The purpose of Form 2059 is to provide information about the:
- client's/consumer's physical, mental and medical conditions and how those conditions affect his ability to conduct activities of daily living (ADL).
- client's/consumer's home environment, living arrangements and household composition.
- caregiver arrangements that are available to assist the client/consumer in ADL. This information is used by the case manager for service planning and by the provider for selecting, orienting and training attendants for service delivery.
- other services and resources to assist the client/consumer in ADL.
When to Prepare or Update
Enter all information regarding the client's/consumer's condition in the Service Authorization System Wizards (SASW). Form 2059 must be complete before initially certifying an applicant for Community Care Services Eligibility (CCSE) services.
For continued accuracy and relevance, review Form 2059 at each reassessment and monitoring contact and update the information as necessary.
Number of Copies
Print a copy of Form 2059 for the case record and for each provider referral.
Each time Form 2059 is completed, a copy of the form must be filed in the client's/consumer's case folder.
Send one copy of Form 2059 with each provider referral.
Send changes in information to the provider and regional nurse, if applicable, any time changes are made that affect the service plan, including annual reassessments and interim reassessments.
The case manager keeps a copy in the case folder for three years and 90 days. The provider keeps copies according to the terms of the contract.
Client No. — Self-explanatory.
Client Name — Self-explanatory.
Action Type — Specify if the action is initial contact, annual reassessment or interim reassessment.
Assessment Date — Enter the assessment date.
1. Conditions which cause functional limitations (health concerns) — Check all medical and mental conditions that the consumer, his family or his physician have identified that cause functional limitations. If a condition is not listed, enter the information in — Other-Comments.
2. Why is client unable to perform, or is limited in, activities of daily living? — Check all applicable manifestations that result from medical and mental conditions. Use the — Other-Comments— space for symptoms or manifestations that are not listed. The client's/consumer's limitations should justify why the services authorized in the service plan are necessary. If preferred, enter additional descriptions about these manifestations in — Other-Comments — . Examples: For missing limb, add — right leg above knee, — or for contractures, add — left arm and fingers.
Check only the manifestations that relate directly to the client's/consumer's physical, mental and medical conditions that affect the client's/consumer's functional ability. Example: The client/consumer may have occasional allergies that are unrelated to his major medical problem and are treatable with over-the-counter medication. In this instance, do not check the box for allergies.
3. Description of client's home environment — Check all information pertaining to the client/consumer or his home environment that could affect service delivery or would be useful knowledge for the provider. If additional information is necessary, enter under — Other-Comments.
4. Client's Living Arrangement — On the Household screen, check if the client/consumer is living with other adults or if the client/consumer is living with someone who is applying for or is receiving CCSE services. Enter the information on the next line.
5. Explanation of current and ongoing role of family or caregiver in meeting client's needs — The information in this section will be populated from the Support Assisting Client screen in SASW. If a caregiver is performing a task or assisting with a task, the task is coded with a C for caregiver or P/C and Caregiver is selected in the Primary Support Type window. The name of the caregiver is entered in the Support Name window and this information will print in this section of the form.
6. Common Household Task(s) being purchased and the reason — This information will be populated from the Purchased Details screens when there are other household members listed. A reason is selected to justify why the client/consumer needs the tasks purchased when there are household members available. The selected reason will print on this section of the form.
7. What other services is client currently receiving or being referred for? — This information will be populated from the Support Assisting Client screen when Agency is selected in the Primary Support Type window.
8. Agency(ies) Selected — This information will be populated from the provider selection in SASW. It will include the service, provider identification, provider doing business as (DBA) name and method of selection.