Form 8578, Intellectual Disability/Related Condition Assessment

Instructions

Updated: 2/2020

Purpose

Applicable Texas Health and Human Services Commission (HHSC) programs use Form 8578 Intellectual Disability/Related Condition Assessment when documenting certain information. These programs include:

• Intermediate Care Facilities for Individuals with an Intellectual Disability or Related Conditions (ICF/IID);
• Home and Community-based Services (HCS);
• Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS);
• Deaf Blind with Multiple Disabilities (DBMD); and
• Local Intellectual Developmental Disability Authority (LIDDA).

The needed information is:

HCS, TxHmL and ICF/IID

• request a level of care (LOC) and level of need (LON) assignment (Purpose Code 2);
• comply with continued-stay review (Purpose Code 3);
• request assignment of a level of need (LON) when necessary (Purpose Code 4);
• request an LOC and LON for a lapsed ID/RC assessment (Purpose Code E for ICF/IID only); and
• demonstrate compliance with federal utilization review requirements.

CLASS and DBMD

• request a level of care (LOC) assignment (Purpose Code 2);
• comply with continued-stay review (Purpose Code 3);
• demonstrate compliance with federal utilization review requirements.

Note: When a Related Condition is a primary diagnosis:

• Use Form 8662, Related Conditions Eligibility Screening Instrument, to verify a diagnosis of a related condition. For CLASS and DBMD, complete this form and submit with Form 8578. For ICF/IID, HCS, and TxHmL, refer to Determination of Intellectual Disability (DID) Best Practice Guidelines.
• The related condition must be listed on the HHS Approved Diagnostic Codes for Persons with Related Conditions List (See the list at ICD-10).

Procedure

When to Prepare

Complete Form 8578 using information collected from the applicant or provided by an interested party on behalf of the applicant when an LOC and LON assignment is requested. Once a person is enrolled in a program, this form is completed for every LOC or LON action.

Transmittal

• For HCS and TxHmL, the LIDDA or provider enters Form 8578 information into Client Assignment and REgistration (CARE).
• For ICF/IID, the LIDDA or provider enters Form 8578 information into the Texas Medicaid & Healthcare Partnership (TMHP) Long-term Care Provider Portal.
• For CLASS, the direct service agency submits:
  • the original Form 8578, Related Conditions Eligibility Screening Instrument;
  • Form 8662; and
  • the instrument that was used to determine adaptive behavior level (ABL) to Intellectual and Developmental Disability (IDD) Program Eligibility and Support (IDD PES) for review.
• For DBMD, the provider submits:
  • the original Form 8578, Related Conditions Eligibility Screening Instrument;
  • Form 8662; and
  • the instrument that was used to determine adaptive behavior level to IDD Waivers/Community Services/Utilization Review for review.

	CLASS	DBMD
Mail	IDD Program Eligibility and Support (IDD PES) CLASS Mail Code: W-254 P.O. Box 149030 Austin, TX 78714-9030	IDD Waivers/Community Services/Utilization Review DBMD Mail Code: W-521 P.O. Box 149030 Austin, TX 78714-9030
Fax	512-438-5135
IDD Portal	hhs.texas.gov/doing-business-hhs/provider-portals/resources/idd-ops-portal

LON Increase Packet Transmittal

• For HCS, TxHmL, and ICF/IID, the LIDDA or provider submits a packet when requesting an LON increase to IDD Waivers/Community Services/Utilization Review for review. Refer to the LON Resources link for instructions.

	HCS/TxHmL/ICF/IID
LON Resources	hhs.texas.gov/doing-business-hhs/provider-portals/long-term-care-providers/resources/idd-waivers-program-enrollmentutilization-review/level-need-lon-resources

Form Retention

Retain copies of all forms in accordance with Texas Administrative Code Title 40 Part 1, Chapter 49, Subchapter C, Record Retention and Disposition, §49.307. The ICF/IID provider or LIDDA must keep the records of people under 18 years of age for three years past their 18th birthday even if the retention period exceeds six years.

Physician's Signature (Complete for ICF/IID Only)

For a person requesting admission into an ICF/IID, Items 19 and 48-55 must be completed, and a physician must sign the paper copy (Item 52) attesting to the information documented in Items 19 and 48 through 51. The physician's name must be printed in full in Item 53.

For a following Form 8578, if the physician has delegated the completion of Items 19 and 48-55 to an advance practice nurse (APN) or a physician assistant (PA), the APN or PA must sign the paper copy (Item 52 attesting to the information documented in Items 19 and 48-51). The APN's or PA's full name must be printed in Item 53. The physician's license number must be noted in Item 55 and the APN's or PA's license number noted in Item 72.

Source of Forms and Information Regarding ID/RC Assessment

hhs.texas.gov/laws-regulations/forms

Refer questions regarding Form 8578 or instructions to:

	HCS/TxHmL/ICF/IID	CLASS	DBMD
LOC	IDD PES 512-438-2484		IDD UR 512-438-4896
LON	IDD UR 512-438-5055	N/A

Form Items

The following table describes the fields as they are displayed on the form.

Item Name	Contents
1. Facility/Provider Name	The name of the facility, if the person lives in an ICF/IID. The name of the provider agency, if the person is receiving waiver services.
2. Contract No.	Contract number under which services are provided to this person.
3. Mailing Address	Provider's mailing address
4. Name (Last/First/Middle)	Applicant's last name, first name and middle name or initial.
5. Applicant's Address	Applicant's current mailing address, including street or P.O. Box, city, state and Zip code.
6. Component Code	Code to indicate the agency component at which the person is or will be receiving services. Applicable for HCS, ICF/IID and TxHmL.
7. Case No.	Applicant's local case number assigned by the agency component. Applicable for HCS, ICF/IID and TxHmL.
8. Medicaid No.	Applicant's Medicaid number, if known.
73. CARE ID	Applicant's Client Assignment and Registration (CARE) system identification number (ID), if known. Applicable for HCS, ICF/IID and TxHmL.
9. HIC/Medicare No.	Applicant's Health Insurance Claim (HIC) number and letters or Medicare number, if known.
10. Date of Birth	Applicant's date of birth in MM-DD-YYYY format.
11. Social Security No.	Applicant's nine-digit Social Security number.
12. Date Completed	Date the RN/LVN/QIDP/ Case Manager/LIDDA Service Coordinator/HCS Provider Representative completes the form, as applicable to the program.
13. Purpose Code	Code to indicate the purpose of this assessment. 2 = No Current Assessment (enrollment or admission) 3 = Continued Stay Assessment (annual renewal) 4 = Change LON on Existing Assessment for HCS/TxHmL and ICF/IID (LON increase requires supporting documentation) E = Request LOC and LON for a lapse in ID/RC Assessments for ICF/IID only.
14. Date of Physical Examination	Date of the most recent physical evaluation in MM-DD-YYYY format.
15. Legal Status	Code to indicate the individual's legal status. 0 = Minor – younger than 18 years of age (with parent/guardian) 1 = Minor (ward of the state) 2 = Minor w/conservator 3 = Adult w/guardian of estate and person 4 = Adult w/guardian of estate 5 = Adult w/guardian of person 6 = Adult w/limited guardianship 7 = Adult w/temporary guardian 8 = Adult w/no guardian
16. Previous Residence	Code to indicate the individual's previous residence/location/program before the current enrollment. 1 = Home (not enrolled in any program) 2 = Hospital 3 = Another ICF/IID community-based facility 4 = HCS, TxHmL, CLASS or other waiver services 5 = State hospital or state supported living center 6 = Nursing facility 7 = Other 8 = Cannot determine
17. Recommended LOC	Code to indicate the LOC recommended by the submitter. 0 = Denial of LOC 1 = LOC I 8 = LOC VIII
18. Recommended LON	Code to indicate the LON recommended by the submitter. 1 = LON 1 (Intermittent) 5 = LON 5 (Limited) 8 = LON 8 (Extensive) 6 = LON 6 (Pervasive) 9 = LON 9 (Pervasive +) Note: See Calculating LON chart. Applicable for HCS, ICF/IID and TxHmL.

Diagnosis

Item Name	Contents
19. Primary Diagnosis	A primary diagnosis is the condition chiefly responsible for the request for programmatic services.
20. Code	Code of primary diagnosis listed in the International Classification of Diseases (ICD). Note: This code must match the primary diagnosis entered in Item 19 on the original (hard) copy.
21. Version Code	Version of the ICD in use by HHSC at the time of the diagnosis for the individual's primary diagnosis.
22. Onset	Month and year of the onset of the individual's primary diagnosis.
23. Medical Diagnosis/DBMD Second Condition	Any current medical diagnoses that the person may have as determined by a licensed physician. Used to indicate factors that have a direct bearing on the required treatment or care or DBMD second condition.
24. Code	Code from the ICD indicating the individual's current medical diagnosis or DBMD second condition.
25. Version Code	Version of the ICD in use by HHSC at the time of the diagnosis for the person's medical diagnosis or DBMD second condition.
26. Psychiatric Diagnosis/Additional Diagnosis(es)	Diagnosis if the person has any current mental disorder, behavioral health disorder(s) or DBMD additional condition as diagnosed by a licensed physician or an authorized provider in accordance with the Diagnosis and Statistical Manual of Mental Disorders (DSM) or ICD.
27. Code	Code from the DSM or ICD for the person's psychiatric diagnosis or DBMD additional condition.
28. Version Code	Version of the DSM or ICD used for the person's psychiatric diagnosis or DBMD additional condition.

Cognitive/Adaptive Functioning

Item Name	Contents
29. IQ	Current IQ score. Must use Determination of Intellectual Disability Best Practice Guidelines (DID BPG). (Only applicable to HCS, TxHmL, and ICF/IID)
68. IQ Instrument	01 = Wechsler Intelligence Scale for Children (WISC) 02 = Wechsler Adult Intelligence Scale (WAIS) 03 = Wechsler Preschool and Primary Scale of Intelligence (WPPSI) 04 = Stanford-Binet form LM (S-B LM) 05 = Cattell Intelligence Test Scale 06 = Peabody Picture Vocabulary Test (PPVT) 07 = Beta 08 = Other 09 = WISC (Revised) 10 = WAIS (Revised) 11 = PPVT (Revised) 12 = Slosson Intelligence Test (SIT) 13 = Leiter International Performance Scale (LIPS) 14 = WISC III 15 = WAIS III 16 = LIPS-Revised 17 = S-B 4th 18 = S-B 5th 19 = WISC IV 20 = SIT-Revised Note: This is not required for CLASS or DBMD.
30. ABL	Code to indicate the individual's ABL.   01 = Mild 02 = Moderate 03 = Severe 04 = Profound Note: CLASS and DBMD providers reference ABL conversion chart. HCS, TxHmL, and ICF/IID reference the DID Best Practice Guidelines. If ABL is 0 for HCS and TxHmL, enter the comment that ABL is 0 in the provider comments on the form.
69. ABL Instrument	01 = Vineland 02 = Inventory for Client and Agency Planning (ICAP)/Other 03 = Vineland ABL Standard Score 04 = Vineland Adaptive Behavior Scales, Second Edition (Vineland-II) 05 = Scales of Independent Behavior – Revised (SIB-R) 06 = American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS)
70. ABL	Assessment Date    To be used by CLASS and DBMD. Date that adaptive behavior level was assessed using one of the approved instruments.
71. Level of Consciousness	Level of Consciousness – The state of awareness, varying from alert wakefulness to a complete lack of responsiveness. This item must be number 1, 2 or 3 for the individual to be eligible for CLASS or DBMD. 1 = Alert – responds quickly to verbal stimuli or/and the environment 2 = Lethargic – easily aroused, but drowsy; may follow two-part commands 3 = Stupor – very hard to arouse; may require vigorous stimuli; may follow simple commands 4 = Comatose – unable to arouse; does not respond to vigorous stimuli; unable to follow commands
74. Score Identified by ABL Instrument	To be used by CLASS and DBMD. The provider notes the assessment score identified by the selected ABL instrument in the applicable format.
75. Functional Assessment	To be used by CLASS and DBMD. The provider notes the total number of Yes responses in Section 4 A.-F. of Form 8662, Related Conditions Eligibility Screening Instrument.

ICAP Data (not required for DBMD and CLASS)

Item Name	Contents
31. Broad Independence	Domain score calculated from the Inventory for Client and Agency Planning (ICAP) assessment.
32. General Maladaptive	Score with + or −, as applicable (CARE system only accepts "−" from key above "p" on computer keyboard).
33. ICAP Service Level	Person's actual service level obtained from the ICAP assessment.

Behavioral Status (ICF/IID, HCS and TxHmL only)

Item Name	Contents
34. Behavior Program	Y (Yes) or N (No) to indicate if a behavior program is in place for the person. Note: If a value of N is entered, Items 35-38 must have a value of 0.
35. Self-injurious Behavior	(Behavior examples include self-inflicted tissue damage, including that related to property destruction, pica and excessive food consumption for individuals with Prader-Willi syndrome.) Code to indicate Level of Caregiver Preventive Intervention: 0 = Not applicable or not on behavior program 1 = Requires additional staff supervision to prevent dangerous behavior (this code indicates a Behavior increase request) 2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior that could be life threatening to the individual or to others. (this code indicates a request for LON 9) Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).
36. Serious Disruptive Behavior	(Behavior examples include threatening strangers, running into traffic and public disrobing.) Code to indicate Level of Caregiver Preventive Intervention: 0 = Not applicable or not on behavior program 1 = Requires additional staff supervision to prevent dangerous behavior 2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior that could be life threatening to the individual or to others. Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).
37. Aggressive Behavior	(Behavior examples include physical attacks against others.) Code to indicate Level of Caregiver Preventive Intervention: 0 = Not applicable or not on behavior program 1 = Requires additional staff supervision to prevent dangerous behavior 2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior that could be life threatening to the person or to others. Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the person (Item 34=Y).
38. Sexually Aggressive Behavior	(Behavior examples include sexual assault, pedophilia and public masturbation.) Code to indicate Level of Caregiver Preventive Intervention: 0 = Not applicable or not on behavior program 1 = Requires additional staff supervision to prevent dangerous behavior 2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior that could be life threatening to the person or to others. Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).

Nursing

Item Name	Contents
39. Service Provider	Code to indicate the licensed or registered professionals who provide nursing services to the individual. 15 = Registered Nurse 16 = Licensed Vocational Nurse
40. Frequency Code	Code to indicate the frequency of nursing services for the individual 0 = Individual does not have these services included in the IPP, ISP or IPC 1 = 15 minutes or less per week (0-13 hours per year) 2 = 16-30 minutes per week (14-26 hours per year) 3 = 31-60 minutes per week (27-52 hours per year) 4 = 61-149 minutes per week (53-130 hours per year) 5 = 150-180 minutes per week (131-156 hours per year) 6 = 181 or more minutes per week (157+ hours per year)

Day Services

Field Name	Contents
41. Service	Code to indicate if the person participates in day services (group settings that are not individualized, including sheltered workshops and enclaves). 0 = Person does not participate 1 = Person does participate
42. Frequency Code	Code to indicate the frequency of the individual's participation in day services. 0 = Person does not participate in day services 1 = up to 5 hours per week 2 = 6-10 hours per week 3 = 11-15 hours per week 4 = 16-20 hours per week 5 = 21-25 hours per week 6 = 26 or more hours per week
43. Funding Code	Code to indicate funding for the day services. 0 = Person does not participate in day services 1 = Medicaid funding 2 = Texas Education Agency funding 3 = Funding from other state agencies 4 = General Revenue funding 5 = Other funding sources (church, senior citizen center, Salvation Army, etc.)

Employment Services

Item Name	Contents
44. Service	Code to indicate the person participates in employment services. 0 = Person does not participate 1 = Person participates in short-term employment services (for example, employment assessments, job development) 2 = Person participates in long-term employment services (for example, ongoing, long-term support to maintain individualized, competitive employment) 3 = Person participates in both short-term and long-term employment services (both 1 and 2)
45. Frequency Code	Code to indicate the frequency of the person participation in employment services. 0 = Person does not participate 1 = up to 5 hours per week 2 = 6-10 hours per week 3 = 11-15 hours per week 4 = 16-20 hours per week 5 = 21-25 hours per week 6 = 26 or more hours per week
46. Funding Code	Code to indicate funding for employment services. 0 = Person does not participate 1 = Medicaid 2 = Texas Education Agency 3 = Department of Assistive and Rehabilitative Services 4 = General Revenue 5 = Other (non-state agency)

Functional Assessment

Item Name

Contents

47. Ambulation

Code to indicate the person's ambulation. 1 = Walks independently; walks with no supervision or physical hands-on assistance. May require mechanical devices (such as cane, crutch or walker), but not a wheelchair. 2 = Walks with intermittent supervision or physical hands-on assistance for difficult maneuvers (such as for stairs, ramps). May or may not require the use of mechanical devices (such as cane, crutch or walker), but not a wheelchair. 3 = Walking requires constant supervision, physical hands-on assistance (with or without mechanical devices, but not a wheelchair), or both. 4 = Wheelchair is the most appropriate method of ambulation.

Physician's Evaluation and Recommendation (ICF/IID Only.)

Item Name	Contents
48. Does medical regimen of the individual need to be under the supervision of an M.D./D.O.?	Check Yes or No to indicate if the person's medical regimen needs to be under the supervision of an M.D. or D.O. Note: Yes must be indicated for the person to be eligible for ICF/IID program.
49. Will the health status of the individual prevent participation in the active treatment of the ICF/IID program?	Check Yes or No to indicate if the person's health status prevents participation in the active treatment of the ICF/IID program. Note: No must be indicated for the person to be eligible for ICF/IID program.
50. To your knowledge, does the individual have a condition of intellectual disability (previously referred to as "mental retardation") and/or a related condition?	Check Yes or No to indicate if the person has a condition of intellectual disability or a related condition. Note: Yes must be indicated for the person to be eligible for ICF/IID program.
51. Do you certify that this individual requires ICF/IID or ICF/IID-RC care?	Check Yes or No to indicate if you certify that this person requires ICF/IID care. Note: Yes must be indicated for the person to be eligible for ICF/IID program.
52. Signature – I attest to Item 19 and Items 48-51 only.	Signature of the M.D./D.O./Advance Practice Nurse/Physician Assistant. For admission to ICF/IID, signature of the M.D./D.O. is required. Signature by designee is allowed for subsequent ID/RC Assessments.
53. Print full Name	Physician's or Advance Practice Nurse/Physician Assistant's printed full name.
54. Date Completed	Date of Physician's or Advance Practice Nurse/Physician Assistant's signature.
55. Physician License No.	Physician's license number.
72. I attest that I have been delegated Items 19 and 48-51 by the physician whose license is noted in Item 55 and I am an APN/PA with the following valid license no.:	Advance Practice Nurse's or Physician Assistant's license number.

Provider Certification

Item Name	Contents
56. Signature of RN/LVN/QIDP/QDDP/Case Manager/LA Service Coordinator/HCS Provider Representative	Signature of RN/LVN/QIDP/ Case Manager/LIDDA Service Coordinator/HCS Provider Representative responsible for the completion of this form. Note:  The following may sign for each program: HCS – LIDDA Service Coordinator (initial only), HCS Provider Representative (all others) TxHmL – LIDDA Service Coordinator ICF/IID – RN, LVN, QIDP CLASS – RN,   DBMD – RN, LVN, Case Manager
57. Print Full Name of RN/LVN/QIDP/QDDP/Case Manager/LIDDA Service Coordinator/HCS Provider Representative	Printed full name of RN/LVN/QIDP/ Case Manager/LIDDA Service Coordinator/HCS Provider Representative who signed the form.
58. Date	Date of the signature of the RN/LVN/QIDP/ Case Manager/LIDDA Service Coordinator/HCS Provider Representative who signed the form.

Requested Begin/End Dates

Item Name	Contents
59. Begin Date	Requested effective date of the LOC determination/LON assignment.
60. End Date	Requested end date of the LOC determination/LON assignment. Note: Use end date only for Purpose Code E for ICF/IID.

For Departmental Use Only

Item Name	Contents
61. LOC (Level of Care)	Code to indicate the assigned level of care. 0 = Denial of LOC 1 = LOC I 8 = LOC VIII
62. LON (Level of Need)	Code to indicate the assigned LON. 1 = LON 1 (Intermittent) 5 = LON 5 (Limited) 8 = LON 8 (Extensive) 6 = LON 6 (Pervasive) 9 = LON 9 (Pervasive +) Note: See Calculating Level of Need Chart.
58. Date	Date of the signature of the RN/LVN/QIDP/ Case Manager/LIDDA Service Coordinator/HCS Provider Representative who signed the form.
63. Effective Date	Effective date of the LOC determination/LON assignment.
64. Expiration Date	Expiration date of the LOC determination/LON assignment.
65. Name of Reviewer	Name of HHSC staff person reviewing the assessment and assigning the LOC/LON.
66. Date Reviewed	Date the assessment was reviewed.
67. Name of Physician	Name of the HHSC physician or designated staff person who reviews the assessment when LOC has been denied (if applicable).

ABL Determination for CLASS and DBMD Programs (HCS/TxHmL and ICF/IID only) must refer to the DID Best Practice Guidelines

ICAP Conversion

Service Level	Adaptive Behavior Level
7,8,9	I
4,5,6	II
2,3	III
1	IV

SIB-R Conversion

RMU Range	Adaptive Behavior Level
82/90 – 100/90	I
34/90 – 81/90	II
5/90 – 33/90	III
0/90 – 4/90	IV

Calculating Level of Need (LON) (HCS/TxHmL and ICF/IID only)

LON Description	ICAP Service Level	Service Score Range	Other
1 Intermittent	7, 8 or 9	>+ 70
5 Limited	4, 5 or 6	40 – 69
8 Extensive	2 or 3	20 – 39
6 Pervasive	1	1 – 19
9 Pervasive +	Any	Any	Must have a value of 2 in at least one of the following items: 35. Self-injurious Behavior 36. Serious Disruptive Behavior 37. Aggressive Behavior 38. Sexually Aggressive Behavior

Behavior Increase (ICF/IID, HCS and TxHmL only):

If at least one of the behavior Items 35 through 38 is a value of one, then a behavior increase is indicated. If the level of need has a value of 1, 5 or 8, then the requested LON will be increased one level when the ID/RC is electronically transmitted to HHSC. Submit documentation justifying the behavior increase must to HHSC within seven calendar days of the electronic transmission of the ID/RC.

Medical Increase (ICF/IID and HCS only):

If Item 40, Nursing: Frequency Code, has a value of 6 indicating that 181 or more minutes per week of nursing services are provided and Item 39, Nursing: Service Provider, has a value of 15 or 16 (15=Registered Nurse, 16=Licensed Vocational Nurse), then a medical increase is indicated. If the level of need has a value of 1, 5 or 8, then the level of need will be increased one level when the ID/RC is electronically transmitted to HHSC. Submit documentation justifying the medical increase to HHSC within seven calendar days of the electronic transmission of the ID/RC.

LON 9 (ICF/IID, HCS and TxHmL only):

If at least one of the behavior Items 35 through 38 is a value of two, then a LON 9 is indicated, and the requested LON will be increased to a LON 9 when the ID/RC is electronically transmitted to HHSC. Submit documentation justifying an initial LON 9 request to HHSC within seven calendar days of the electronic transmission of the ID/RC.

Other

1. A LON 6-Pervasive will never be increased to a LON 9-Pervasive + when requesting a behavior or medical increase.
2. In ICF/IID, a person's LON can only be increased one time. For example, if an individual's ID/RC satisfies both the behavior criteria for an increase and the nursing criteria for an increase, then the LON is only increased one level.
3. Cost caps for people enrolled in HCS are based on their LON. If the information on the ID/RC indicates a person receives 181 or more minutes per week of nursing services and these services are provided by a registered nurse (RN) or a licensed vocational nurse (LVN), then that person's cost cap will be increased to the LON 6 cost cap if the current LON has a value of 8.