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 500–1
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 500–2
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 500–3
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 ______