Form 2060 is used to collect and document essential information to establish the eligibility status of an applicant for Community Care Services Eligibility (CCSE).
Form 2060 is used to:
- determine the weekly hours of Personal Attendant Services (PAS) in CCSE or Client Managed Personal Attendant Services (CMPAS);
- determine if the person meets the eligibility requirement for having an unmet need for CCSE services;
- determine if the person meets the eligibility requirement score for the CCSE service requested;
- provide an instrument for assessing the person's needs, functional impairments and ability to perform activities of daily living;
- document the basis for establishing a priority status for CCSE PAS that includes Primary Home Care (PHC), Community Attendant Services (CAS) and Family Care (FC); and
- document information on service planning issues for PHC, CAS, CMPAS and FC people.
When to Prepare or Update
Form 2060 must be completed in its entirety. Each task must be given an impairment score and be coded in the service arrangement column. The Task/Hour guide must be completed for each purchased task and each purchased task must have subtasks marked in Part C. CCSE staff use pages 1 and 2 of the form for entry into the Service Authorization System Online Wizard (SASOW) only.
Complete Part A, Functional Assessment, at the initial assessment before certifying the applicant's functional eligibility on Form 2064, Eligibility Worksheet. After the initial assessment, complete or update Part A at least once a year for each person. Complete Part A when the person needs:
- a new service and their current Form 2060 score is below the minimum score for that service; or
- an additional purchased task and their current Form 2060 score for that task is zero.
When Part A is revised or updated, the person must be asked each question in Part A. The score for each item must be redetermined before changing the total score.
Complete Part B, Task/Hour Guide, and Part C, Task/Minute and Subtask Guide, at the initial assessment of an applicant who will receive PAS. Review all of Part B at each reassessment of a person receiving PAS.
Note: Form 2060 is not required for Day Activity and Health Services.
Number of Copies
Complete one Form 2060. After the information is entered into SASOW for Form 2060, the worksheet may be discarded.
Applicant or Member Name — Enter the first and last name of the applicant or member.
Medicaid ID No. — Enter the applicant or members Medicaid ID Number.
Date — Enter the date Part A is completed. Check if Part A, Part B or both are completed. If Part B is completed after Part A, enter both dates.
Companion Case Name — Enter the first and last name of all people (if any) residing in the same household who are also receiving CCSE, CMPAS, STAR+PLUS or STAR+PLUS Waiver (SPW) purchased attendant care services.
Companion No. — Enter the companion case number.
Update — Enter the date either Part A or Part B is updated. Check which parts of the form are being updated.
Part A — Functional Assessment
Complete Part A during a face-to-face or phone interview with a person. Score Items 1-2, 4-12 and 14-23, Do not include the score for Item 4 in the Total Score (Item 24).
Score the person according to the following scale:
|0||None. No functional impairment. The person can conduct activities without difficulty and has no need for assistance.|
|1||Mild. Minimal or mild functional impairment. The person can conduct activities with minimal difficulty and needs minimal assistance.|
|2||Severe. Extensive or severe functional impairment. The person has extensive difficulty carrying out activities and needs extensive assistance.|
|3||Total. Total or complete functional impairment. The person is completely unable to carry out any part of the activity.|
A person has an impairment with respect to an activity if they are limited, either physically or mentally, in their ability to carry out that activity.
Numbers 0 and 3 are absolutes in the sense that they indicate no functional impairment or total dependency. Example: If a person can perform any of the dressing task for themselves, a 3 is not appropriate. If they can perform the dressing task completely without difficulty, a 0 is appropriate.
The first time an item is addressed, use the wording of the question as written, and then explain or paraphrase, if necessary. Ask follow-up questions if there is a need to verify the first response. Enter a score for each question.
Remember that Form 2060 is designed to assess a person's capacity for self-care. Score each item according to this capacity for self-care and not according to the person's access to a resource to assist with the task. In scoring each item, use the person's response, plus any observations or knowledge of the person from other sources.
See the Community Care Services Eligibility Handbook, Section 2430, Functional Assessment, for descriptions of other factors that can affect the person's ability to care for themselves.
Use the following examples for each item to help differentiate between scores of 1 and 2. A person may score a "1", but not request assistance with a task.
|1 = Minimal/Mild Impairment||2 = Extensive/Severe Impairment|
Person can bathe self, but needs supplies laid out.
Person can bathe self, but needs assistance drawing and testing the temperature of the water.
Person needs standby assistance for safety, reminding or monitoring.
Person needs minimal assistance getting in and out of tub or shower.
Person may accomplish bath for self by using a chair or other adaptive device for assistance.
Person needs extensive help getting in and out of tub or shower.
Person needs hands on help with bathing and drying of body.
Person must always use adaptive devices and needs assistance with arranging adaptive devices for the bath.
Person can only manage sponge baths due to disabilities.
Person requiring a bed bath can assist with some part of the task.
Person needs occasional help with zippers, buttons or putting on shoes and socks.
Person may need help laying out or selecting clothes.
Person needs reminding or monitoring for completion of dressing.
Person always needs help with zippers, buttons or shoes and socks.
Person needs help getting into garments, that is, putting arms in sleeves, legs in pants or pulling up pants.
Person may dress totally inappropriately without help or would not finish dressing without physical assistance.
|3. Exercising||Walking with the Person. Not scored.|
Person may need standby assistance but only occasional physical help.
Person needs verbal reminders or encouragement.
Person eats with adaptive devices but requires help with applying and positioning.
Person usually needs extensive hands-on assistance with eating.
Person 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 the person can eat some finger foods.
|5. Grooming||Impairment score is based on the highest level of impairment for all grooming tasks.|
|5a. Shaving, Oral Care and Nail Care|
Person can manage grooming, but needs supplies laid out or handed to them; needs standby for safety and assistance with grooming tools.
Person can accomplish grooming, but needs reminding or monitoring.
Person is unable to adequately shave face or underarms and legs because of inability to see well, to reach or to successfully use equipment.
Person is unable to adequately brush teeth and perform oral care.
Person is unable to adequately care for nails.
|5b. Routine Hair and Skin Care|
Person can manage hair and skin care but needs supplies laid out.
Person needs reminding to do tasks.
Person needs assistance to comb or brush hair.
Person needs assistance applying non-prescription lotion to skin.
Person is unable to adequately perform washing hair (shampooing), drying hair or setting (rolling or braiding) hair.
Person is unable to adequately wash hands and face or apply makeup.
Person 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.
Person may need help with supplies or equipment.
Person needs some assistance with clothing during toileting.
Person needs standby assistance.
Person may have catheter or colostomy bag, and occasionally needs assistance with management.
Person often is unable to get to the bathroom on time to urinate or has occasional episodes of fecal incontinence.
Person may wear incontinence products to manage the problem and needs assistance with them.
Person usually needs assistance with catheter or colostomy bag.
Person needs assistance with a bedpan or urinal, or with emptying a catheter bag or changing an external catheter or colostomy bag.
Person needs diapers changed or needs assistance with feminine hygiene products.
|7. Hygiene in Toileting|
Person can usually manage cleaning self after toileting except on occasional days when bending or moving is particularly difficult, or when incontinence occurs.
Person may have catheter or colostomy bag, and occasionally needs assistance with management.
Person often needs assistance with cleaning after toileting because of difficulty in reaching, or due to incontinence problems. Clothes are sometimes soiled and odorous.
Person usually needs assistance with catheter or colostomy bag.
Person usually can get out of bed or chair with minimal or standby assistance.
Person may accomplish transfer without help but needs standby assistance for safety.
Person needs some assistance in adjusting or changing position in a bed or chair (positioning).
Person usually needs hands-on assistance when rising to a standing position or moving into a wheelchair to prevent losing balance or falling.
Person can help with the transfer by holding on and supporting themself.
Person can assist some with non-ambulatory movement from one stationary position to another (transfer). This task does not include carrying.
|9. Walking |
Person walks alone without assistance for only short distances.
Person can walk with minimal difficulty using an assistive device or by holding onto walls or furniture.
Person needs assistance in positioning for use of a walking apparatus or putting on and removing leg braces and prostheses for ambulation.
Person has considerable difficulty walking even with an assistive device.
Person can walk only with assistance from another person and never walks alone outdoors without assistance.
Person may use a wheelchair periodically.
Person needs assistance with wheelchair ambulation. Wheelchair ambulation is defined as pushing the wheelchair for the person.
Person 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.
Person cannot move heavy furniture or do extensive scrubbing or mopping.
Person can only do very light housework like dusting, washing a few dishes or straightening up magazines or newspapers.
Person cannot see well enough or does not have the strength or flexibility to sweep floors, change bed linens or carry heavy objects.
Person does hand washing but has difficulty wringing and hanging heavy laundry to dry.
Person can do most laundry tasks, but needs minimal assistance to put clothes in machines, sort clothes, fold them and put them away.
Person may have strength but may not be able to see or turn washer dials, or may require supervision or instruction to use a washer.
Person may do light hand washing but cannot bend or lift or carry loads of clothes to manage most laundry. They cannot hang clothes out at all or get them off a line, but may fold them and help put them away.
Person may not be able to wring out clothes without help. If a laundromat is used, the person has considerable difficulty getting there.
Person has special laundry needs due to incontinence or other physical problems and needs laundry more frequently than once a week.
|12. Meal Preparation|
Person can do some meal preparation but has some difficulty. Person can prepare simple foods or warm up food like frozen meals or food prepared by others.
Person may have difficulty with cutting meats or other foods.
Person can prepare foods but needs assistance with meal planning or minimal assistance in preparing meals.
Person is unable to cook meals due to physical impairment and can only do minimal preparation of simple cold foods like sandwiches or cereal.
Person has difficulty opening cans and preparing fresh foods for cooking.
Person regularly has difficulty seeing or turning burners on and sometimes forgets to turn them off.
Person needs prepared meals pureed or ground up for serving.
|13. Escort||Not scored.|
Person decides what to buy, but needs assistance preparing a shopping list.
Person can shop if someone goes along to help.
Person may shop by phone but needs assistance carrying or storing groceries.
Person can do most shopping, but needs extra items picked up between shopping trips.
Person may still decide what to buy, but seldom, if ever, goes to a store and needs shopping for all items and picking up medications.
Person may not be able to shop by phone because of communication difficulties.
Person cannot regularly carry or store most of the purchases without help.
|15. Assistance with Medications|
Person can self-direct* medications, but occasionally needs help with opening the containers.
Person may need to be reminded to take medications.
*Self-direct means the person can:
Person can self-direct* medications, but needs help opening and closing medication containers or needs the medication brought within reach and returning medication to the proper storage area.
Person can self-direct * medications, but has a visual impairment and may not be able to read labels.
Person can self-direct* medications, but must be reminded to ensure that medications are taken as prescribed.
Person can self-direct* medications but needs assistance with pouring a predetermined quantity of liquid to be ingested.
Person can self-direct* medications but needs assistance in reordering medications from a pharmacy.
This task may not be purchased if the functional score is a 3.
|16. Trim Nails||Person can trim their own fingernails but may have difficulty doing their toenails by themselves.||Person trims fingernails only when no one is available to help. |
Person is unable to reach and trim toenails and has difficulty using scissors or clippers.
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 a person with diabetes not to trim the nails, score the task a 3.
Person occasionally gets dizzy 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.
Person may have experienced an occasional fall because of imbalance or the person's movement is restricted because of fear of falling.
Person usually experiences some imbalance and needs to hold onto a support when he first stands up to steady himself.
Person suffers from dizziness that affects his balance and would likely fall if assistance was not available.
|18. Open Jars, Containers|
Person can open some containers but may have difficulty with very large jars, special medicine caps or containers that require special opening instructions or procedures.
Person may use an assistive device.
Person cannot open large jars or new bottles or jars without help or an assistive device.
Person may be able to open small jars and bottles that have been previously opened.
Person can use phone but may have difficulty hearing or getting to the phone quickly when it rings.
Person may need to go out of the home to use phone but can do so without much difficulty.
Person may be able to answer or talk on the phone but may not be able to dial the correct number.
Person is sometimes not able to get to a phone when necessary.
On Items 20 and 21, use information other than the person's perception of themselves only if:
- the person provides inaccurate information because of their physical or mental impairment;
- there are inconsistencies between the information the person is providing and CCSE staff's observation of the person; or
- there is conflicting information provided by a family member present during the interview.
To properly score these questions, if CCSE staff are unsure of the information provided by the person, they will:
- get as much information as possible from the person; and
- contact a third party (such as a family member or friend) who is aware of the person's cognitive abilities; or
- use their judgment to score the question if no one is available who knows the person's cognitive abilities.
20. — Initial scoring: These questions are based on the person's perception of themselves.
0 – If the answer to both questions is no. Stop here.
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 questions is yes.
21. — Scoring instructions: This question is based on the person's perception of themselves. Does the person indicate they have trouble concentrating and has memory lapses? Does the person indicate they need help making decisions?
0 – If the answer to the question is not at all.
1 – If the answer to the question is occasionally, 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 person. This may be a family member, caregiver or the person who called in the intake. Information from home health attendants or CCSE staff observations can be used to score this question, but only as a last resort. CCSE staff 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 CCSE staff feel the information provided by the attendant is accurate, they can score the information based on the attendant's knowledge and observation of the person.
0 = The answer to the question is the person 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 person 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 person makes poor decisions and needs cues or supervision for most decisions.
3 = The answer to the question is the person is severely impaired and rarely makes his own decisions.
23. — Scoring instructions: This question is based on someone's observation of the person. This may be a family member, caregiver or the person who called in the intake. Information from home health attendants or CCSE staff observations can be used to score this question, but only as a last resort. CCSE staff 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 CCSE staff feel the information provided by the attendant is accurate, he can score the information based on the attendant's knowledge and observation of the person.
0 = The answer to the question is no.
1 = The answer to the question is the person has some short-term memory problems and can perform tasks for self with occasional reminders.
2 = The answer to the question is the person has memory lapses resulting in frequently not performing tasks even with reminders.
3 = The answer to the question is the person has memory lapses resulting in inability to perform routine tasks on a daily basis.
24. Total Score — Enter the total score of Items 1-2, 5-12 and 14-23.
Service Arrangement Column
The Service Arrangement column will be coded according to the program.
Service Arrangement (CCSE) — Enter the following codes to indicate the service provider.
|S||Self. Use S if the applicant or person performs the task without any assistance. The Functional Wizard defaults to S if the impairment score is 0.|
|C||Caretaker. Use C when all the task is being performed by a relative, neighbor or friend on a regular basis.|
|P||Purchased. Use P if any part of the task is to be purchased all of the time or at times when another service arrangement type is not available to assist. |
For Home-Delivered Meals (HDM) - only cases with no PAS purchased, the Service Arrangement column for meal preparation is the only task marked P with no allocation of time if lunch is purchased through HDM. The other tasks are not coded for HDM. Check the block HDM in Item 12 to indicate that the meal is provided through HDM. In the Functional Wizard, select the option Provided Through HDM Only.
For HDM with other PAS purchased, no time is allocated if HDM is the only meal indicated as being purchased in Item 12. In Item 12, use Breakfast, Lunch and Supper to designate the meals purchased through PAS. If lunch is purchased through PAS on the days HDM is not authorized, documentation should support the authorization of lunch through PAS on some days and HDM on others. In the Functional Wizard, select the option Provided Through a Combination of PAS/HDM. If meals are only purchased through PAS, select the option Provided Through PAS Only.
A service arrangement code of P should never appear under Item 15, Assistance with Medications, if the functional score is 3. Since a 3 indicates total inability to perform any aspect of the task, only a licensed nurse or designated informal support or caregiver may fulfill this need.
Purchased/Caregiver. Use P/C when the caregiver is assisting with or performing a purchased task during the time the attendant is present. Document in Comments the part of the task the caregiver performs.
Example 1: The caregiver assists with bathing by laying out supplies but needs the attendant to assist with the bath.
Example 2: The person requests a five-day plan and the daughter, who is the caregiver, works M-W-F. The daughter assists the person with bathing on T-Th 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 or on weekends, a general comment may be entered in the Comments section on the first task, rather than comments on each task. The tasks are not coded as P/C, but P only for purchased tasks.
Example 3: The person 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 general comment, "Caregiver (use name and relationship) assists in the evenings and on weekends" in the Comments section for Bathing is adequate documentation. Code the task as P.
|A||Other agency. Use A when a non-HHSC 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 Comments 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 for not applicable in the SASO Primary Support Type field when the applicant or person 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 applicant or person is a double amputee and is unable to walk or use wheelchair ambulation. No time will be allotted for the task. Explain in Comments the task is not applicable. |
The N/A used to designate a task as not applicable will show up in the Service Arrangement column on Form 2060 generated by SASO.
N/A also means none available. The Functional Wizard defaults to N/A in the Primary Support Type field if the impairment score is 1-3. This N/A will also show up in the Service Arrangement column on Form 2060 generated by SASO.
Support Score Column
Support Score (CCSE PAS) — If a PHC, CAS, CMPAS or FC person's functional score is 3 for a purchased priority task (feeding, toileting, transfer, meal preparation), determine the likelihood of that task being done if the attendant does not show up during a normally scheduled service shift. Use the following scale and enter the score in the Support Score column by the appropriate item.
1 = It is very likely that the task would be done even if the attendant does not show up.
2 = The task will probably be done if the attendant does not show up.
3 = The task will probably not be done if the attendant does not show up.
4 = It is very unlikely the task will be done if the attendant does not show up.
In determining this support score, do not consider caregivers as available if they would be at work or school, even if they could come to the person's home if the attendant was not there. Do not enter a support score for an item if either that task is not purchased or the score for that item is not 3.
Part B — Task/Hour Guide Column
Complete Part B for PHC, CAS, CMPAS, FC cases.
Minutes Per Day — Refer to Page 3 and 4 for the minimum and maximum times for each task by impairment score. For each task to be authorized, enter the daily number of minutes needed to conduct that task based on the impairment score and the minute range for that task. Times must be shown in 5-minute increments and if needed, rounded up to the next 5-minute increment.
The subtasks must be checked to indicate specifically what the person needs. A person scoring a 2 or 3 may need all subtasks under the impairment score for 1 and additional subtasks under the impairment score of 2.
The allotted time must be within the range for the impairment score and cannot be higher or lower, except in the following situations:
Example: The person scores a 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 impairment score 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 impairment score of 1, so ten minutes is allowed. Documentation is required to explain the variance. No supervisory approval is required.
Example: The person scores a 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 impairment score 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.
- If a person has a compelling reason for not wanting any of the subtasks under the appropriate impairment score, but only wants subtasks listed in a lower impairment score, CCSE staff or the MCO service coordinator must document the person's request and allocate minutes in the minute range for the subtasks selected. Document the reason, and no supervisory approval is required.
- If a person has a caregiver or other agency performing part of a task and only subtasks in a lower impairment score are needed, document the person's request and allocate minutes in the minute range for the subtasks selected. Document the reason, and no supervisory approval is required.
A task may be purchased if it is performed at least once a month by the provider. Allotted time for the task must be prorated into a weekly amount. Example: Escort 1/mo. × 120 mins. ÷ 4.33 = 28 mins. per week (round up to the next 5-minute increment) = 30 min. per week.
Escort may be shown as PRN (as needed), if it occurs less than once a month no time is allocated.
Note: If the person has extenuating circumstances, other than the exceptions listed above, and requires either more or less time outside the range, for the subtasks within the appropriate impairment score, obtain supervisory approval. Do not change the impairment score to adjust the minutes, or for the convenience of a provider or attendant. For supervisory approval, document the person's extenuating circumstances and justify the need for minutes outside the range. The request must be handwritten or an email as well as the supervisor's approval or disapproval. Documentation of the request and the approval or disapproval must be filed in the case record. Supervisory approval is required for adjustment of time outside the ranges to specific tasks and to combinations of tasks that have ranges.
Companion Cases — For general household tasks, including cleaning, shopping and meal preparation, use the companion minute range rather than the person’s range. Time is allotted per person based on their impairment score. 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 person's impairment score using the companion minute ranges.
Example 1: On cleaning, Mr. Jones scores a 3 and Mrs. Jones scores a 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 impairment score 1 in the companion range. Mr. Jones is allowed the maximum of 180 minutes under impairment score 3 in the companion range.
Example 2: On meal preparation, Mr. and Mrs. Smith both score a 2. However, they have different schedules and need some meals shared and others on a person’s basis. Calculate each person'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 person’s 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 people 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 person or companion range, as appropriate, and check the box. Total the minutes for the Total Minutes per Week. Divide the total 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 5-minute increment. Enter this amount on Form 2060, Page 1, Minutes per days for 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, enter the number of days per week the attendant will conduct that task. Enter in the Comments section if the task is performed less than once a week. For the task of Feeding, enter the total number of meals per week.
Total Minutes — Multiply the minutes per day by the days per week to obtain the weekly Total Minutes Per Week for each task.
Grand Total Minutes — Add the total minutes for each task to obtain the Grand Total Minutes for all tasks. For SPW, transfer this amount to Form 2060-A, Section IV, Box 1.
Hours Needed — Divide the Grand Total 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 a person needs seven hours and 10 minutes of service each week, enter 7.5 in Hours Needed. This field is N/A for SPW.
Less Total A&A Hours — If the person receives Aid and Attendance (A&A) Benefits from Veterans Affairs, reduce the Hours Needed by applying the formula shown on Page 2.
Total Authorization — Enter the total weekly hours that can be authorized. Round the time up to the next highest half hour. The authorized hours cannot exceed 42 for a priority person or 50 for all other people. If fewer than six hours are authorized, explain in the Comments section. For CCSE, see the CCSE Handbook, Section 4420, Eligibility, and Section 4633, Functional Eligibility, for allowable reasons.
Priority Status — Check the box Yes if there is at least one purchased priority task such as feeding, toileting, transfer or meal preparation and:
- the person's functional score for that task is 3, and the support score for that task is 4; and
- it is determined that there is a high likelihood the person's health, safety or well-being would be jeopardized if PAS were not provided on a single given shift.
Do not assign priority status or a support score of 4 if the person is not in jeopardy.
If the person does not meet priority status, check the No box.
Note: Check the Yes box for a SPW person. By program requirements, all waiver people have priority status.
Monthly Amount of A&A — Enter the total amount of Aid and Attendance or Housebound Benefits received by the person. See the Community Care Services Eligibility Handbook, Section 2531, Veterans Affairs Aid and Attendance and Housebound Benefits, for a description of benefits.
Conversion to Weekly Amount — Divide the monthly amount by 4.33 to arrive at the weekly amount.
Conversion to Hours/Total A&A Hours — Divide the weekly amount by the maximum non-priority attendant care rate without regard to service authorized. If the person meets the priority status criteria, use the maximum priority status attendant care rate.
This is the number of hours that can be purchased with the A&A benefits. Enter this amount on Page 1 in Less Total A&A Hours and subtract to arrive at the total hours that can be authorized.
Signature – CCSE Staff — Sign Form 2060 after completing the form, but before asking for a variance if needed. An update to the form must be initialed. The Auto Form 2060 completed using SASO Wizards does not require a signature. CCSE staff's printed name on the form will suffice.
Signature – Supervisor: Variance — Request the supervisor's approval if the person requires minutes outside the mandated minute range. Document the reason for the variance and submit the documentation to the supervisor. The supervisor will indicate approval by signing this form or if not approved, will not sign the form. If approval is via email, check the Email OK box, print the supervisor's name and enter the date approval was obtained. A copy of the documentation and the email must be filed in the case record.
Comments — Use this space, as needed, to explain tasks and hours authorized.
Part C–Task/Minute and Subtask Guide
The Task/Minute and Subtask Guide beginning on Page 3 provides mandatory guidelines for the minutes that may be allowed per task per impairment score. It also contains the subtasks involved in performing the task. Carefully consider whether the person needs total assistance or assistance with only one or more of the subtasks when calculating time on Part B. See exceptions under the Minutes Per Day section.
It is mandatory to check the appropriate subtasks to justify time calculations for the overall task. If the person scores 2 on a task, check all applicable subtasks under Impairment Score 2. Also, all the appropriate subtasks under Impairment Score 1 may be checked. For a score of 3, the checkbox Total Help under Impairment Score 3 is marked, but subtasks under Impairment Score 1 and 2 are checked to identify the specific needs of the person. Any exceptions as described in the Minutes Per Day section must be documented. This information can be referenced at reassessments and service plan changes.