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Form 8510 is completed for applicants/individuals being assessed for Community First Choice (CFC) PAS/HAB services in the Home and Community-based Services (HCS) and Texas Home Living (TxHmL) Programs and Intellectual and Developmental Disability (IDD) Waiver. The form is used in conjunction with Form 8665, Person-Directed Plan, as an instrument for collecting and documenting essential information to determine the number of CFC Personal Assistance Services/Habilitation (PAS/HAB) hours to be authorized on the applicant’s/individual’s Individual Plan of Care (IPC).
- is developed through a person-centered planning process;
- occurs with the support of a group of people chosen by the individual (and the legally authorized representative (LAR) on the individual's behalf); and
- accommodates the individual's style of interaction, communication and preferences regarding time and setting.
The service coordinator should discuss with the individual/LAR the importance of the program provider being included when completing Form 8510.
In conjunction with Form 8665, Form 8510 is used to:
- identify and document the individual’s current and preferred living arrangement;
- determine the individual’s outcomes and identify the HAB and PAS activities to achieve the outcomes;
- assess the individual's needs, functional impairments, ability to perform activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks;
- identify natural supports available to the individual and needed service system supports;
- identify any special needs, requests, or considerations staff should know when supporting this individual; and
- document the individual’s need for CFC PAS/HAB.
When to Prepare or Update
Form 8510 is completed by the service coordinator, with input from the service planning team, when an individual’s person directed plan (PDP) indicates a need for CFC PAS/HAB and at least annually for individuals receiving CFC PAS/HAB in the HCS or TxHmL programs. The form is also updated whenever the individual’s needs have substantially changed and a revision to the number of CFC PAS/HAB hours is needed on the individual’s IPC.
The service coordinator must keep the original copy of the form in the individual's case record and provide a copy to the HCS or TxHmL program provider.
Section 1: Background Information
Individual’s Name ─ Enter the individual’s name on each page of the assessment.
Date of Assessment ─ Enter the date.
Individual’s Medicaid No. ─ Enter the individual’s nine-digit Medicaid number.
Date of Birth ─ Enter the individual’s date of birth.
Waiver Program ─ Check the box for HCS or TxHmL.
Individual’s Client Assignment and Registration (CARE) No. – Enter the identification number.
Waiver Program Provider ─ Enter the name of the provider.
Component Code ─ Enter the Component Code.
Local Intellectual and Developmental Disability Authority (LIDDA) – Enter the name of the LIDDA.
Component Code ─ Enter the Component Code.
Financial Management Services Agency (FMSA) ─ If applicable, enter the FMSA.
Component Code ─ Enter the FMSA Component Code, if applicable.
Employment Status ─ Check the appropriate box to indicate the individual’s employment status, employed, unemployed, retired or N/A. Check N/A if the individual is under age16.
Gender ─ Check the appropriate box to indicate the individual’s gender.
Educational Level ─ Check the appropriate box to indicate the individual’s education level. If none of the boxes apply to the individual’s education level, select “other” and document the individual’s education level. Enter N/A if individual is currently in school.
Participants ─ List each person, other than the individual, who participated in this assessment.
Assessment for ─ Check the appropriate box to indicate the Individual Plan of Care assessment being conducted.
Note: The information contained in this form is obtained through an information gathering conversation (the discovery process) about the individual’s abilities, preferences, and goals in line with person centered planning principles.
Section 2: Needs Assessment Questionnaire and Task/Hour Guide
The Needs Assessment Questionnaire and Task/Hour Guide is comprised of three sections:
- Part A – Functional Assessment. This part is used to assess an individual’s level of support needs, who currently provides the service, and whether the individual needs that service purchased.
- Part B – Task/Hour Guide. When a task needs to be purchased, the Task/Hour Guide details how much time is needed for providing either the PAS or HAB service.
- Part C – Subtasks and PAS Minute Ranges. This section is used to indicate the subtasks the individual needs assistance or training with when a task is purchased.
Note: The Task/Hour Guide must be completed for each purchased task and each purchased task must have subtasks indicated in Part C.
A ─ Functional Assessment
The functional assessment is comprised of the following:
- Support Level
- Service Arrangement
The Support Level is designed to assess an individual’s capacity for self-care. Score each item according to this capacity for self-care and not according to the individual’s access to a resource to assist with the task. In scoring each item, use the individual’s response, plus any observations or knowledge of the individual from other sources.
Each PAS task has an associated question to assist in scoring the support level. The first time an item is addressed, use the wording of the question as written. Then explain or paraphrase if necessary. Ask follow-up questions if there is a need to verify the first response. PAS task item 1-23 must be given a support level.
For PAS activities, score the individual according to the following scale:
|0||=||None. No functional impairment. The individual is able to conduct activities without difficulty and has no need for assistance.|
|1||=||Mild. Minimal/mild functional impairment. The individual is able to conduct activities with minimal difficulty and needs minimal assistance.|
|2||=||Severe. Extensive/severe functional impairment. The individual has extensive difficulty carrying out activities and needs extensive assistance.|
|3||=||Total functional impairment. The individual is completely unable to carry out any part of the activity.|
An individual has an impairment with respect to a particular activity if he or she is limited, either physically or mentally, in his or her ability to carry out that activity. An impairment could also be a behavioral challenge resulting in difficulty accomplishing the task.
Numbers “0” and “3” are absolutes in the sense that they indicate no functional impairment or total dependency. Example: If an individual can perform any of the dressing tasks for himself or herself, a “3” is not appropriate. If he or she can perform the dressing task completely without difficulty, a “0” is appropriate.
Enter a score for each question in the Support Level column.
Use the following examples for each item to help differentiate between scores of “1” and “2”. An individual may score “1”, but not request assistance with a task. The following are only examples of appropriate scores based on the individual’s abilities. If an example is appropriate for an individual but the score for that example is not, give the appropriate score and explain your choice.
Note: A guide to determine support level of 1 or 2 is at the end of Section 2.
|1 = Minimal/Mild Impairment||2 = Extensive/Severe Impairment|
|1.||Bathing||Individual is able to bathe self, but needs supplies laid out. Individual is able to bathe self, but needs assistance drawing and testing the temperature of the water. Individual needs standby assistance for safety or reminding/monitoring. Individual needs minimal assistance getting in and out of tub or shower. Individual may accomplish bath for self by using a chair or other adaptive device for assistance. Individual requires partial supervision or cueing. Individual requires assistance with bathing but can be left alone to soak in the tub. Individual refuses to bathe without multiple prompts.||Individual needs extensive help getting in and out of tub or shower. Individual needs hands on help with actual bathing and drying of body. Individual must always use adaptive devices and needs assistance with arranging adaptive devices for the bath. Individual can only manage sponge baths due to disabilities. Individual requiring a bed bath can assist with some part of the task. Individual always requires cueing or ongoing supervision while bathing. Individual gets out of the tub multiple times while bathing due to behavioral challenges (i.e. fear of water) or cognitive ability (i.e. does not understand reason for showering).|
|2.||Dressing||Individual needs occasional help with zippers, buttons or putting on shoes and socks. Individual may need help laying out and/or selecting clothes. Individual needs reminding or monitoring for completion of dressing. Individual occasionally refuses to get dressed.||Individual always needs help with zippers, buttons or shoes and socks. Individual needs help getting into garments; that is, putting arms in sleeves, legs in pants or pulling up pants. Individual may dress totally inappropriately without help and/or would not finish dressing without physical assistance. Individual needs help dressing because he or she routinely undresses him or herself.|
|4.||Feeding||Individual may need standby assistance but only occasional physical help. Individual needs verbal reminders or encouragement. Individual eats with adaptive devices but requires help with applying and positioning. Individual can feed self but occasionally smears food on table due to behavioral challenges or cognitive ability.||Individual usually needs extensive hands-on assistance with eating. Individual may hold eating utensils but needs continuous assistance during meals, and would not complete meal without continual help. Spoon feeding of most foods is required, but individual can eat some finger foods. Individual needs constant supervision because he or she has Prader Willi Syndrome, pica disorder, or polydipsia. Individual requires constant supervision during eating due to risk of choking.|
|5.a||Grooming||Support level is based on the highest level of support level needed on any grooming task in (5a-5b).|
|5.b||Shaving, Oral Care and Nail Care||Individual can manage grooming, but needs supplies laid out or handed to him; needs standby for safety and assistance with grooming tools. Individual can accomplish grooming, but needs reminding/monitoring. Individual occasionally refuses to complete grooming tasks.||Individual is unable to adequately shave (face or under arms and legs) because of inability to see well, to reach or to successfully use equipment. Individual is unable to adequately brush teeth and perform oral care. Individual is unable to adequately care for nails. Individual routinely refuses to complete grooming tasks.|
|5.c||Routine Hair and Skin Care||Individual can manage hair and skin care but needs supplies laid out. Individual needs reminding to do tasks. Individual needs assistance to comb or brush hair. Individual needs assistance applying non-prescription lotion to skin. Individual sometimes requires prompting to complete tasks. Individual pushes hands away when hair is brushed.||Individual is unable to adequately perform washing hair (shampooing), drying hair or setting (rolling/braiding) hair. Individual is unable to adequately wash hands and face or apply makeup. Individual refuses to complete tasks or has moderate behaviors surrounding these tasks. Individual always needs assistance because he or she screams when face gets wet. Individual always requires prompting to complete tasks.|
|6.||Toileting||Individual has instances of urinary incontinence and needs help because of this from time to time. Fecal incontinence does not occur unless caused by a specific illness episode. Individual may need help with supplies or equipment. Individual needs some assistance with clothing during toileting. Individual needs standby assistance. Individual may have catheter or colostomy bag, and occasionally needs assistance with management.||Individual often is unable to get to the bathroom on time to urinate or has occasional episodes of fecal incontinence. Individual may wear incontinence products to manage the problem and needs assistance with them. Individual usually needs assistance with catheter or colostomy bag. Individual needs assistance with a bedpan or urinal, or with emptying a catheter bag or changing an external catheter or colostomy bag. Individual needs diapers changed or needs assistance with feminine hygiene products.|
|7.||Hygiene in Toileting||Individual can usually manage cleaning self after toileting except on occasional days when bending or moving is particularly difficult, or when incontinence occurs. Individual may have catheter or colostomy bag, and occasionally needs assistance with management. Individual occasionally needs assistance toileting due to cognitive ability (i.e., lack of understanding of hygiene) or due to behavioral challenges (i.e., fecal smearing).||Individual often needs assistance with cleaning after toileting because of difficulty in reaching, or due to incontinence problems; clothes are sometimes soiled and odorous. Individual usually needs assistance with catheter or colostomy bag. Individual routinely needs assistance toileting due to cognitive ability (i.e., lack of understanding of hygiene) or due to behavioral challenges (i.e., fecal smearing).|
|8.||Transfer||Individual usually can get out of bed or chair with minimal or standby assistance. Individual may accomplish transfer without help, but needs standby assistance for safety. Individual needs some assistance in adjusting or changing position in a bed or chair (positioning). Individual may sometimes need prompting to complete transfers.||Individual usually needs hands-on assistance when rising to a standing position or moving into a wheelchair to prevent losing balance or falling. Individual is able to help with the transfer by holding on and supporting him or herself. Individual can assist some with non-ambulatory movement from one stationary position to another (transfer). This task does not include carrying. Individual usually needs assistance transferring due to behavioral challenges or cognitive ability.|
|Individual walks alone without assistance for only short distances. Individual can walk with minimal difficulty using an assistive device or by holding onto walls or furniture. Individual needs assistance in positioning for use of a walking apparatus or putting on and removing leg braces and prostheses for ambulation. Individual may need repeated prompts while ambulating.||Individual has considerable difficulty walking even with an assistive device. Individual can walk only with assistance from another person and never walks alone outdoors without assistance. Individual may use a wheelchair periodically. Individual needs assistance with wheelchair ambulation. Wheelchair ambulation is defined as pushing the wheelchair for the individual. Individual needs assistance walking due to behavioral challenges or cognitive ability.|
|10.||Cleaning||Individual can do most tasks around the house, like picking up, dusting, washing dishes, sweeping, straightening the bed, carrying out trash, light vacuuming or cleaning sinks. Individual cannot move heavy furniture nor do extensive scrubbing or mopping. Individual may be capable of cleaning but may refuse or sometimes require repeated prompts to complete tasks.||Individual is able to do only very light housework like dusting, washing a few dishes or straightening up magazines/newspapers. Individual cannot see well enough or does not have the strength or flexibility to sweep floors, change bed linens or carry heavy objects. Individual may excessively collect items or neglect to pick up after themselves Individual may be capable of cleaning but routinely refuses or requires repeated prompts to complete tasks.|
|11.||Laundry||Individual does hand washing but has difficulty wringing and hanging heavy laundry to dry. Individual is able to do most laundry tasks, but needs minimal assistance to put clothes in machines, sort clothes, fold them and put them away. Individual may have strength but may not be able to see or turn washer dials, or may require supervision/instruction to use a washer. Individual may be capable of doing laundry activities but may refuse or require repeated prompts to complete tasks.||Individual may do light hand washing but cannot bend or lift or carry loads of clothes to manage most laundry; and cannot hang clothes out at all or get them off a line, but may fold them and help put them away. Individual may not be able to wring out clothes without help. If a laundromat is used, the individual has considerable difficulty getting there. Individual has special laundry needs due to incontinence or other physical problems and needs laundry more frequently than once a week.|
|12.||Meal Preparation||Individual can do some meal preparation, but has some difficulty. Individual can prepare simple foods or warm up food like frozen meals or food prepared by others. Individual may have difficulty with cutting meats or other foods. Individual can prepare foods, but needs assistance with meal planning or minimal assistance in preparing meals. Individual may need assistance carrying food items or meal preparation items. Individual needs assistance with hygienic and safe practices around food preparation and storage.||Individual is unable to cook meals due to physical impairment and can only do minimal preparation of simple cold foods like sandwiches or cereal. Individual has difficulty opening cans and preparing fresh foods for cooking. Individual regularly has difficulty seeing or turning burners on and sometimes forgets to turn them off. Individual needs prepared meals pureed or ground up for serving.
Individual may be fearful or unable to use kitchen appliances safely due to behavioral challenges or cognitive ability.
|14.||Shopping||Individual decides what to buy, but needs assistance preparing a shopping list. Individual can shop if someone goes along to help. This could be prompting or assistance with using money to purchase items. Individual may shop by telephone but needs assistance carrying or storing groceries. Individual can do most shopping, but needs extra items picked up between shopping trips.||Individual may still decide what to buy, but seldom, if ever, goes to a store and needs shopping for all items and picking up medications. Individual may not be able to shop by telephone because of communication difficulties. Individual cannot regularly carry or store most of the purchases without help. Individual may wander off during shopping due to cognitive ability or yell/cry during shopping trips due to behavioral challenges.|
|15.||Assistance with Medications||Individual can self-direct* medications, but occasionally needs help with opening the containers. Individual may need to be reminded to take medications.
*Self-direct means the individual can:
|Individual can self-direct* medications, but needs help opening containers and/or needs the medication brought to within reach. Individual can self-direct * medications, but has a visual impairment and may not be able to read labels. Individual can self-direct* medications, but must be reminded to ensure that medications are taken as prescribed.
This task may not be purchased if the functional score is “3.”
|16.||Balance||Individual occasionally gets dizzy and/or needs to steady himself by holding onto furniture or a person and may need to hold someone's arm to go up and down stairs. Individual may have experienced an occasional fall because of imbalance or the applicant's/Individual's movement is restricted because of fear of falling.||Individual usually experiences some imbalance and needs to hold onto a support when he first stands up to steady himself. Individual suffers from dizziness that affects his balance and would likely fall if assistance was not available.|
|17.||Open Jars, Containers||Individual can open some containers but may have difficulty with very large jars, special medicine caps or containers that require special opening instructions or procedures. Individual may use an assistive device.||Individual cannot open large jars or new bottles/jars without help or an assistive device. Individual may be able to open small jars and bottles that have been previously opened.|
|18.||Telephone||Individual can use telephone but may have difficulty hearing or getting to the telephone quickly when it rings. Individual may need to go out of the home to use telephone but can do so without much difficulty.||Individual may be able to answer and/or talk on the telephone but may not be able to dial the correct number. Individual is sometimes not able to get to a telephone when necessary. Individual may be able to use the telephone but may require repeated prompting and monitoring to use appropriately (i.e. individual is susceptible to being taken advantage of by telemarketers).|
Service Arrangement ─ Enter the following codes to indicate the service provider for PAS and HAB activities./p>
|Self. Use “S” if the Individual performs the task without any assistance.|
|C =||Caregiver. Use “C” when all of the task is being performed by or training is being provided by an unpaid caregiver, such as a relative, neighbor or friend on a regular basis.|
|P =||Purchased. Use “P” if any part of the task is to be purchased all of the time or at times when another service arrangement type is not available to assist.
For TxHmL only, an individual receiving Home Delivered Meals (HDM), meal preparation as a CFC PAS/HAB task must not be purchased for the meal that is being delivered. For example, If Wednesday lunch is being delivered through HDM, then CFC PAS/HAB may not be purchased for meal preparation for Wednesday lunch.
If the support level score is “3”, a service arrangement code of “P” must not be used for Item 15, Assistance with Medications.
|P/C =||Purchased/Caregiver. Use “P/C” when the caregiver is assisting with, performing a purchased task or training the individual on how to perform the task during the time the attendant is present. Document in the Preferences and Special Considerations section the part of the task the caregiver performs or provides training on.
Example 1: The caregiver assists with bathing by laying out supplies, but needs the CFC PAS/HAB service provider to assist with the bath.
Example 2: The individual requests a five-day plan and the daughter, who is the caregiver, works Monday, Wednesday and Friday. The daughter assists the individual with bathing on Tuesday and Thursday during the time the CFC PAS/HAB service provider is present performing other tasks.
When the caregiver is not available during the time purchased tasks are delivered and helps only in the evenings and/or on weekends, a general comment may be entered in the Comments section. The tasks are not coded as “P/C,” but “P” only for purchased tasks.
Example 3: The individual requests a five-day plan and the caregiver works full time. The caregiver will assist in the evenings and on the weekend, but does not assist with tasks during the time the CFC PAS/HAB service provider is present. A comment, "Caregiver (use name and relationship) assists in the evenings and on weekends" in the Preferences and Special Considerations section is adequate documentation. Code the task as “P.”
Example 4: The caregiver packs breakfast and lunch for the individual but the CFC PAS/HAB service provider provides training to the individual on meal preparation for dinner.
Example 5: The caregiver assists the individual on and off the toilet but the CFC PAS/HAB service provider teaches the individual about toileting hygiene.
|A =||Other agency. Use “A” when an agency that does not contract with the HCS/TxHmL program provider is performing the task.|
|P/A =||Purchased/Agency. Use “P/A” when another agency is available to perform the task on some days, but not other days. Document in the Preferences and Special Considerations section the part of the task the other agency performs.|
|N/A =||Not Applicable or None Available. Not Applicable: The only tasks that can be not applicable are Walking and Assistance with Medications. Use “N/A” when the individual is unable to perform any part of the walking task, exercise task or assistance with medications task, and there is no caregiver or other agency totally performing the task. For example, an individual is a double amputee and is unable to walk or use wheelchair ambulation. No time will be allotted for the task. Explain in the Preferences and Special Considerations section the task is not applicable.|
Part B — Task/Hour Guide Column
PAS Minutes Per Day — For each PAS task to be purchased as CFC PAS/HAB, enter the daily number of minutes needed to conduct that task based on the support level and the minute range for that task indicated in Part C for PAS. Times must be shown in five-minute increments and, if needed, rounded up to the next five-minute increment. The time allotted for PAS must be within the range indicated in Part C for the support level and cannot be higher or lower, except in the following situations:
- If an individual has a compelling reason for not wanting any of the subtasks under the appropriate support level, but only wants subtasks listed in a lower support level, document the individual's request and allocate minutes in the minute range for the subtasks selected. Document the reason.
Example: The individual scores “2” on bathing. She needs assistance with drying. However, when discussing subtasks, she states she would like standby assistance for safety and drawing of water, all under the support level of “1.” She states her skin is very sensitive and she would not allow help with drying as she is afraid it would hurt her. The subtasks checked are all under the support level of “1,” so ten minutes is allowed. Documentation is required to explain the variance.
- If an individual has a caregiver or other agency performing part of a task and only subtasks in a lower support level are needed, the service coordinator must document the individual's request and allocate minutes in the minute range for the subtasks selected. Document the reason.
Example: The individual scores “2” for bathing, but only wants assistance with laying out supplies and drawing water because her daughter provides all hands-on assistance with the bathing task. The task is marked “P/C.” The subtasks under the support level of “1” are checked and ten minutes is allowed for the subtasks to be purchased. Documentation is required to explain the variance.
A task may be purchased if it is performed at least once a month by the CFC PAS/HAB service provider. Time allotted for the task must be prorated into a weekly amount. Example: Escort 1/month × 120 minutes. ÷ 4.33 = 28 minutes/week (round up to the next five-minute increment) = 30 minutes/week.
Escort may be shown as PRN (as needed), if it occurs less than once a month no time is allocated.
Note: If the individual has extenuating circumstances (other than the exceptions listed above) and requires time outside the range (either more or less) for the subtasks within the appropriate support level, then enter the requested number of minutes. Do not change the support level to adjust the minutes, or for the convenience of a service provider.
HAB Minutes Per Day — For each task to be purchased as CFC PAS/HAB, enter the daily number of minutes needed to provide habilitation on that task. As a guide, an individual with an LON 1 would likely benefit from more HAB minutes than an individual with an LON 5 or 6.
Days Per Week — For each PAS task and each HAB task to be purchased as CFC PAS/HAB, enter the number of days per week the CFC PAS/HAB service provider will conduct that task. Enter in the Preferences and Special Considerations section if the task is performed less than once a week. (For the task of Feeding, enter the total number of meals per week.)
Sub-Total Minutes Per Week — Multiply the minutes per day by the days per week to obtain the Sub-Total Minutes Per Week for each PAS and HAB task.
Part C — Subtasks for PAS and HAB and PAS Minute Ranges
Note: The minute ranges in this section only apply to PAS activities.
The subtasks listed in columns for support levels 1, 2, and 3, relate to PAS. The boxes in the HAB columns relate to the subtasks in the columns to the left of the HAB column.
Boxes are checked to identify the PAS subtasks and the HAB subtasks. Note that some PAS subtasks are not suitable to be checked for HAB (e.g., stand-by assistance for safety, reminding and monitoring, total help with feeding).
The subtasks in Part C must be checked to indicate specifically what the individual needs. An individual with a Support Level score of “2” or “3” may need all subtasks under the support level for “1” and additional subtasks under the support level of “2.”
Preferences or Special Considerations
Indicate any preferences or special considerations identified during the discovery process in the space provided for each task. This could include the individual’s preference to take baths over showers, or factors such as behaviors that result in higher scores.
Section 3: Additional Habilitation Activities
The information below includes examples of habilitation activities and may be used to determine whether an individual needs habilitation training in these specific tasks. The service coordinator must ensure all HAB activities on this form relate to an outcome in the individual’s PDP.
Information about the service arrangement is below the examples.
|19.||Money Management||Individual may need assistance counting money, learning how to budget, paying for items among others.|
|20.||Interpersonal Communication||Individual may need assistance communicating with others, in person, on the phone, or on the computer.|
|21.||Community Integration||Individual may need assistance finding, participating in and accessing community activities.|
|22.||Reduction of Challenging Behaviors||Individual may have challenging behaviors that can be reduced through behavior support plans, prompting, rewards, or redirection among others.|
|23.||Accessing Leisure Time and Recreational Activities||Individual may need assistance finding activities they would like to participate in during leisure time or accessing those activities,|
|24.||Self-Advocacy||Individual may need assistance learning how to advocate for themselves or for causes. Advocating for oneself could include asserting preferences or requesting needed services.|
|25.||Socialization/Development of Relationships||Individual may need assistance with development and maintenance of relationships or appropriate social behaviors.|
|26.||Personal Decision Making||Individual may need assistance making decisions for him or herself, including assistance in assessing what is important to that individual, pros and cons, as well as consequences.|
|27.||Accessing Community Resources||Individual may need assistance finding, participating in and accessing community resources such as free meal programs, churches, or parks.|
|28.||Use of Augmentative Communication Devices||Individual may need assistance operating, learning to use, or accessing an augmentative communication device.|
|29.||Other||Include other activities that the individual may have a need for habilitation training in the “other” category if it does not fit in an existing category.|
|30.||Other||Include other activities that the individual may have a need for habilitation training in the “other” category if it does not fit in an existing category.|
Section 4: Health-Related Tasks
Except for those who use the Consumer Directed Services (CDS) option, information for this section can be found on the Nursing Screen Tool or the Nursing Assessment. If the person uses the CDS option and there is no Nursing Screen Tool or Nursing Assessment, ask the questions about health-related tasks.
Medication Administration ─ Answer Yes or No if the individual requires administration of medication to ensure that medications are received safely. Check the appropriate box(es) for the routes of administration of medication.
Special Procedures ─ Answer Yes or No for all questions.
Eating ─ Answer Yes or No for all questions.
Bathing ─ Answer Yes or No if the individual needs assistance.
Toileting ─ Answer Yes or No for all questions.
Mobility ─ Answer Yes or No for all questions.
Section 5: Living Arrangement ─
Indicate if the individual lives alone, with parents, spouse/partner/relative or non-relatives/room mates. Provide the relationship, age and presence of a disability for all who reside in the same household as the individual.
Section 6: Caregiver Availability ─
To be completed for each caregiver.
Name ─ Enter the name of the caregiver.
Relationship to Individual ─ Enter the relationship.
Work Schedule ─ Enter the schedule for each day of the week.
Unpaid Support Supervision Provided to Individual ─ Enter the schedule for each day of the week. Provide additional comments relevant to caregiver schedules. For example, document if the individual's unpaid caregiver also provides care and support to others in the home or has other barriers not indicated.
Section 7: Nursing Services –
Enter the schedule for nursing waiver or private duty nurse.
Section 8: Individual’s Work/School Schedule
Day Activity ─ Check the appropriate box for Day Activity and Health Services (DAHS), Employment, Employment Assistance, Supported Employment, Day Habilitation or Other. Enter the hours for each day of the week and total the hours. Provide any additional information in the Comments section.
Education ─ Check the appropriate box for School, Home Schooled, Higher Education or Other. Enter the hours for each day of the week and total the hours. Provide any additional information in the Comments section.
Section 9: Calculating Total Personal Assistance Services (PAS) and Habilitation (HAB) Hours
Total PAS Minutes Per Week — Add the sub-total minutes for each task 1-19 to obtain the Total PAS Minutes for all tasks.
Total PAS Hours Needed Per Week ─ Divide the Total PAS Minutes by 60 to determine the weekly total in hours. Round the weekly number of hours to the next highest half hour to determine the total hours to authorize. Example: If an individual needs 7 hours and 10 minutes of service each week, enter 7.5 in Hours Needed.
Total HAB Minutes Per Week ─ Add the sub-total HAB minutes for each task 1-19, and 24-36 to obtain the Total HAB Minutes for all tasks.
Total HAB Hours Needed Per Week ─ Divide the Total HAB Minutes by 60 to determine the weekly total in hours. Round the weekly number of hours to the next highest half hour to determine the total hours to authorize. Example: If an individual needs 7 hours and 10 minutes of service each week, enter 7.5 in Hours Needed.
Total Combined PAS and HAB Hours Per Week — Enter the total weekly hours that can be authorized by adding together the Total PAS Hours Per Week and the Total HAB Hours Needed Per Week. Round the time up to the next highest half hour.
CFC PAS/HAB Recommended Total Hours ─ Indicate the total combined recommended CFC PAS/HAB hours as listed at the end of Section IV.
Section 10: Acknowledgement Page – Signing this page affirms:
- The individual/LAR/LIDDA service coordinator/program provider participated in the service planning process.
- The individual/LAR/LIDDA service coordinator/program provider understands that this document and the hours listed on this plan are only a recommendation and not a guarantee of services to be provided. This recommendation will, however, be used to guide the approval and provision of services for CFC.
Signature – Individual and/or Signature – Legally Authorized Representative ─ The individual and/or LAR must sign and date this form after completion. Any updates to the form must be initialed and dated by the individual/LAR. If the individual/LAR refuses to sign the form, the LIDDA service coordinator should note this on the signature line of the form.
Printed Name ─ Print the individual’s and/or LAR’s name legibly.
Signature – Service Coordinator ─ The service coordinator must sign and date the form after completion. Any updates to the form must be initialed and dated by the service coordinator.
Printed Name ─ Print the service coordinator’s name legibly.
Signature – Program Provider ─ The program provider acknowledges participation in the assessment and must sign and date the form after completion.
Printed Name ─ Print the program provider’s name legibly.