Form 2059-W, Summary of Individual's Need for Service Worksheet

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Effective Date: 7/2013


Updated: 7/2013


To record information during the home visit to be entered into the Service Authorization System Wizards (SASW) for Form 2059, Summary of Client's Need for Service, regarding the individual's:

  • physical, mental and medical conditions and how those conditions affect his ability to conduct activities of daily living (ADL).
  • home environment, family and the resources that he has available to assist him in his 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.
  • functional condition and capacity that is consistent with and justifies the authorized service plan.


When to Prepare or Update

Complete Form 2059-W for all applicants during the initial home visit assessment. Use the information for entry into SASW.

For continued accuracy and relevance, review Form 2059 at each reassessment and monitoring contact and update the information in SASW.

Number of Copies

Complete one Form 2059-W. After the information is entered into SASW for Form 2059, the worksheet may be discarded.

Detailed Instructions

Individual Name — Self-explanatory.

Assessment Date — Enter the date of the home visit assessment.

Individual No. — Enter the individual's Medicaid number or identification number assigned, if one is available.

Action Type — Enter if the action is initial, interim or reassessment.

1. Medical Conditions Reported by the Individual — Enter all conditions that the individual, his family or his physician has identified that cause functional limitations.

2. Functional Limitations (Why the Individual is Unable to Perform or Limited in ADL) — Check all applicable manifestations that result from the conditions listed in Item 1. Use the "other" space for symptoms or limitations that are not listed. The items checked should relate to the medical diagnosis in Item 1 and should justify why the services authorized in the service plan are necessary.

Check only the functional limitations that relate directly to the individual's physical, mental and medical conditions listed in Item 1 and that affect the individual's functional ability. Example: The individual may have occasional, mild pain that is unrelated to his major medical problem and is treatable with aspirin. In this instance, do not check the box for pain.

The following descriptions define the manifestations listed in this item. Consult the regional nurse if assistance is needed in making a determination:

Dizziness — A whirling sensation in the head that may lead to falls or a feeling of faintness.

Blackouts — A temporary loss of consciousness.

Falls Easily — Instability, problem with balance and may include a history of falling.

Paralysis — Loss of the ability to move part or parts of the body.

Contractures — Permanent shortening of muscles or tendons causing deformity or distortions. Example: A scarred arm and hand from a severe burn that has caused distortion and loss of full use of the limb.

Missing Limb — A missing arm or leg that may be a birth defect or amputation.

Tremors — Involuntary trembling or quivering that may be caused by weakness, emotional stress or disease.

Spasticity — Muscular incoordination, manifested by uncontrollable jerky movements. Example: Cerebral palsy.

Limited Dexterity — Incomplete movement of major joints, particularly those in the hands and fingers, and person may not be able to grip, hold items, bend or stoop.

Shortness of Breath — Wheezing, gasping or pausing in speech to catch one's breath.

General Weakness — Physical frailty.

Can't Stand for Long — Ability to stand but inability to stand for a normal length of time. Do not check this box for an individual who is bedfast or chairbound.

Bedfast — Confined to bed, cannot sit in a chair or wheelchair and stays in bed at all times.

Chairbound — Ability to sit in a chair or wheelchair, but inability to walk.

Pain — Hurting or aching in varying degrees. Write in the degree of severity and the frequency, if needed.

Numbness — Devoid of sensation in part or parts of the body.

Limited Range of Motion — An impaired joint that cannot be extended or flexed to a normal degree, causing restricted motion. Example: A stiff shoulder that prevents stretching to reach an object or a stiff wrist or ankle that cannot be moved or rotated in a normal way.

Cognitive Impairment — Lack of awareness and judgment.

Vision Impairment — Varying degrees of inability to see, including blindness. Write in the degree of severity, if needed.

Hearing Impairment — Varying degrees of inability to hear, including total deafness

Speech Impairment — Inability to speak clearly, exhibiting a speech impediment or inability to vocalize at all.

Lack of ADL (activities of daily living) Skills — Inability to learn to perform routine personal care or maintenance tasks. Example: An individual with intellectual and developmental disabilities or an individual who is not trainable in caring for himself and/or maintaining his surroundings. Do not check this box for individuals who lack ADL skills, but are trainable.

Behavior/Emotional Problems — Abnormal or erratic behavior, such as hostility or other unacceptable social behavior. Also, moodiness or mood swings, withdrawal or depression.

Nausea — Stomach distress with an urge to vomit.

Incontinence — Inability to control bladder and/or bowels.

Other — Specify other problem.

3. Description of Individual's Home Environment — Check all appropriate boxes to describe the individual's home environment.

Residence — Check the location of the individual's home. Mark if the home is Adequate.

Explanation of specific problems that impact service delivery — Mark if the home is "Inadequate Unsafe" or "Inadequate Questionable" and check the reasons.

Laundry — Mark the appropriate box.

Assistive Devices — List the assistive devices the individual has to help in the home.

4. Individual's Living Arrangement — Check the appropriate box. If the individual is in a residential care facility or an adult foster care home, check the AFC/RC box.

5. Household/Caregivers — Enter the name and relationship of all household members and caregivers. Check "Y" for yes if the person lives in the household and "N" for no if the caregiver does not live in the household. List the tasks the individual and/or caregiver reports they provide for the individual. This information will also be captured on Form 2060, Needs Assessment Questionnaire and Task/Hour Guide.

If the caregiver performs the entire task for the individual note the task here and code "C" for the task on the "Impairment Scoring" screen in SASW.

If the caregiver assists only on the weekends or evenings, note that here and do not use code "C" for that task on Form 2060 if the task needs to be purchased during the service plan hours. Enter a comment on the task on the "Impairment Scoring" screen that the caregiver helps only on weekends or evenings.

In Caregiver Status, describe the reason the caregiver or household member cannot assist with all tasks. These reasons can be:

  • works full time
  • attends school
  • ill health
  • caregiver needs ongoing relief (if the caregiver is requesting caregiver support)
  • applicant needs continual care (if the caregiver is performing tasks, but the applicant needs additional help beyond what the caregiver is currently doing)
  • unwilling (enter this reason only if the household member has stated that he is not willing to help or perform needed tasks for the individual as this person is not considered a caregiver, only a household member)
  • companion case (a spouse or other household member who is applying for or receiving Community Care Services Eligibility benefits — note which service).

Do not list other family members if they are not in the household and are not currently performing any caregiver tasks.

6. Common Household Task(s) Being Purchased and the Reason: — List the reason a common household task must be purchased for the individual's special needs.

7. Other Agencies Serving Individual and Limitations — List any additional service the individual is receiving or has been referred to. Explain any limitations in the service provided that would require the task to be purchased. Example: Skilled home health will provide bathing two times per week, but the individual would like a bath daily. When appropriate, refer the individual for needed services that can be provided by other state agencies. (Refer to Appendix XV, Services Available from Other State Agencies, in the Community Care Services Eligibility Handbook for a description of services.)

8. Agency(ies) Selected — Note the agency or agencies selected for service delivery. List the service, provider identification, name the provider is doing business as (DBA) and method of selection.