Form H6516, Community First Choice Assessment

Documents

Effective Date: 3/2015

Instructions

Updated: 3/2015

Purpose

Form H6516 is completed for applicants/individuals being assessed for Community First Choice (CFC) services. The form is used as an instrument for collecting and documenting essential information to determine the functional needs of applicants/individuals age 21 and over for CFC services.

Individuals in the Home and Community-based Services (HCS), Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) waivers will not use this tool. Existing tools utilized in these waivers will be used to assess for CFC services.

For the remainder of the instructions, the term “individual” is defined as an applicant/member requesting CFC services.

Form H6516:

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

Form H6516 is used to:

identify the individual’s strengths, preferences, support needs and desired outcomes;
identify what is important to the individual;
identify and document the individual’s current and preferred living arrangement;
determine the Habilitation (HAB), Personal Assistance Services (PAS), Emergency Response Services (ERS) and Support Management needs of an individual;
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;
document the individual’s preferences for when to receive CFC services;
document the risks to the individual’s health and safety, as well as a plan to mitigate those risks;
identify any special needs, requests or considerations staff should know when supporting this individual; and
document the individual’s unmet needs.

Procedure

When to Prepare or Update

Form H6516 is completed by the local authority (LA) or managed care organization (MCO) in its entirety when an individual is applying for CFC services and at least annually for individuals receiving CFC services. The form is also updated whenever the individual’s needs have substantially changed.

Assessor from this point forward refers to the local authority or MCO completing the form.

If an individual or LAR does not know the information requested or refuses to answer, document that in the space provided.

Form Retention

The LA must keep the original copy of the form in the individual's case record and provide a copy to the MCO.

The LA must retain the form for six years following the later date of the expiration or termination of the contract or the termination of services. The LA must retain protected health information and all records, reports, and source documentation related to service event data sufficient to support an audit concerning contracted expense and services, including work papers used to calculate individual costs.

The MCO must retain the form for five years after the case is closed, in accordance with record retention requirements.

Detailed Instructions

Individual’s Name - Enter the individual’s name. (Required on each page of the assessment).

Individual’s Medicaid No. – Enter the individual’s nine-digit Medicaid number.

Date of Birth – Enter the individual’s date of birth.

Date of Assessment – Enter the date this assessment is completed.

Gender – Check Male or Female to indicate the individual’s gender.

Employment Status – Check the appropriate box to indicate the individual’s employment status: employed, unemployed or retired.

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.

Participants – List each person, other than the individual, who participated in this assessment.

Type of Assessment – Check the type of assessment being conducted: initial, renewal or revision.

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 I: Individual’s Profile

One Page Profile – The “One-Page Profile” format is based on work by The Learning Community for Person Centered Practices.

Insert Photo Here (optional) – If available, insert one or two recent photos of the individual or photos of people, places or things that are important to the individual. This is optional, but provides additional information about the individual.

A little about myself – Enter a descriptive narrative including general information you have learned about this individual through the discovery process.

What people like and admire about me – Enter a descriptive narrative including what you have learned through the discovery process that others like and admire about the individual.

What's important to me – (“Important To”) Enter what you have learned through the discovery process that is important to the individual. “Important to” reflects what is important from the individual’s perspective and is based on conversation with and/or observation of the individual. The information might include important relationships, how the individual prefers to interact, things the individual likes to do or not do, preferred routines, relevant background information that may affect how the service should be delivered and what the individual wants to do in the future. Remember the individual’s response is limited to the knowledge and experiences he/she has to date. Additional efforts should be explored to increase his/her awareness of additional possibilities and experiences to increase his/her options of choice.

What others need to know and do to support me – (“Important For”) Enter important information you have learned through the discovery process about the individual, such as how the individual communicates and how to best communicate with him or her. Include what you have learned through the discovery process that is important for the individual, as identified by those who know him or her best. “Important for” reflects information that is important for the service provider to know and understand about the individual. This information should be related to health, safety and any supports regarded as necessary to enhance the individual to be a valued individual of the community. Enter information such as health needs, supervision requirements, specific behavioral needs and special instructions for those who support the individual. This section includes contraindications and special justifications for deviating from typical routines or activities (for example, adult day care three days a week, four hours a day, or a job four days a week, five hours a day). List any barriers that could prevent the outcomes/purposes from being achieved. Things identified as “important for” are not usually included as “important to” the individual.

What the people are like who support me best – Enter important information about the type of people in the individual’s life who provide support to him or her, including characteristics and traits that make those people most supportive (for example, someone with a gentle voice who enjoys the same activities as the individual, etc.). Provide any information that may be important to a successful match between the individual and the CFC PAS/HAB provider. You may also include types and characteristics that do not support the individual well.

How I like to spend my day – Enter important information you have learned through the discovery process about the individual, such as what the individual enjoys doing during the day and important routines or rituals for the individual. Indicate if the individual enjoys being in the community, staying home, being with large groups or being alone.

The services I am currently receiving are – Enter important information you have learned through the discovery process about the individual’s current services, both professional and non-professional. This may include therapies, waiver and non-waiver supports.

Section II: Important People in the Individual’s Life

(“Important Because”) – List the people who are close to the individual and who know and care about the individual. This will help the provider in determining who to speak with in certain situations. It will also help to ensure that the individual does not lose contact with important people in his or her life. (Additional rows may be added, if necessary.) Enter the names, relationships, telephone numbers, addresses, email addresses and the reason the individual/LAR has identified this individual as being important to list on this form. Physicians and professionals should be included in the Community/Other section.

Examples of important people are:

He takes the individual to work.
She is a friend the individual calls every weekend.
He stays with the individual until mom comes home from work.
She is the individual’s favorite teacher and helps tutor on weekends.
He takes the individual to Special Olympics practices and out to eat.
The individual stays with him during the holidays.

Section III: Living Situation

Current Residence – Check the most appropriate box from the list to indicate where the individual currently resides.

Own Home or Apartment

Alone – Check this box if the individual lives alone. (This includes an individual living alone who receives in-home services.)
With spouse/partner/relative – Check this box if the individual lives in his or her own home with a spouse/partner/relative. If the individual lives with a spouse/partner/relative who is being paid, this box should be checked.
With non-relatives/roommates – Check this box if the individual lives with a non-relative or with other roommates. This includes if the individual lives with a caregiver who is paid or unpaid, or if the individual lives in a dorm or community living situation.

Someone Else’s Home or Apartment

Relative – Check this box if the individual lives in a relative’s home. The individual’s relative may be a paid or unpaid support providing services such as personal care to the individual.
Non-relative – Check this box if the individual lives with a non-relative who may also be the individual’s caregiver who is paid or unpaid, but is not living in the individual’s own home or relative’s home.

Group Residential Setting

Certified or Licensed Group Home – Check this box if the individual lives in a group home. This includes one-three bed DBMD assisted living home and three- or four-person residences operated by certified HCS program providers.
Assisted Living Facility (ALF) – Check this box if the individual lives in an ALF.

Institution

Nursing Home – Check this box if the individual lives in a nursing home as his/her permanent residence. If the individual is currently in a hospital or nursing home for rehabilitation, but maintains a home elsewhere, do not select this box. For example, if the individual is in the nursing facility for rehabilitation but has an apartment that he or she intends to return to, then the apartment is the current residence. The individual’s permanent living arrangement should be indicated rather than the temporary setting.
Intermediate Care Facility for Individuals with an Intellectual Disability or Related Conditions (ICF/IID) – Check this box if the individual lives in an ICF/IID facility. This includes state supported living centers (SSLCs).
Institution of Mental Disease (IMD) – Check this box if the individual is currently living in an IMD, including a state psychiatric facility.

Other Living Arrangements

No Permanent Residence – Check this box if the individual does not have a permanent residence. For example, check this box if the individual lives in a homeless shelter. A hotel or motel would go under “no permanent residence” if it is a temporary arrangement. If the hotel or motel serves as the permanent residence, select one of the options under the Own Home or Apartment category.
Other–Specify – Check this box only if no other box is appropriate and specify the individual’s living arrangement.

If you need to provide additional information about the living arrangement, use the notes box at the end of this section rather choosing “other” when an existing option would be appropriate.

Prefers to Live – Check the appropriate box or boxes from the list to indicate the individual’s preference related to where he/she lives. The “Prefers to Live” question asks only for the individual’s own stated preference. It is used to determine if the individual lives where he/she wants to live and to track changes over time. Note: Record where the individual would like to live, not where anyone else wants the individual to live, and not where others think is realistic. Explain the individual's options to assist the individual in understanding his/her options.

Own Home or Apartment

Alone – Check this box if the individual prefers to live alone. (This includes an individual who prefers to live alone and who may receive in-home services.)
With spouse/partner/relative – Check this box if the individual prefers to live in his or her own home with a spouse/partner/relative. This could be with a spouse/partner/relative who is being paid.
With non-relatives/roommates – Check this box if the individual prefers to live with a caregiver who is paid or unpaid, or who prefers to reside in a dorm or community living situation.

Someone Else’s Home or Apartment

Relative – Check this box if the individual prefers to live in a relative’s home.
Non-relative – Check this box if the individual prefers to live with a non-relative who may also be the individual’s paid or unpaid caregiver, but is not in the individual’s own home/relative’s home.

Group Residential Setting

Certified or Licensed Group Home – Check this box if the individual prefers to live in a group home. This includes if the individual prefers to live in a three- or four-person residence operated by a certified HCS program provider.
ALF – Check this box if the individual prefers to live in an ALF.

Institution

Nursing Home – Check this box if the individual prefers to live in a nursing facility.
ICF/IID – Check this box if the individual prefers to live in an ICF/IID. This includes if an individual prefers to live in an SSLC.
IMD – Check this box if the individual prefers to live in an IMD, including a state psychiatric facility.

Other Living Arrangements

No Permanent Residence – Check this box if the individual prefers a non-permanent residence. For example, check this box if the individual prefers living in a homeless shelter.
Other–Specify – Check this box only if no other box is appropriate and specify the individual’s preferred living arrangement.
Unable to determine individual’s preference for living arrangement – Check this box if you are not able to determine the individual’s living preference due to challenges with communication, cognitive ability, etc..

Do you want more information about community living options? – Check Yes, No or N/A to indicate that you have asked the individual if he/she wants more information about community living options. Then, check the appropriate box to indicate if the individual would like to know more about community living options: Yes, No or N/A. If the individual selects Yes, the box in Section VII, Information and Referrals, Community Living Options, should also be evaluated to determine if a referral needs to be made.

If you need to provide additional information about the living arrangement, use the notes box at the end of this section rather choosing “other” when an existing option would be appropriate.

What is the LAR’s preference for living arrangements for this individual? – Check the appropriate box or boxes from the list to indicate the individual’s LAR’s preference related to where the individual lives.

Not applicable – There is no relative or LAR, or if the relative or LAR does not have any preferences around the individual’s place of residence.
Stay at current residence
Move to own home/apartment (includes living with spouse/relative, non-relatives and caregivers)
Move to a certified or licensed group home (includes three- and four-person residences operated by certified HCS program providers)
Move to an ALF (includes all size ALFs)
Move to a nursing facility or other institutional setting (e.g., ICF/IID, SSLC or IMD)
No consensus among multiple parties
Someone else's home (including the home of a relative, non-relative or caregiver)

Do you want more information about community living options? – Check Yes, No or N/A to indicate that you have asked the LAR if he/she wants more information about community living options. Then, check the appropriate box to indicate if the guardian/LAR would like to know more about community living options: Yes, No or N/A. If the individual selects Yes, the box in Section VII, Information and Referrals, Community Living Options, should also be evaluated to determine if a referral needs to be made.

Note: Provide any additional information regarding information and referrals for the individual. For example, indicate why the individual was or was not referred for a service.

Section IV: 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.

Part A – Functional Assessment
The functional assessment is comprised of the support level and service arrangement.

Support Level

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. The support level is not required for an individual only receiving habilitation.

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 items 1-23 must be given a support level.

For PAS activities only, score the individual according to the following scale:

Score	Score Details
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.

	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.
3. Exercising	Not scored.
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. Grooming	Support level is based on the highest level of support level needed on any grooming task in (5a-5b).
5a. 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.
5b. 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.
9. Walking (Ambulation)	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 or 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.
13. Escort	Not scored.
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: identify the proper medication by name or sight (color and/or shape); identify the purpose of the medication (e.g., for my heart, for pain, for allergies); determine the correct dosage is being taken (e.g., one pill); and identify the time medication is needed (e.g. morning, lunchtime, etc.).	Individual or LAR can self-direct* medications, but needs help opening containers and/or needs the medication brought to within reach. Individual or LAR can self-direct * medications, but has a visual impairment and may not be able to read labels. Individual or LAR can self-direct* medications, but must be reminded to ensure that medications are taken as prescribed. Unless medication is a delegated task, it cannot be purchased if the score for medication is “3.” Total help indicates the individual cannot self-direct medications and requires either skilled assistance or supervision from informal support.< Total help indicates the individual can self-direct medications, but due to a functional limitation, is unable to self-administer medications or due to cognitive limitations where the individual refuses to take medications.
16. Trim Nails	Individual can trim his own finger nails but may have difficulty doing his toe nails by himself. Individual may be capable of trimming nails but refuses or is unable due to behavioral challenges or cognitive ability.	Individual trims finger nails only when no one is available to help. Individual is unable to reach and trim toe nails and has difficulty using scissors or clippers. Individual may be capable of assisting but refuses or is unable due to behavioral challenges or cognitive ability.
	Note: A diagnosis of diabetes does not automatically indicate a score of “3”; many people with diabetes can trim their nails. If a medical practitioner has instructed an individual with diabetes not to trim the nails, score the task “3.”
17. 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.
18. 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.
19. 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).

Items 20-23 are assessed for PAS only.

On Items 20 and 21, the assessor can use information other than the individual’s perception of himself only if:

the individual provides inaccurate information because of his or her physical or mental impairment;
there are inconsistencies between the information the individual is providing and the assessor's observation of the individual; or
there is conflicting information provided by a family member present during the interview.

To properly score these questions, if the assessor is unsure of the information provided by the individual, he will:

get as much information as possible from the individual;
contact a third party (family member, friend, etc.) who is aware of the individual's cognitive abilities; or
use his or her judgment to score the question if no one is available who knows the individual's cognitive abilities.

20. – Initial scoring: These questions are based on the individual's perception of self.

“0” – If the answer to both questions is “No,” stop here.
Final scoring:
“1” – If the answer to all four questions is “No.”
“2” – If the answer to any one of these four questions is “Yes.”
“3” – If the answer to at least two of these four question is “Yes.”

21. – Scoring instructions: This question is based on the individual's perception of self. Does the individual indicate he or she has trouble concentrating and has memory lapses? Does the individual indicate he or she needs help making decisions?

“0” – If the answer to the question is not at all.
“1” – If the answer to the question is occasionally or a couple times.
“2” – If the answer to the question is frequently, more than a couple times but not every day.
“3” – If the answer to the question is every day.

22. – Scoring instructions: This question is based on someone's observation of the individual. This may be a family member, relative, caregiver or the person who called in the intake. Information from home health attendants or assessor observation can be used to score this question, but only as a last resort. The assessor must make every effort to contact a third party to provide the information. There should be documented attempts in the case record to contact other resources. If no other source is available, and the assessor feels the information provided by the attendant is accurate, he or she can score the information based on the attendant’s knowledge and observation of the individual.

“0” = The answer to the question is the individual makes consistent and reasonable decisions independently (for example, pays bills and makes financial decisions, keeps own medical appointments, maintains own household).
“1” = The answer to the question is the individual makes simple decisions without assistance (for example, what to wear, what to buy at the grocery store, when to do housekeeping chores).
“2” = The answer to the question is the individual makes poor decisions and needs cues/supervision for most decisions.
“3” = The answer to the question is the individual is severely impaired and rarely makes his own decisions.

23. – Scoring instructions: This question is based on someone's observation of the individual. This may be a relative, caregiver or the person who called in the intake. Information from home health attendants or assessor observation can be used to score this question, but only as a last resort. The assessor must make every effort to contact a third party to provide the information. There must be documented attempts in the case record to contact other resources. If no other source is available, and the assessor feels the information provided by the attendant is accurate, he or she can score the information based on the attendant's knowledge and observation of the individual.

“0” = The answer to the question is “No.”
“1” = The answer to the question is the individual has some short-term memory problems and can perform tasks for self with occasional reminders.
“2” = The answer to the question is the individual has memory lapses resulting in frequently not performing tasks even with reminders.
“3” = The answer to the question is the individual has memory lapses resulting in inability to perform routine tasks on a daily basis.

Service Arrangement – Enter the following codes to indicate the service provider for PAS and HAB activities.

Code	Details
S	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 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 PAS only, if the functional score is “3,” a service arrangement code of “P” should only appear under Item 15, Assistance with Medications, if it is a delegated task. Unless delegated, since “3” indicates total inability to perform any aspect of the task, only a licensed nurse or designated informal support/caregiver may fulfill this need. Habilitation may still be provided, if appropriate, for an individual with a functional score of “3.”
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 attendant 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 attendant 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 attendant 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 attendant provides training to the individual on meal preparation for dinner. Example 5: The caregiver assists the individual on and off the toilet but the attendant teaches the individual about toileting hygiene.
A	Other agency. Use “A” when a non-contracted agency 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.

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.

Information about the service arrangement is below the examples.

Service Arrangement	Example
24. Money Management	Individual may need assistance counting money, learning how to budget and paying for items, among others.
25. Interpersonal Communication	Individual may need assistance communicating with others, in person, on the phone or on the computer.
26. Community Integration	Individual may need assistance finding, participating in and accessing community activities.
27. Reduction of Challenging Behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks	Individual may have challenging behaviors that can be reduced through behavior support plans, prompting, rewards or redirection, among others.
28. Accessing Leisure Time and Recreational Activities	Individual may need assistance finding activities he or she would like to participate in during leisure time or accessing those activities.
29. Self-Advocacy	Individual may need assistance learning how to advocate for himself or for causes. Advocating for oneself could include asserting preferences or requesting needed services.
30. Socialization/Development of Relationships	Individual may need assistance with development and maintenance of relationships or appropriate social behaviors.
31. Personal Decision Making	Individual may need assistance making decisions for himself, including assistance in assessing what is important to that individual, pros and cons, as well as consequences.
32. Accessing Community Resources	Individual may need assistance finding, participating in and accessing community resources such as free meal programs, churches, parks, self-advocacy training or events.
33. Use of Augmentative Communication Devices	Individual may need assistance operating, learning to use, or accessing an augmentative communication device.
34. 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.
35. 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.

Part B – Task/Hour Guide Column

Minutes Per Day – For each task to be authorized as PAS, 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. Times must be shown in five-minute increments and, if needed, rounded up to the next five-minute increment. For each task to be authorized as HAB, enter the daily number of minutes needed to provide training on that task.

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 and no supervisory approval is required. 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. No supervisory approval is required.
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 assessor must document the individual's request and allocate minutes in the minute range for the subtasks selected. Document the reason and no supervisory approval is required. 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. No supervisory approval is required.

A task may be purchased if it is performed at least once a month by the 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 and 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, obtain supervisory approval. Do not change the support level to adjust the minutes or for the convenience of a provider or attendant. For supervisory approval, document the individual's extenuating circumstances and justify the need for minutes outside the range. The request must be in writing and the supervisor's approval or disapproval must be in writing. Documentation of the request and the approval/disapproval must be filed in the case record. Supervisory approval is required for the adjustment of time outside the ranges to specific tasks and to combinations of tasks that have ranges.

Companion Cases – For PAS only. Check the box in each companion case eligible section to indicate if there is a companion case. For general household tasks, including cleaning, shopping and meal preparation, use the companion minute range rather than the individual range. Time is assigned per individual based on the individual's support level. Check the box(es) in the Total Minutes Per Week column for cleaning, meal preparation and/or shopping to indicate that time is authorized for these tasks to the companion case. In situations where there are more than two companions in the household, assign time based on the individual's support level using the companion minute ranges.

Example 1: On cleaning, Mr. Jones scores “3” and Mrs. Jones scores “1.” Mrs. Jones can do some light housekeeping, but due to her husband's incapacity, he needs all cleaning tasks performed in his area. Mrs. Jones is allowed the maximum of 45 minutes under support level “1” in the companion range. Mr. Jones is allowed the maximum of 180 minutes under support level “3” in the companion range.
Example 2: On meal preparation, Mr. and Mrs. Smith both score “2.” However, they have different schedules and need some meals shared and others on an individual basis. Calculate each individual's time based on the meals needed within the impairment range. Use the time in the companion minute range for shared meals and time in the individual range for non-shared meals. Use the Optional Meal Preparation Chart as a tool for calculating time.

Optional Meal Preparation Chart (for a Varied Meal Schedule) – This is an optional chart to assist in calculating time for meals for individuals who have a varied schedule. There is no requirement for this chart to be completed as it is a tool only to assist in calculating times. Enter the time for each meal by the number of days the meal is needed for the total minutes for each type of meal. Use the individual or companion range, as appropriate, and check the box. Total the minutes for the Total Minutes per Week.

Divide the Total Minutes per Week by the number of days per week meals will be authorized for the Average Daily Minutes. If needed, round this amount up to the next five-minute increment. Enter this amount in Part B, Minutes Per Days for the task of Meals. In Days Per Week, enter the highest number of days meals are prepared, even if not all meals are prepared daily.

Days Per Week – For each task to be authorized as PAS or HAB, enter the number of days per week the attendant 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 or HAB task.

Part C – Subtasks and PAS Minute Ranges

Note: The minute ranges in this section only apply to PAS activities. Indicate using the checkbox if habilitation is needed for any of the subtasks, but when completing the Task/Hour Guide for habilitation, do not use the minute ranges indicated in Part C.

The subtasks in Part C must be checked to indicate specifically what the individual needs. An individual scoring “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 activity. This could include the individual’s preference to take baths over showers, or factors such as behaviors that result in higher scores. Additionally, any comments regarding each task can be documented in this space as well.

Calculating Total PAS and Habilitation Hours

Total PAS Minutes Per Week - Add the subtotal 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. This field is N/A for HCBS STAR+PLUS Waiver.

Total Habilitation Minutes Per Week – Add the subtotal HAB minutes for each task 1-19, and 24-36 to obtain the Total HAB Minutes for all tasks.

Total Habilitation 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 Habilitation 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.

Section V. Health-Related Tasks Screening Tool

The Health-Related Tasks Screening Tool is used to determine if the individual may have nursing tasks when the individual or his or her LAR is requesting CFC PAS/HAB. The assessor asks the individual/LAR and then records his or her answer. The assessor is not expected to answer these questions for the individual/LAR.

A. Physician Delegation - Answer Yes or No to the question regarding physician delegation (physicians may delegate medical acts to an unlicensed person when the unlicensed person is able to carry out the act properly and safely. As the physician remains responsible for the medical act performed, delegation is made to a specific person and does not encompass any person who is caring for the individual. Writing an order for an individual’s care does not constitute delegation to an unlicensed person). If the answer is Yes, skip to Section C.

B. Medication Administration – Check Yes or No to the question regarding medication administration. If the answer is Yes, check all of the routes of medication administration that are currently used.

C. Special Procedures – Answer Yes or No to the questions regarding special procedures.

D. Eating - Answer Yes or No to the questions regarding eating.

E. Bathing – Answer Yes or No to the question regarding bathing.

F. Toileting – Answer Yes or No to the questions regarding toileting.

G. Mobility – Answer Yes or No to the questions regarding mobility.

H. Health-Related Task Screening Tool Review – Review the Yes responses in Section B and make a referral to the MCO to then take further action if any tasks are indicated that may need to be delegated tasks or HMAs.

Section VI: Emergency Response Service (ERS)

Check Yes or No to indicate whether the individual needs ERS. If Yes, describe how the individual will benefit from ERS in the space provided. Any additional comments regarding special considerations or preferences should go in this space as well.

Section VII: Information/Referrals

Check the box or boxes from the list to indicate the referrals appropriate for the individual, including follow up from the community living options question in Section III.

STAR+PLUS Waiver
Waiver Interest List (Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Medically Dependent Children Program (MDCP), Texas Home Living (TxHmL), Home and Community Based Services (HCS))
State Supported Living Center crisis diversion slot
Preadmission Screening and Resident Review (PASRR) crisis diversion slot
Other Medicaid services, such as durable medical equipment, augmentative communication systems, seating and positioning systems, power/custom mobility equipment, nursing and therapy services
Other non-Medicaid or community service
Housing options (Refers to housing-only services such as Section 8 housing assistance and other independent or subsidized housing arrangements that are affordable, integrated and accessible.)
Community living options (Refers to services and programs which support community living, including in-home nursing, attendant and habilitation services, minor home modifications, respite, and adaptive aids, among others.)
Other – Specify any other referrals that are appropriate for the individual

Notes: Provide any additional information regarding information and referrals for the individual. For example, indicate why the individual was or was not referred for a service.

Section VIII: Support Management

Check Yes or No to indicate if the individual is currently receiving support management.
Check Yes or No to indicate whether the individual would like to receive support management.

If Yes for 1 or 2, complete 3.

Identify any needs, requests or considerations specific to this service that are necessary for the staff to know when supporting the individual in achieving his/her outcomes.

Section IX: Service Delivery Options

For initial assessment: Check Yes or No to indicate if the individual is interested in self-directing CFC services.

For renewal: Check the appropriate box to indicate what service delivery option the individual is currently using: Agency, Consumer Directed Services or Service Responsibility Option. Check Yes or No to indicate if the individual wants to change his service delivery option.

Section X: Goals/Desired Outcomes

Enter what the individual or LAR wants to accomplish from these services. There may be one or more goals/outcomes the individual or LAR has identified. Goals/outcomes can be specific or general depending on the request of the individual or LAR and his or her specific needs.

Check Yes or No to indicate if any of the CFC services documented on this form are critical to health and safety.

Section XI: Summary of Recommended Community First Choice Services

Community First Choice PAS/HAB Recommended Total Hours – Indicate the total combined recommended CFC PAS/HAB hours as listed at the end of Section IV.

Support Management: Indicate the response given in Section VIII by checking Yes or No.

ERS – Indicate the response given in Section VI by checking Yes or No.

Health-Related Tasks indicated in Section V? – Indicate Yes or No if there are health-related tasks indicated in Section V.

Section XII: Acknowledgement

Signing this page affirms:

The individual/LAR/Representative/Assessor participated in the service planning process.
The individual/LAR/Representative/Assessor 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 of Individual/Legally Authorized Representative and Date – The Individual or LAR must sign and date Form H6516 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 assessor should notate this on the signature line of the form.

Printed Name of Individual – Print or enter the individual’s name.

Printed Name of LAR – Print or enter the LAR’s name.

Signature of Assessor and Date – The assessor must sign and date Form H6516 after completion. Any updates to the form must be initialed and dated by the assessor.

Printed Name of Assessor – Print or enter the assessor’s name.

Signature of Representative and Date – If a representative participates in the completion of the assessment, he or she must sign and date Form H6516 after completion. Any updates to the form must be initialed and dated by the representative, if applicable.

Printed Name of Representative – Print or enter the representative’s name.

Signature of Other Person and Date – If there is another person who participates in the completion of the assessment, he or she must sign and date Form H6516 after completion.

Printed Name of Other Person – Print or enter the other person’s name.

Instructions for Opening a Form