(rep payee, POA, guardian, etc.), frequency, and consumer satisfaction
with current type/level of assistance in place.
 
b. Is additional money management assistance requested/indicated?
Describe type and consumer preference(s).
 
4. Household Chores
Screen Code: 0 1 2
a. Describe household chore assistance currently in place or note
ability to manage household chores independently. Describe the type of
help needed (laundry, cleaning, snow removal, etc.) and any tasks
where consumer is independent. Describe frequency and consumer
satisfaction with current type/level of assistance and provider(s).
 
b. Is additional household chore or adaptive equipment
requested/indicated? Describe type and consumer preference(s).
 
5. Telephone
Ability - Screen Code: 1a 1b
Access - Screen Code: 2a 2b
a. Describe telephone/communication systems currently in place.
Describe type (basic, wireless, cellular, PERS, etc.) and consumer
satisfaction with the systems now installed.
 
b. Are additional communication aids or adaptive telephone systems or
equipment requested/indicated? Describe type and consumer
preference(s).
 
6. Transportation
Screen Code: 1a 1b 1c 1d 2 3
a. Describe transportation assistance currently in place or ability to
transport self independently. Describe transport assistance type (bus,
taxi, specialized vehicle, volunteer, etc.) and consumer satisfaction
with current transportation services.
 
b. Are additional transportation services or vehicle adaptations
requested/indicated? Describe type and consumer preference(s).
 
D – Communication and Cognition
1. Communication
Screen Code: 0 1 2
a. Describe communication assistance/aids currently in place. Describe
type (interpreter, assistive listening devices, low vision aids,
telecommunications aids, etc.) and consumer satisfaction with
communication aids now in place.
 
b. Are additional communication aids or adaptive communication
equipment requested/indicated? Describe type and consumer
preference(s).
 
2. Memory / Orientation
Screen Code: 0 1 2 3
a. Memory/orientation concerns expressed at time of referral? Describe
concerns and any health/safety risk reported.
 
Reported by: (consumer, family, friend, physician, other source)
 
b. Memory/orientation impairment evident at assessment? Describe
concerns and any health/safety risk noted.
 
Further assessment/follow-up indicated? (Specify)
 
3. Cognition / Judgment
Screen Code: 0 1 2 3
a. Decision-making concerns expressed at referral? Describe concerns
and any health/safety risk reported.
 
Reported by: (consumer, family, friend, physician, other source)
 
b. Decision-making abilities or impairments evident at assessment?
Describe abilities and any health/safety risk noted.
 
Further assessment/follow-up indicated? (Specify)
 
E – Behaviors and Mental Health
NOTE: For CIP 1A/1B applicants—if screen codes 1, 2 or 3 are checked
in items 2 or 3 below, attach the behavior intervention plan to the
assessment/supplement.
1. Wandering
Screen Code: 0 1 2 3
a. Describe the frequency of wandering and level of risk as reported
at referral.
 
Describe the person’s awareness, if any, of the risk that wandering
poses to his/her health and safety.
 
Is the wandering behavior purposeful?
 
b. Describe any safety measures or intervention plans in place to
address wandering behavior (increased supervision, alarm, etc.)
 
c. Are additional safety measures/intervention plans indicated?
Specify:
 
2. Self-Injurious Behaviors
Screen Code: 0 1 2 3
a. Describe self-injurious behaviors observed or documented.
 
b. If a behavior intervention plan is in place, who is responsible for
implementing the plan? (If no plan, why?)
 
3. Offensive or Violent Behaviors to Others
Screen Code: 0 1 2 3
a. Describe the offensive, violent or dangerous behavior observed or
documented.
 
b. If a behavior intervention plan is in place, who is responsible for
implementing the plan? (If no plan, why?)
 
4. Mental Health Needs
Screen Code: 0 1 2 3
a. Describe mental health needs observed or documented.
 
b. If mental health treatment or services are in place, who is
responsible for providing the treatment or services? (If no
treatment/services are in place, why?)
 
5. Substance Abuse
Screen Code: 0 1 2
a. Describe substance abuse problems observed or documented.
 
b. If substance abuse treatment or services are in place, who is
responsible for providing the treatment or services?
 
SECTION 3: HOME AND COMMUNITY ENVIRONMENT
A – Home Environment—Safety and Accessibility (Home safety/access
issues may be those identified by the consumer or the assessor.)
1. Identify any needed repairs or modifications inside of the home
that will improve safety or accessibility (e.g., doors, steps,
railings, tub/shower, heating/plumbing/electrical, etc.) List:
 
2. Identify any needed repairs or modifications outside of the home
that will improve safety or accessibility (e.g., ramp, steps/stairs,
lighting, locks/security, etc.) List:
 
3. Identify any structural barriers to emergency evacuation from the
home. Participant cannot access exit(s) (blocked/locked doors, cannot
use stairs, steps, etc.).
 
Other structural concerns? Specify:
 
4. Identify any concerns about the person’s ability to evacuate in an
emergency:
Independent With cues or direction With assistance Evacuation plan in
place? Yes No
If unable to evacuate independently, who will assist?
 
5. Other concerns about the home: Expensive rent/utilities Lack of
privacy Lack of space Needs major repairs—List:
 
Other concerns
 
B – Community Environment—Safety and Access to Community Resources
1. Do you feel safe/secure in your home? Yes No In your neighborhood?
Yes No
If no, list safety concerns (high crime, too crowded, too isolated,
etc.)
 
2. Does your home’s location limit access to social and community
resources (e.g., see family, attend activities, access medical care,
banking, shopping, etc.)? Yes No If yes, describe:
 
3. Preferences—Setting: Urban Rural Live alone With others Stay in
current setting
Move to: Another neighborhood/community Another living arrangement
(home, apartment, CBRF, etc.)
List preference(s) (living arrangement, setting, etc.)
 
SECTION 4: MAXIMIZING INDEPENDENCE
A – Personal Independence
1. Do you make your own choices about your daily routine (waking/bed
time, social activities, etc.)? Describe
 
2. Did you have the opportunity to choose and direct the help you
receive (service provider, type of service, schedule, etc.)?
Yes No—If no, do you have a preferred service provider(s), service
schedule, etc.? Describe:
 
3. Do you generally make your own decisions about your medical care
and treatment (choosing a doctor/health care provider, making
appointments, etc.)? Yes No—If no, who helps with those decisions or
makes the decisions for you?
 
4. What do you like to do in your free time? (hobbies, crafts,
interests, etc.)
 
5. What do you want to do in the future? (Includes BIG plans or not so
big plans: see the world, change the world—or—see a movie, change my
address, etc.)
 
B – Community Participation—Social
1. What kind of outside activities (classes, clubs, community/sporting
events, church, etc.) do you enjoy?
 
2. What stops you from pursuing the activities you enjoy? (Identify
barriers to participation—e.g., health, lack of information,
transportation, attendant care, cost, etc.
 
3. Do you see your friends (other than caregivers) as often as you’d
like? Describe:
 
If no, what stops you from seeing them (health, distance,
transportation, etc.)?
 
C – Community Participation—Employment / Education
1. Are you interested in pursuing employment (volunteer/paid,
full-time/part-time)? Specify:
 
2. Are you interested in pursuing educational opportunities (take
class, complete degree program, etc.)? Specify:
 
3. If applicable, what stops you from pursuing your employment or
education interests? (Identify barriers to pursuit of education/
employment interests—e.g., lack of information, transportation gaps,
cost, etc.).
 
SECTION 5: PARTICIPANT RIGHTS / INFORMED CHOICE
Completion of section 5 is REQUIRED FOR CIP 1A/1B and BIW. Section 5
is optional for CIP II/COP-W.
A – Respecting Rights and Choices
Yes
No
1. Has the person/guardian participated in the assessment and plan
process?
2. Have the participant rights been reviewed with the person and
his/her guardian?
3. Does the participant understand their rights?
If “no,” is the guardian informed and able to act on the participant’s
behalf?
4. Has the person/guardian been given a choice of service provider?
5. Has the person/guardian participated in interviewing potential
providers?
6. Has person/guardian contacted provider references?
7. Has the person/guardian been given a choice of living arrangement?
B – Legal Issues
1. Chapter 51/Chapter 55 petition/hearing pending?
2. Court-ordered medication/treatment/services?
3. Restraining orders in place/pending?
4. Civil/criminal charges pending?
5. Other court history (traffic, bankruptcy, etc.)?
Explain any “yes” above
 
SIGNATURE – Assessor (Qualified Care Manager/Support and Service
Coordinator, RN)
Date Signed
SIGNATURE – Registered Nurse
Date Signed