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mr_dd waiver nursing acuity grid

By Katie Franklin,2014-08-04 09:11
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mr_dd waiver nursing acuity grid

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS 刚刚好够好看好看更快更好看个好看过后

    MR/DD WAIVER NURSING ACUITY GRID

    8 HOURS PER DAY OR MORE NURSING SERVICES Member __________________________ Agency_________________________________

    Medicaid Number __________________________

     Pt Sc Pt Sc Pt Sc Weight < 100 lbs Weight < 125 lbs Weight 125 lbs or greater 2 3. 0 4. 5 Minimal on-going assessments Moderate on-going assessments Frequent visual monitoring 2 4. 0 9. 0

     (less than daily) (Hands on every 4 - 6 hours) (both technical and patient assessment)

     VS/GLU/NEURO/RESP assess < q4 hr* Continual assessments 1. 5 6. 0

     VS/GLU/NEURO/RESP assessments > q 4 hr 1. 0 Routine meds > q 4 hrs Complicated med schedule > q 2 hrs VS/GLU/NEURO/RESP assessments > q 2 hr 2 5. 0 3. 0

     Central line Regular blood draws/IV Peripheral site ** 2. 5 4. 5

     Occasional transfusion/IV < month Regular blood draws/IV central line ** 2. 5 6. 0

     IV Rx < q 4 hr 4. 5 Uncomplicated tube feeding Tube feeding with minimal problem IV Rx q 4 hr or more often 2 2. 5 6. 0 Difficult/prolonged oral feeding Occasional reflux Central line with TPN 2 0. 5 6. 0

     Gastrostomy tube Chemotherapy 0. 5 6. 0 DHHR - WORKING DRAFT ONLY - Chapter 5001

    Version 1 Effective Date DISCLAIMER: This manual does not address all the complexities of Medicaid policies and

    procedures, and must be supplemented with all State and Federal Laws and Regulations.

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS

    02 via cannula low flow rate Tracheostomy (routine care) IV pain control 2 1. 5 6. 0 Suctioning < q 2 hrs Suctioning > q 2 hrs Ventilator 2 2. 5 9. 0 Aspiration precautions Humidification No respiratory effort 2 1. 5 12. 0

     C PAP or IMV < 12 hours/day 6. 0

     C PAP or IMV > 12 hours/day 9. 0

     CPT or Neb Tx < q 4 hours Standby 1. 5 3. 0 Requires all personal care/hygiene Rehab transition (from ventilator) 2 9. 0

     Mild-mod seizures (Req min intervention) CPT or Neb Rx > q 4 hr * (enter #_____ ) 2. 5 3. 0

     Frequency < 4 x day CPT or Neb Rx > q 2 hr * (enter # _____ ) 1. 5 3. 0

     Frequency 4 - 6 x day Severe seizures ( reg IM or IV intervention ) 2. 0 4. 5 Uncontrolled incontinence Intermittent straight catheter Frequency > 6 x day 2 3. 5 1. 5 Awake no more than 3 hr a night Moderate sleep disturbance Uncontrolled incontinence (Frequent linen change) 2 3. 5 6. 0

     (Awake/turned q > 2 hr a night) Communication deficit Disorientation/combative Severe sleep disturbance (Awake > q 2 hr) 2 5. 0 6. 0

     (cognitive or verbal) (Strikes out, attempts to hurt self) Developmental deficit < 80 lbs 2 1. 5

     < 110 lbs Disoriented/combative > 140 lbs 2. 0 6. 0

     < 140 lbs 2. 5 DHHR - WORKING DRAFT ONLY - Chapter 5002

    Version 1 Effective Date DISCLAIMER: This manual does not address all the complexities of Medicaid policies and

    procedures, and must be supplemented with all State and Federal Laws and Regulations.

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS Developmentally delayed mobility Requires isolation 2 6. 0 Basic ROM (No PT or OT program) Full OT (Set program q 4 hr) Acute mobility problems (Potential for skin breakdown) 2 5. 5 6. 0 Play therapy Full PT (Set program q 4 hr) 2 5. 0 Fracture or casted limb Attends therapy with nurse 2 6. 0 Body cast RN case management < 4 hrs week *** Peritoneal dialysis 2 2. 5 6. 0

     RN case management > 4 hrs week *** 5. 0

     TOTAL TOTAL TOTAL

    Pt - Point Sc - Score * Give points for each type of assessment and each Neb or CPT Rx ** Give points for each IV Rx or blood draw ordered to a maximum of 10 points

     *** Documentation must support item selected Nurse: ___________________________________ Date:_____________________________________ Signature: _________________________________ Total Points:_______________________________

MR/DD WAIVER

    DHHR - WORKING DRAFT ONLY - Chapter 5003

    Version 1 Effective Date DISCLAIMER: This manual does not address all the complexities of Medicaid policies and

    procedures, and must be supplemented with all State and Federal Laws and Regulations.

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS

    MR/DD WAIVER NURSING PSYCHOSOCIAL GRID

    8 HOURS PER DAY OR MORE NURSING SERVICES

    Member ______________________________ Agency__________________________ Medicaid Number ______________________________

     Minimal Pt Sc Moderate Pt Sc Extensive Pt Sc

    Managed by primary care provider Requires periodic medical specialty Requires multidisciplinary team approach Medical Management 1 2 3 or one specialist. consultation.

    Other caregivers present in home Other caregivers available outside of home by No other caregivers available Primary Caregivers 1 2 3 to provide care. arrangement.

    At least 2 responsible adults in At least 2 responsible adults in the home. Primary caregiver may or may not be primary wage earner. Wage Earner 1 2 3 home. Primary caregiver is not Primary caregiver contributes to wage earnings Only one responsible adult in home. primary wage earner. or is primary wage earner.

    No other dependents/or dependents 1 to 3 dependents with moderate medical or Greater than 3 dependents in the home with intense medical Family Constellation 1 2 3 have minimal needs. emotional needs. or emotional needs.

    Family exhibits problem Family requires assistance in identifying Family requires extensive assistance to recognize problems Problem Solving 1 2 3 identification and problem solving problems/problem solving. and identify solutions. Skills skills.

    Family follows through with Family needs encouragement to follow through Family follows through on recommendations only with Coping 1 2 3 recommendations, keeps on recommendations. Inconsistent in keeping extensive support and assistance. appointments. appointments.

    Support systems present and Support system present but family needs Support systems absent. Support Systems 1 2 3 utilized. encouragement to utilize.

    No history of mental illness, and/or History of mental illness or behavior problems Current diagnosis of mental illness and/or behavior Other Stressors 1 2 3 behavior problems. among family members. problems among family members. Resource Utilization Family's physical survival and Family resources are inadequate, barely meets Family does not meet its needs for security and physical 2 4 6 and/or Private security needs are met. its needs for security and physical survival. survival. Unable to buy the necessities. Requires intensive Insurance Community resources and/or Able to buy only necessities. Requires assistance to identify and utilize resources. private insurance utilized. assistance in

    identification/utilization of resources.

    No safety or health hazards Needs assistance to correct safety and health Home inadequate to meet minimum safety and health Safety/Shelter 1 2 3 identified in home environment. hazards. standards.

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS

    ADL's met consistently. Inconsistent in meeting ADL's. ADL's not met. ADL's (age 1 2 3 appropriate)

     TOTAL TOTAL TOTAL

Pt - Point Sc - Score

    Nurse:___________________________________________

     Date_________________________

    Signature:________________________________________ Total Points___________________

MR/DD WAIVER

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS

    West Virginia Department of Health and Human Resources

    ICF/MR Level of Care Evaluation

? Initial ? Annual Renewal ? Title XIX MR/DD Waiver

    Service Coordination Agency: _______________________________________________________ Address: __________________________________________________________________________ Service Coordinator:________________________________________________________________ Contact Person: ____________________________________________________________________ Date: ________________________________________________________________

     I. DEMOGRAPHIC INFORMATION

1. Individual‟s Full Name 2. Sex: 3. Medicaid #

     ? F ? M

    4. Address (including Street/Box, City, State & Zip)

5. County 6. Social Security # 7. Birthday (MM/DD/YY) 8. Age 9. Phone

10. Spouse‟s Name 11. Address (if different from above)

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS

    12. Check if applicant has any of the following:

     a. ? Guardian d. ? Power of Attorney g. ? Other ______________________

     b. ? Committee e. ? Durable Power of Attorney

     c. ? Medical Power of Attorney f. ? Living Will

    Name & Address of Representative: _____________________________________________________________

    _________________________________________________________________________________________

Phone:( )

13. Living Arrangement

    ? Natural/adoptive family ? Specialized family care provider

    ? ISS One person (Intensive support setting) ? ISS 2 person (Intensive support setting)

    ? ISS Three person (Intensive support setting) ? Group Home (4 or more persons)

    14. Description of current living arrangements, including formal and informal support(i.e. family, friends, other services)

    ___________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________________________________________________________________________________

    15. Significant Health History (include recent hospitalization(s) and/or surgery(s) with dates, history of infectious disease)

    ______________________________________________________________________________________________________________________________________________________________________________________________________

    ___________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS

     II. MEDICAL ASSESSMENT NAME: _______________________________

     DATE: _______________________________

    16. Height Weight BP P R T

17. Allergies:

    CODE: ? = NORMAL N = NOT DONE NA = NOT APPLICABLE X = ABNORMAL (PLEASE DESCRIBE) SKIN

EYES/VISION

NOSE

THROAT

MOUTH

SWALLOWING

LYMPH NODES

THYROID

HEART

LUNGS

BREAST

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS

    ABDOMEN

EXTREMETIES

SPINE

GENITALIA

RECTAL (MALES INCLUDE PROSTATE)

BI-MANUAL VAGINAL

    NEUROLOGICAL ALERTNESS

COHERENCE

ATTENTION SPAN

SPEECH

SENSATION

COORDINATION

GAIT

MUSCLE TONE

REFLEXES

VISION

     TITLE XIX MR/DD WAIVER MANUAL

     - WORKING DRAFT ONLY

     PURPOSE OF THIS DRAFT IS TO SOLICIT INPUT FROM STAKEHOLDERS DENTAL

HEARING

     NAME

    __________________________________

     DATE _________________________________

    MEDICAL ASSESSMENT II, CONT.

    Problems requiring Special Care (check all appropriate blanks)

     MOBILITY CONTINENCE STATUS FEEDING Ambulatory ______ Continent _____ Feeds self _____

    Ambulatory w/human help ______ Incontinent _____ Needs to be fed _____

    Ambul. w/mechanical help ______ Not Toilet trained _____ Gastric/J tube _____

    Wheelchair self propelled ______ Catheter _____ Special Diet _____ Wheelchair w/assistance ______ Ileostomy _____ Transfer w/assistance ______ Colostomy _____ Bedfast ______

     PERSONAL HYGIENE/SELF CARE MENTAL AND BEHAVIORAL DIFFICULTIES Needs total care ______ Alert _____ Self-injurious behavior _____

    Independent ______ Confused/Disoriented _____ EPS/TD _____

    Needs Assistance ______ Irrational behavior _____ Unable to communicate _____

     Needs close supervision _____

    ________________________________________________________________________________________________________________________

    ADDITIONAL RECOMMENDATIONS

VISION THERAPY ______

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