(Revised 03/01/2024 ML #3829)
An application for services must include a complete functional assessment that was conducted by the HCBS Case Manager with the individual in the home where the individual resides. THIS ASSESSMENT IS FOR INDIVIDUALS 18 YEARS OF AGE OR OVER. The HCBS Comprehensive Assessment enables the HCBS case manager to record the individual’s functional impairment level and correlate that to the need for in-home and community-based services.
The HCBS Comprehensive Assessment is intended to collect information based on the individual’s response(s), information reported by significant other, individual’s natural supports (such as family or friends) person-centered planning team members, and the HCBS case manager's observation. In most cases, the individual is the respondent of choice, and the HCBS case manager should make every attempt to conduct the interview with the individual.
Individuals must actively participate in the functional assessment to the best of their ability. Case managers must document in the narrative if there is a medical reason why the individual cannot participate in the assessment or answer questions directly. If a third party (including family) reports that the individual cannot participate in the assessment, but the case manager questions if this information is accurate, the case manager may request medical documentation to confirm that the individual is not capable of participating before eligibility can be established.
It is the responsibility of the individual to provide all information necessary to establish eligibility per NDAC 75-03-23-15. Proof of blindness, disability, and functional limitation may include, but is not limited to, complying with all requests for medical records or an evaluation, such as from physical therapy, occupational therapy, speech, neuro-psychological evaluation etc. The case manager may use the supporting records and evaluations in completing the comprehensive assessment and/or determining eligibility for HCBS.
Eligible individuals will not be required to rely on natural supports if they choose not to do so or if the proposed support person is unable or unwilling to provide natural supports.
KEY FACTORS:
Section A. Demographics
Vision Tool
Section B. Health Conditions
Section C1. Functional Assessment - ADL
Activities of Daily Living (ADL)
Section C2. Functional Assessment - IADL
- Instrumental Activities of Daily Living (IADL)
- Individual Specific Needs
- Specialized Support
- Supervision/Structured Environment
Section D. Quality Review
Section E. SPED Financial
Section F. Caregiver Assessment
Risk Assessment/Health and Safety Plan
Narratives and Signatures/Dates
The HCBS case manager must document the following information in either the HCBS Comprehensive Assessment or case notes.
Record related comments which the individual’s or family member offers. Document if comments are self-reported, reported by family, collateral contacts, or observation.
HCBS case managers are not expected or qualified to make medical diagnoses. Through observation and interviews, the HCBS case manager must obtain pertinent medical information and any collateral information regarding the individuals wellbeing, physical and behavioral health needs. This information can be from self-reported information, collateral contacts, or medical information.
All questions on the HCBS Comprehensive Assessment must be answered if they apply to the individual in any way.
The HCBS Comprehensive Assessment Form and completion instructions are as follows:
Participant Assessment. HCBS case managers should be sure to confirm the accuracy of the information in the participant assessment during annual and six-month reviews and as changes occur.
Section A. Demographics
Section B. Health Conditions
An individual’s physical health is an important indicator of overall well-being. The purpose of this section is three-fold:
This section collects basic information related to the individual’s cognitive and emotional functioning. Both emotional health and cognitive capacity have an impact on ability to maintain a level of self-care, and consequently have an impact on the individual’s ability to remain at home.
Section C1. Functional Assessment
Activities of Daily Living (ADL)
Section C2. Functional Assessment - IADL
Instrumental Activities of Daily Living (IADL)
Individual Specific Needs
Specialized Support
Supervision/Structured Environment
Life Domain Vision Tool
Developed by the Charting the LifeCourse Nexus - LifeCourseTools.com • © 2020 Curators of the University of Missouri | UMKC IHD • March2020
The completion of the vision tool is required for all service programs except Basic Care.
The Vision Tool must be completed initially, every six months and to reflect any changes in the needs and preferences of the member and caregiver(s), including the individual’s desire to move to a community setting.
The Charting the LifeCourse Vision tool is a working document that allows the individual and the person-centered planning team to discuss and explore the eight (8) life domains. The vision tool becomes part of the individuals person-centered plan of care and must be included in the individual’s copy of the care plan.
The Vision Tool is used as a discovery tool that it utilized and expanded upon throughout the continuum of HCBS services, including transition supports through Money Follows the Person (MFP) and Aging Services HCBS programming. The initial vision tool is completed by the entity who is leading the transition and then built on throughout the care planning process.
The Life Domain Vision Tool encompasses discussion on 8 life domains; Daily Life & Employment, Community Living, Social and Spirituality, Healthy Living, Safety & Security, Advocacy & Engagement, Supports for Family, and Supports and Services. The Vision Tool is used as a tool to explore what a “good life” means to the individual.
The process of completing the Vision Tool includes an assessment through conversation with the individual. The conversation is centered around identifying the individual’s strengths, needs and positive attributes in addition to an assessment of financial concerns, legal issues, fire safety, falls, access to health care, family issues, natural, community, and social supports, mental health/behavioral health needs, cognitive decision making, nutrition, medication, employment, education, and housing. Through assessment, planning and goal setting, the Vision Tool provides an opportunity for the person-centered plan to focus on the individual as a whole and explore what the individual views as their strengths, needs and goals moving forward. The vision tool serves as a portion of the person-centered plan that follows the individual through their life and can be flexible to the needs and aspirations of the individual. Individuals may be asked to describe their preferences, and goals as part of the 8 life domains of the vision tool.
The process of completing the vision tool can be very personal and bring up subjects that the individual may not wish to discuss. If an individual does not wish to engage in conversation about one or more of the domains, the case manager must document in the relevant life domain the individual did not wish to discuss this domain.
The case manager may need to engage other community partners and supports as part of the person-centered planning process to meet the identified needs, barriers, or goals of the individual.
Daily Life & Employment
The Daily Life and Employment domain encompasses school and education, life-long learning, employment, volunteering, routines and life skills.
The case manager engages the individual in facilitated discussion about what their vision is to have a good life regarding to employment, education or volunteering. Discussion focuses on the individual’s daily routine and if they are living the life they desire.
Examples of questions that may be asked to facilitate discussion can be found under the Daily Life and Employment section of the HCBS Comprehensive Assessment Companion Guide.
Community Living
The Community Living domain encompasses housing, home adaptations, home modifications, community access, and transportation.
The case manager engages the individual in facilitated discussion centered on what the individual sees as important in their lives in relation to housing, community living, access to the community, and any transportation needs.
Home Environment. Physical environment may impact positively or negatively on an individual’s overall well-being, and thus, an evaluation of physical environment is an essential portion of the assessment process. This section presents some key areas which require the HCBS case manager's evaluation. It may elicit information useful in determining whether specialized housing equipment, home adaptations, relocation, or home repair are necessary to enable the individual to remain in the most integrated setting desired.
Social and Spirituality
The Social Support and Spirituality domain encompasses friends, relationships, leisure activities, personal networks and faith community. The case manager facilitates discussion about community integration and social supports to assist the individual in exploring options and desires the individual has for having their social and spiritual needs met. The case manager and the individual discuss formal and natural supports along with the individual’s vision for what they would like to have for a support system.
Healthy Living
Healthy living is inclusive of medical, mental and behavioral health needs, nutrition, wellness, access to health care, health care needs, physical health information, functional impairments, current health status, medication use, health risk factors, falls, and cognitive decision making. The case manager facilitates discussion on the fore mentioned subcategories to build an understanding of the individual's view of healthy living.
Safety & Security
The safety and security domain encompasses emergencies, legal rights and issues, legal representative issues, financial concerns, mental/behavioral health related safety concerns, cognitive issues, fire safety. Through assessment, visual observation, collateral conflict and facilitated discussion the case manager and the individual explore the individual’s safety and security.
Advocacy & Engagement
Advocacy and engagement include assessment and facilitated discussion on citizenship, valued roles, making choices, setting goals, the individual's views and responsibilities, leadership, and peer support. The case manager engages the individual to explore strengths, needs, barriers, and risks that are identified. The case manager may need to engage community partners and supports to provide supportive decision making, peer supports, or other supportive services identified to meet the individual’s needs.
Supports for Family
Supports for family and/or natural supports includes understanding what the individual wants regarding to family involvement and engagement in their supports and services. Facilitated discussion encompasses understanding who the individual views as family and who the individual views as support. Family may include both biological family or chosen family as part of their family network. The case manager may consider the caregiver assessment and any identified needs or barriers identified through the assessment. Discussion may include both formal and natural support systems along with options (such as peer support, support groups, or respite care) to alleviate caregiver stress.
Supports and Services
All providers and services that will best meet the individual's needs and from whom the individuals receive cares are documented in the Services and Supports Domain. The case manager facilitates discussion around what support the individual needs and/or wants to live as independently as possible, and what the possibilities are for securing the needed supports.
Functional Assessment
Activities of Daily Living
HCBS case managers require specific information regarding the activities an individual can perform in order to arrange for services which enable the client to remain at home.
This section allows the HCBS case manager to determine the level of impairment an individual’s is experiencing, based on specific medical, emotional and cognitive status. It is based on standard scale which have been tested and validated in programs serving the individuals with physical disabilities.
The questions measure the degree to which an individual can perform various tasks that are essential to independent living. These tasks, called Activities of Daily Living (ADLs), include: bathing, dressing/undressing, eating, toileting, continence, transfer in/out of bed or chair, and indoor mobility.
The scale used to measure independence in ADLs uses ratings from 0 to 3. A score of zero represents complete independence (no impairment), while 3 represents complete dependence (impairment). Each item measures the level of impairment of the individual, regardless of how much help they might be receiving at present. In completing the section, the HCBS case manager should check the number which best corresponds to the individual’s impairment level. The following general definitions must determine the ratings.
Information on each of the ADLs can be collected by observation, from the individual, a significant other, or collateral contact.
HCBS case managers will want to know how the individual usually performs a task, i.e., most of the time. An individual who has occasional difficulty should be coded based on their usual performance. However, occasional difficulties should be noted in the corresponding narrative/note.
Barthel Scale Scoring (as defined by C.V. Granger, July, 1974) Mahoney FI, Barthel D. “Functional evaluation: the Barthel Index.” Maryland State Med Journal 1965;14:56-61. Used with permission. Permission is required to modify the Barthel Index or to use it for commercial purposes.
| 0: | Completely Able - Activity completed under ordinary circumstances without modification, and within reasonable time. (A "reasonable time" involves an amount of time the client feels is acceptable to complete the task and an amount which does not interfere with completing other tasks, as well as the professional judgment of the Case Manager based on the client's age, health condition, (e.g. arthritis) and situation. |
| 1: | Able with Aids/Difficulty - Activity completed with prior preparation or under special circumstances, or with assistive devices or aids, or beyond a reasonable time. |
| 2: | Able with Helper - Activity completed only with help or assistance of another person, or under another person's supervision for safety, or by cuing. ANOTHER HUMAN IS INVOLVED IN ACTIVITY; but client performs at least half the effort him/herself. |
| 3: | Unable - Client assists minimally (less than half of effort), or is totally dependent. |
Some general concepts govern the manner in which an individual is compared with the assessment criteria: The individual is considered as a "whole entity." The Case Manager does not measure physical capacity, cognitive ability, or affective state separately, but rather one's functioning as a whole. For example, if one has ample physical strength and skill to complete a task, but also has cognitive limitations which prevent the individual from doing so, that person cannot complete it. The Case Manager also measures the individual’s level of functioning in the present. What the individual could or could not do in the past is not an issue nor is what the individual, under hypothetical conditions, might be able to do in the future. Each task must be looked at as the sum of its parts. One must be able to complete all parts of a task in order to complete the task.
Further information to assist with evaluating the functional impairment includes the following; the case manager indicates the level of impairment in the Functional Assessment by choosing one of the four (4) selections (the number behind the description of the impairment indicates the points associated with the level of impairment). The total impairments and associated points are automatically added on the final screen of the functional assessment in the assessment tool. A Rating 2 OR 3 ON THE ASSESSMENT OF AN ADL INDICATES AN IMPAIRMENT.
The four (4) options for level of impairment under each ADL task is as follows:
For each ADL the case manager must note the reason individual is not able to independently complete the ADL task as follows:
Example: I need support with bathing due to overall weakness and unsteadiness getting in and out of the shower.
The note may include:
Example: I want assistance with bathing three times a week before bedtime.
The note may include:
(Helpful hint: this is where the case manager starts to calculate how many units are needed for the overall service that the task fits under. Which will be noted under (c.) of the ADL. Such as bathing, dressing and nail care are all personal care tasks and would be authorized under the overall service of personal care.
For example: The frequency of the task for bathing would be as follows: The individual needs assistance with bathing for 30 minutes three times a week, and there are 5 weeks in a month. The individual would need 30 units of personal care services (PCS) for bathing.
Additionally, the individual needs one unit three times a week for dressing (frequency of bathing indicates 15 units a month) and 1 unit a week for nail care (5 units a month). This would add up to 50 overall units of PCS for the individual would need to be authorized. In letter (c.) the overall units for the authorized service (ie. PCS) will be noted.
In the box provided describe how this need is met.
Example: QSP will support me with this task as part of the overall service of personal care. Total units authorized for personal care services are not to exceed 50 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
[if Other] Describe
Example: I get anxious and panicky when water runs over my face in the shower. It makes me feel like I am going to suffocate.
A full description of the specific ADL and required documentation in the assessment is as follows:
This item measures the individual’s applicant's/client's ability to bathe or shower or take sponge baths independently for the purpose of maintaining adequate hygiene as needed for the client's individual’s circumstances. Consider minimum hygiene standards, medical prescription, or health related considerations such as incontinence, skin ulcer, lesions, cognitive ability, and balance problems. Consider ability to turn faucets, regulate water temperature, wash and dry completely.
For each ADL the case manager must note the reason individual is not able to independently complete the task in section a. of the ADL as follows:
Example: I need support with bathing due to overall weakness and unsteadiness getting in and out of the shower.
The note may include:
Example: I want assistance with bathing three times a week before bedtime.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me with this task as part of the overall service of personal care. Total units authorized for personal care services are not to exceed 50 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
[if Other] Describe
Example: I get anxious and panicky when water runs over my face in the shower. It makes me feel like I am going to suffocate.
This item refers to the individual’s ability to feed themselves, including cutting meat and buttering bread. Consider individual’s ability to chew, swallow, cut food into manageable size pieces, and to chew and swallow hot and cold foods/beverages. It does NOT refer to meal preparation. (This is covered in Meal Preparation).
Example: I need support with eating due to overall weakness and limited dexerity.
The note may include:
Example: I need assistance with eating three times a day for breakfast, lunch and dinner.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me with this task as part of the overall service of personal care. Total units authorized for personal care services are not to exceed 50 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
[if Other] Describe
Example: I prefer to eat soft foods due to mouth soreness.
This item measures an individual’s indoor mobility. The HCBS case manager may ask an applicant/client, "How do you usually get around inside?"
Example: I need support with mobility inside due to overall weakness.
The note may include:
Example: I need assistance with ambulating around the house 5 times a day.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing stand by assistance and a gait belt as part of the overall service of personal care. Total units authorized for personal care services are not to exceed 50 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
[if Other] Describe
This item measures the level of assistance the individual needs in transfers.
Include the ability to reach assistive devices and appliances necessary to ambulate, and the ability to transfer (to/from) between bed and wheelchair, walker, etc.; the ability to adjust the bed or place/remove handrails, if applicable and necessary. Do not consider ambulation, itself, as this is considered under Get Around Inside.
Example: I need support with mobility inside due to overall weakness.
The note may include:
Example: I need assistance with ambulating around the house 5 times a day.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing stand by assistance with a gait belt as part of the overall service of personal care. Total units authorized for personal care services are not to exceed 50 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
[if Other] Describe
This item measures the individual’s ability to dress or undress. Consider individual’s needs of appropriate dress for weather or street attire. Consider ability to get clothes from closets and drawers as well as putting them on. Also include ability to put on prosthesis or assistive devices. Consider fine motor coordination for buttons and zippers, and strength for undergarments or winter coat. Do not include style or color coordination. Do not include tying shoes.
Example: I need support with dressing after my shower due to overall fatigue and unsteadiness.
The note may include:
Example: I need support with dressing after my shower three days a week.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing stand by assistance with dressing as part of the overall service of personal care. Total units authorized for personal care services are not to exceed 50 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
[if Other] Describe
This item deals with the individual’s ability to get to the bathroom, get on/off the toilet, clean him/herself, manage clothes, and flush.
Consider frequency of need and need for reminders.
Example: I need support with dressing after my shower due to overall fatigue and unsteadiness.
The note may include:
Example: I need support with toileting 7 times a day.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by physical assistance on and off of the toilet and assisting with readjusting clothing as part of the overall service of personal care. Total units authorized for personal care services are not to exceed ?? units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
Indicate the individual's bowel and bladder continence level.
Example: I need support continence to include assistance with changing undergarments and incontinence supplies due to limited strength and impaired ability to bend or move body.
The note may include:
Example: I need support with continence three times a day in the morning, afternoon and at bedtime.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing physical assistance to change incontinence products and assisting with readjusting clothing as part of the overall service of personal care. Total units authorized for personal care services are not to exceed ?? units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
INSTRUMENTAL ACTIVITIES OF DAILY LIVING
This section deals with an individual’s ability to carry out tasks which may not need to be done every day but are important for living independently. Intervention may be required to help an individual adapt to difficulties experienced in performing IADL activities. IADL items include meal preparation, housework, laundry, shopping, taking medicines, getting around outside, transportation, money management, and communication. Performance of IADL items requires mental as well as physical capacity. For example, taking medications and managing money require memory, judgment, and intellectual ability. The IADL scale measures the functional impact of emotional, intellectual, and physical impairments.
Not all individuals have the opportunity to perform IADL tasks. For example, an individual who lives with a relative or spouse might not prepare meals simply because another person routinely does this task. Similarly, some individuals do not manage their own money because a spouse does it. However, the IADL scale is designed to measure an individual’s physical and cognitive ability to perform these tasks, regardless of the individual's opportunity to perform them. In asking individuals about IADL tasks, HCBS case managers must stress what the person can do rather than what he/she is doing, for example: "Can you prepare meals, do housework, shop, etc.?"
The HCBS Case Manager will want to know how the individual usually performs a task, i.e., most of the time. Individuals who have occasional difficulty should be scored based on their usual performance, noting occasional difficulties in the narrative/note.
The HCBS case manager obtains information regarding IADL impairments by observation, interview with family or friends, or by direct self-report of the client. The scale used to rate each IADL task differs slightly from the ADL scale.
It includes three basic categories of functioning:
| 0: |
Without help. Applicant/client is able to perform task independently, without supervision, reminder or assistance. |
| 1: |
With help. Applicant/client is able to perform task only with assistance, reminder, cuing or supervision. |
| 2: |
Cannot do at all. Applicant/client is not able to perform task at all, even with assistance. |
In IADL score it is especially valuable to look at each task as the sum of its parts. Doing the laundry, for example, includes requirements of the physical ability to carry the wash to the washing machine, the cognitive ability to operate the washing machine including the measuring of soap and setting of controls, the physical ability to move clothes from washer to dryer, the cognitive ability to operate the dryer, the skill to fold and physical ability to carry the clean laundry back from the machine. If one can operate the washer and dryer but cannot carry the clothes to or from the machines, this person rates a #1, "with help."
SCORES OF 1 OR 2 IN ASSESSMENT OF AN IADL INDICATES AN IMPAIRMENT
Standard Definitions for each IADL item are as follows:
The HCBS case manager may ask the individual, "Can you prepare your own meals?" Regardless of whether the individual actually does prepare meals, ask whether they can.
Consider the individual’s ability to prepare hot and/or cold meals that are nutritionally able to sustain the client or therapeutic, as necessary. Consider individual’s cognitive ability, such as ability to remember to prepare meals, individual’s ability to prepare food, to open containers, to properly store and maintain foods, and to use kitchen appliances. Do not consider clean up because it is part of housework. Do not include canning of produce or baking of such items as cookies, cakes, and bread.
Example: I need support with meal preparation due to overall fatigue and I cannot stand for any length of time.
The note may include:
Example: I need support with meal preparation, the need for meal preparation is met by receiving home delivered meals for 7 days a week.
The note may include:
In the box provided describe how this need is met.
Example: HDM’s supports me by providing a meal 7 days a week. Total units authorized for home delivered meals 31 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
This item refers to the individual’s ability to use the telephone, as well as comprehend oral and written communication. Include getting telephone numbers and placing calls. The individual must be able to reach and use the telephone, answer the telephone, dial, articulate and comprehend. If the individual uses special adaptive telephone equipment, score the client based on the ability to perform this activity with that equipment.
In scoring communication, the case manager must look at each task as the sum of its parts. In determining an individual's functional impairment, we must consider whether the individual is impaired in communication using their primary language. For example, an individual who may not be able to fluently speak or understand English, but is able to communicate in their primary language, would not be considered impaired. However, if the individual’s physical and cognitive ability to perform these tasks in their native language is impaired, the individual would be scored according to their level of impairment.
Special equipment in common use includes:
(NOTE: The use of an emergency response system device should not be considered when scoring this item because it can only be used for emergencies and does not enable its user to make or receive other essential calls such as arranging physician appointments or grocery deliveries.)
The tasks of routine writing/reading fall within the scope of the IADL of communication. Include the ability to understand and effectively respond to business mail, such as insurance mailings, applications for benefits, etc. If the individual needs a routine regimen of assistance with routine writing or reading of correspondence, this functional impairment may be documented within the scope of the IADL of communication. Again, when determining whether an individual is scored as impaired in communication, the case manager must consider the ability of the individual to complete related tasks involving their primary language.
If an individual has no telephone, ask about his/her ability to use a telephone elsewhere (i.e., at a neighbor's home).
Example: I need support with communication to organize my mail and assist with arranging appointments as it is challenging to organize my thoughts and tasks since my last hospitalization.
The note may include:
Example: I need support twice weekly with mail and arranging appointments.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing assistance with mail and making appointments as part of the overall service of homemaker. Total units authorized for homemaker services are not to exceed 70 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
This item measures the individual’s ability to do his/her laundry.
Can the applicant/client sort, carry, load and unload, fold and put away clothes? Consider the ability to work a coin-operated machine. Do not score if the only problem is that laundry facilities are located outside the home as the need for transportation is covered in Transportation. Consider the individual’s cognitive ability to complete these tasks. Consider individual’s physical and cognitive ability to complete these tasks even if applicant/client lives with others who do them for the individuals.
Example: I need support with laundry due to overall weakness and difficulties bending, lifting and carrying laundry.
The note may include:
Example: I need support with laundry on.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me washing laundry once a week. Total units authorized for homemaker are not to exceed 70 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
This item measures the ability of the individuals to take medicine by oneself. This is defined as: remembering to take medicine; getting the medicine from the place it is kept within the home; measuring the proper amounts; swallowing the pill; applying the ointment; or giving oneself injections (including the filling of syringe).
Score 0 for individuals who has no needs for medication or who perform tasks independently. Score according to client's ability to perform the task even if commonly done by others. Score need for service monitoring of medications due to possibility of overdose as a (2.) Do not include obtaining of medication from pharmacy as this is covered under Transportation.
Example: I need with medication due to overall weakness and diminished dexterity.
The note may include:
Example: I need support with medication twice a day.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me opening my pill container and bringing me a glass of water. Total units authorized for personal care services are not to exceed ?? units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
This item measures the individual ability to shop for groceries and other essentials assuming transportation or delivery is available.
Consider ability to make shopping lists, to function within the store, to locate and select items, to reach and carry purchases, to handle shopping carts, to communicate with store clerks, and to put purchases away. Do not consider banking, posting mail, monetary exchanges, or availability of transportation in scoring this item. Individual’s ability to access transportation is measured under Transportation and ability to manage money is measured under Management of Money.
Example: I need support carrying my items with shopping as I cannot bend lift and carry due to pain and overall weakness.
The note may include:
Example: I need support with shopping one times a week.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing physical assistance with shopping under the overall service of homemaker. Total units authorized for homemaker are not to exceed ?? units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
This item refers to the individual’s ability to move around outside, to walk or get around by some other means (i.e., wheelchair), and to do so without assistance.
Consider ability to negotiate stairs, streets, porches, sidewalks, and entrances and exits of residence and destination.
Example: I need support mobility outside the home to access essential services such as shopping, due to overall weakness and needing assistance with my wheelchair.
The note may include:
Example: I need support with mobility outside the home one time per week.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing physical assistance to get outside my home to push my wheelchair as part of the overall service of personal care. Total units authorized for personal care services are not to exceed ?? units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
This item measures an individual’s ability to use transportation. For this question only, ability to use transportation includes access to a means of transportation.
Consider ability to negotiate entering and exiting of vehicle. Consider the ability to secure appropriate and available transportation and to know locations of home and essential places. Lack of appropriate and available transportation as needed, will increase the score. Consider cognitive as well as physical ability to use transportation.
Example: I need support accessing transportation by scheduling transportation for appointments and navigating getting in and out of the vehicle due to weakness and confusion with organizing tasks.
The note may include:
Example: I need support with transportation one time per week.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing physical assistance scheduling appointments as part of the overall service of personal care. Total units authorized for personal care services are not to exceed ?? units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
This item refers to the individual’s ability to do routine housework.
The HCBS case manager might ask the individual "Are you able to do routine housework (such as dusting)?" and "Are you able to do heavy housework (such as washing floors)?" Again, be sure to stress ability, physical and cognitive, rather than actual performance.
Consider minimum hygienic conditions required for individual’s health and safety. Do not include laundry. Do not include refusal to do tasks if refusal is unrelated to the impairment.
Example: I need support housework due to overall weakness and fatigue.
The note may include:
Example: I need support with housework once a week for 2 hours.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing physical assistance housework as part of the overall service of homemaker. Total units authorized for personal care services are not to exceed 70 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
[if Other] Describe
This item refers to the individual’s ability to handle money and pay bills.
Consider client's ability to plan, budget, write checks or money orders, and exchange currency and coins. Include the ability to count and to open and post mail. Do not increase the score based on insufficient funds.
Some individuals may have a legal representative (guardian, conservator or representative payee).
Example: I need support with money management and organizing the associated paperwork due to confusion and inability to track tasks that need to be completed.
The note may include:
Example: I need support money management one time per week.
The note may include:
In the box provided describe how this need is met.
Example: QSP will support me by providing assistance with going through my mail and paperwork as part of the overall service of homemaker. Total units authorized for personal care services are not to exceed 70 units a month.
Indicate the appropriate outcome of the service authorized, if other indicate in the text box the appropriate outcome.
Outcomes
Individual Specific Needs
Some individual needs require additional training and expertise for a qualified service provider to assist the individual with their individual specific needs. The specific needs are grouped into two categories and may require the QSP to get additional education. The case manager must ensure that the authorized QSP has the correct global endorsements or have been trained in the “Client Specific Needs” and this is listed on their QSP status in order for the QSP to be able to perform the task.
The Global Endorsements are:
The following Client Specific Endorsements (J-N) require verification of the provider’s ability to provide the service for a particular client who requires the endorsement. Note: Send the completed Request for Client Specific Endorsement, SFN 830 to Medical/HCBS Services only if the client’s case manager has authorized service for that endorsement.
Apnea monitor*
Cognitive/supervision*
Community integration
Exercises*
Eye care
Fingernail care (may not be authorized if individual has diabetes, heart or other circulatory conditions)
Hair care/shaving
Hoyer lift*
Indwelling bladder catheter*
Jobst stockings
Ostomy care
Oxygen/medical gases*
Postural/bronchial drainage
Prosthesis/orthotics*
Skin care
Social appropriateness
Specialty bed (Ric)*
Suppository/Bowel Program*
Ted socks*
Teeth, mouth, denture care
Vital signs**
Care Coordination
Emergency Response System
Nurse Education
Extended Personal Care
Extended Personal Care – Nurse
Chore per Job
Chore Labor
Chore Labor (lawn)
Chore Labor (snow removal)
The tasks with an asterisk require additional information and documentation on file. The additional information is as follows:
A written, signed recommendation for the task of vital signs provided by a nurse or higher credentialed medical provider must be on file which outlines the requirements for monitoring, the reason vital signs should be monitored, and the frequency.
When the tasks of Temp/Pulse/Respiration/Blood Pressure are authorized, the individual to be contacted for readings must be listed on the PreAuth in Therap.
For the task/activity of exercise, a written recommendation and outlined plan by a therapist for exercise must be on file and is limited to maintaining or improving physical functioning or communication that was lost or decreased due to an injury or a chronic disabling condition (i.e., multiple sclerosis, Parkinson’s, stroke etc.). Exercise does not include physical activity that generally should be an aspect of a wellness program for any individual (i.e., walking for weight control, general wellness, etc.).
“Client Specific Endorsements” These activities and tasks may be provided by a service provider who has demonstrated competency and carries a client specific endorsement to provide the required care within the identified limitations. The case manager must maintain documentation that a health care professional has verified the provider’s training and competency specific to the individual’s need in the client's file.
Specialized Support
Supervision/Structured Environment
Supervised or Structured Environment Scoring
Discuss the need for supervision, and if there is a need for 24-hour supervision. What factors contribute to the individuals need for supervision. How has the individual been managing in periods when there has not been supervision? Describe any health or safety risks associated with the lack of appropriate supervision.
A setting such as adult foster care, adult residential care or basic care does not justify the need for supervision.
Quality Review
Case Managers are required to continuously monitor to ensure an individual is being afforded the rights of privacy, dignity and respect, and freedom from coercion and restraint (including the limited use of restraints that are allowable under Adult Residential Services). The Quality Review process is used to obtain information from individuals/responsible parties that is related to quality and quantity of services. The information is aggregated and reviewed by the department to develop quality measures and services.
The Quality Review is to be completed for all individuals, regardless of funding source, with the exception of Basic Care. The Quality Review helps to determine an individual’s satisfaction with services but is also used to determine compliance with the HCBS settings rule. Any violations of rights must be reported to Program Administration. This section is to be completed during the annual assessment and six-month review. This section is not to be completed during an initial assessment, as services have not yet been implemented.
Financial Assessment
A financial assessment is required in accordance with policy for Service Payments for the Elderly and Disabled (SPED) 525-05-25-20 regarding financial information for SPED and Medicaid Waiver for Home and Community Based Services 525-05-25-10.
For individuals receiving SPED, this section of the Participant Assessment, along with the SFN 820, must be completed. Instructions for completion of the complete SFN 820, SPED Income and Asset form and assessment in can be found at https://www.nd.gov/dhs/policymanuals/52505/52505.htm.
Caregiver Assessment
The caregiver assessment must be completed initially and every six months for all formal/paid live-in providers, including FHC and FPC providers.
Discuss options for respite care and other programming that may provide caregiver supports and relief. Options may include support groups, Powerful Tools for Caregiver evidence-based training, socialization opportunities, the Alzheimer’s Association, etc. This assessment may be done via telephone if the individual is not able to participate in a face-to-face meeting.
Risk Assessment and Health and Safety Plan
The Risk Assessment and Health and Safety Plan must be completed initially, annually, and every six months. The Risk Assessment and Health and Safety Plan may need to be updated when there is a critical incident, QSP complaint, or VAPS report that identifies a risk or potential risk: including but not limited to risks related to financial concerns, legal issues, fire safety, falls, access to health care, family issues, natural, community or social supports, mental health/behavioral health needs, cognitive decision making, nutrition, medication, employment, education, and housing. The case manager and client will review the assessment results and develop the Risk Assessment and Health and Safety Plan to reduce or help mitigate risk.
A risk assessment must be completed in the following circumstances:
The risk assessment may include:
Recipients must be fully informed of the plan and any modifications made to their stated preferences or goals to assure safety. The risk assessment must be completed in collaboration with the individual and/or their legal representative and any other formal or natural supports the individual wishes to include in the assessment of risk and risk mitigation planning. Documentation must be included to assure that the intervention will not cause harm to the recipient.
The individual and/or their legal representative must sign the risk assessment and be given a signed copy.
A copy of the signed risk assessment must be retained in the individual’s file.
Narrative/Case Note:
All contacts relating to the individual must be documented in the case notes in Therap.
Requirements