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MAP 351A Form, Waiver Assessment

By Vernon Barnes,2014-06-28 13:10
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MAP 351A Form, Waiver Assessment ...

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

    MEDICAID WAIVER ASSESSMENT Name (last, first, middle) (mo., day, yr.) Date of birth Medicaid number

     / / Street address County code Sex (check one) Marital status (check one)

    Divorced Married Separated Male Single Widowed Female

    City, state and zip code Emergency contact (name) Emergency contact (phone #)

     ( ) - Member phone number Is member able to read and Member’s height ( ) - write Yes No Member’s weight Type of program applied for (check one) Adjudicated /Nonadjudicated________ Home and Community Based Waiver Model Waiver II Type of application (check one) Acquired Brain Injury Waiver Michelle P Waiver Certification Re-certification Re-application Supports for Community Living Waiver Consumer Directed Option Blended

    Member admitted from (check one) Certification period (enter dates below) Home Hospital Nursing facility ICF/MR/DD Begin date / / End date / / Other Certification number:

    Has member’s freedom of choice been explained and Has member been informed of the process to make

    verified by a signature on the MAP 350 Form Yes No a complaint Yes No (see instructions) Physician’s name Physician’s license number Physician’s phone number

     (enter 5 digit #) ( ) - Enter member’s primary diagnosis: HCB (ICD-9 code); SCL (DSM code); ABI (ICD-9 and/or DSM)

Enter all diagnoses including DSM or ICD-9 codes: Is the member diagnosed with one of the following?

     Mental Retardation/ IQ= (Date-of-onset / / ) AXIS I: (mental illness) Developmental Disability (Date-of-onset / / ) AXIS II: (MR/DD) Mental Illness (Date-of-onset / / ) AXIS III: (Medical) Brain Injury Cause of Brain Injury:

    Date of Brain Injury: / /

    Rancho Scale

    Assessment/Reassessment provider Provider number Provider phone number name: ( ) -

Street address City, state and zip code

Provider contact person

MAP 351 Page 1 of 15 (Rev. 3/07)

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

     Name (last, first) Medicaid Number

    *For SCL, MP and ABI waivers only *add additional pages as needed Community Inclusion (what do you like to do or where would you like to go in the community, where do you go for recreation, do you not get to go somewhere that you would like to)

Relationships (How do you stay in contact with your friends and family, do you need assistance in making or keeping

    friends, who are your friends)

    Rights (do you understand your rights, are any of your rights restricted, do you know what is abuse or neglect)

    Dignity and Respect (how are you treated by staff, do you have a place you can go to be with friends or to be alone or have privacy)

    Health (who are your doctors ,do you have any health concerns, what medicine do you take, how do they make you feel,)

Lifestyle (do you have a job, do you want to work, do you want to go to school, do you go to the bank, do you have

    spending money to carry)

Satisfaction with supports (are you satisfied with your services and supports, what do you like about them, what do you

    dislike about them, do you feel like you have choices about what you can do, are you happy with your life, what are you

    happy about, what are you unhappy about)

MAP 351 Page 2 of 15 (Rev. 3/07)

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

     Name (last, first) Medicaid Number 1) Is member independent with Comments:

     dressing/undressing

    Yes No(If no, check below all that apply and comment) Requires supervision or verbal cues Requires hands-on assistance with upper body Requires hands-on assistance with lower body Requires total assistance

    2) Is member independent with grooming Comments: Yes No(If no, check below all that apply and comment) Requires supervision or verbal cues Requires hands-on assistance with oral care shaving nail care hair

     Requires total assistance

    3) Is member independent with bed mobility Comments: Yes No (If no, check below all that apply and comment) Requires supervision or verbal cues Occasionally requires hands-on assistance Always requires hands-on assistance Bed-bound

     Required bedrails

    4) Is member independent with bathing Comments: Yes No (If no, check below all that apply and comment) Requires supervision or verbal cues Requires hands-on assistance with upper body Requires hands-on assistance with lower body Requires Peri-Care

     Requires total assistance

    5) Is member independent with toileting Comments: Yes No (If no, check below all that apply and comment) Bladder incontinence Bowel incontinence Occasionally requires hands-on assistance Always requires hands-on assistance

     Requires total assistance

     Bowel and bladder regimen

    6) Is member independent with eating Yes No Comments: (If no, check below all that apply and comment) Requires supervision or verbal cues Requires assistance cutting meat or arranging food Partial/occasional help Totally fed (by mouth)

     Tube feeding (type and tube location)

MAP 351 Page 3 of 15 (Rev. 3/07)

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

     Medicaid Number Name (last, first)

    7) Is member independent with ambulation Comments: Yes No (If no, check below all that apply and comment) Dependent on device Requires aid of one person Requires aid of two people History of falls (number of falls, and date of last fall)

    8) Is member independent with transferring Comments: Yes No (If no, check below all that apply and comment) Requires supervision or verbal cues Hands-on assistance of one person Hands-on assistance of two people Requires mechanical device

     Bedfast

    1) Is member able to prepare meals Yes No Comments: (If no, check below all that apply and explain in the comments) Arranges for meal preparation Requires supervision or verbal cues Requires assistance with meal preparation Requires total meal preparation

    2) Is member able to shop independently Comments:

     Yes No (If no, check below all that apply and explain in the comments) Arranges for shopping to be done Requires supervision or verbal cues Requires assistance with shopping

     Unable to participate in shopping

    3) Is member able to perform light housekeeping Comments: Yes No (If no, check below all that apply and explain in the comments) Arranges for light housekeeping duties to be performed Requires supervision or verbal cues Requires assistance with light housekeeping

     Unable to perform any light housekeeping

    4) Is member able to perform heavy housework Comments: Yes No (If no, check below all that apply and explain in the comments) Arranges for heavy housework to be performed Requires supervision or verbal cues Requires assistance with heavy housework

     Unable to perform any heavy housework

MAP 351 Page 4 of 15 (Rev. 3/07)

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

    Medicaid Number Name (last, first)

    5) Is member able to perform laundry tasks Comments: Yes No (If no, check below all that apply and explain in the comments) Arranges for laundry to be done Requires supervision or verbal cues Requires assistance with laundry tasks

     Unable to perform any laundry tasks

    6) Is member able to plan/arrange for pick-up, Comments: delivery, or some means of gaining possession of medication(s) and take them independently Yes No (If no, check below all that apply and explain in the comments) Arranges for medication to be obtained and taken correctly Requires supervision or verbal cues Requires assistance with obtaining and taking medication

     correctly

     Unable to obtain medication and take correctly

    7) Is member able to handle finances independently Comments: Yes No (If no, check below all that apply and explain in the comments) Arranges for someone else to handle finances Requires supervision or verbal cues Requires assistance with handling finances

     Unable to handle finances

    8) Is member able to use the telephone independently Comments: Yes No (If no, check below all that apply and explain in the comments) Requires adaptive device to use telephone Requires supervision or verbal cues Requires assistance when using telephone

     Unable to use telephone

    1) Does member exhibit behavior problems Comments: Yes No (If yes, check below all that apply and explain Date of functional analysis: / / and/or the frequency in comments) Date of behavior support plan: / / Disruptive behavior Agitated behavior Assaultive behavior

     Self-injurious behavior

     Self-neglecting behavior

MAP 351 Page 5 of 15 (Rev. 3/07)

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

     Medicaid Number Name (last, first)

    2) Is member oriented to person, place, time Comments: Yes No (If no, check below all that apply and comment) Forgetful Confused Unresponsive Impaired Judgment

    3) Has member experienced a major change or Description: crisis within the past twelve months Yes No (If yes, describe)

    4) Is the member actively participating in social Description: and/or community activities Yes No (If yes, describe)

    5) Is the member experiencing any of the following Comments: (For each checked, explain the frequency and details in the comments section) Difficulty recognizing others Loneliness

    Sleeping problems Anxiousness Irritability Lack of interest

    Short-term memory loss Long-term memory loss Hopelessness

     Suicidal behavior

    Medication abuse Substance abuse Alcohol Abuse

MAP 351 Page 6 of 15 (Rev. 3/07)

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

    Name (last, first) Medicaid Number

    6) Cognitive functioning (Participant’s current Comments: level of alertness, orientation, comprehension, concentration, and immediate memory for simple commands)

     Alert/oriented, able to focus and shift

    attention, comprehends and recalls task

    directions independently. Requires prompting (cueing, repetition, reminders) only under stressful or unfamiliar

     conditions.

     Requires assistance and some direction in

    specific situations (e.g., on all tasks involving shifting of attention), or consistently requires low stimulus environment due to distractibility.

     Required considerable assistance in routine

    situations. Is not alert and oriented or is unable to shift attention and recall directions

    more than half the time.

     Totally dependent due to disturbances such

    as constant disorientation, coma, persistent

    vegetative state, or delirium.

     7) When Confused (Reported or Observed): Comments:

     Never In new or complex situations only On awakening or at night only

     During the day and evening, but not

    constantly

     Constantly NA (non-responsive)

     8) When Anxious (Reported or Observed): Comments:

     None of the time Less often than daily Daily, but not constantly

     All of the time

     NA (non-responsive)

     9) Depressive Feelings (Reported or Observed): Comments:

     Depressed mood (e.g., feeling sad, tearful) Sense of failure or self-reproach Hopelessness

     Recurrent thoughts of death

     Thoughts of suicide

     None of the above feelings reported or observed

    MAP 351 Page 7 of 15 (Rev. 3/07)

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

Name (last, first) Medicaid Number

     10) Member Behaviors (Reported or Observed): Comments:

     Indecisiveness, lack of concentration Diminished interest in most activities Sleep disturbances

     Recent changes in appetite or weight

     Agitation

     Suicide attempt None of the above behaviors observed or reported

     11) Behaviors Demonstrated at Least Once a Comments:

    Week: Memory deficit: failure to recognize familiar persons/places, inability to recall

     events of past 24-hours, significant memory

    loss so that supervision is required.

     Impaired decision-making: failure to

    perform usual ADL’s, inability to

    inappropriately stop activities, jeopardizes

    safety through actions.

     Verbal disruption: yelling, threatening,

    excessive profanity, sexual references, etc.

     Physical aggression: aggressive or

    combative to self and others (e.g. hits self,

    throws objects, punches, dangerous

    maneuvers with wheelchair or other

    objects).

     Disruptive, infantile, or socially

    inappropriate behavior (excludes verbal

    actions).

     Delusional, hallucinatory, or paranoid

    behavior.

     None of the above behaviors demonstrated.

12 ) Frequency of Behavior Problems (Reported or

    Observed) such as wandering episodes, self abuse, verbal disruption, physical aggression, etc.: Never

     Less than once a month

     Once a month

     Several times each month

     Several times a week

     At least daily

MAP 351 Page 8 of 15 (Rev. 3/07)

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

    Name (last, first) Medicaid Number

     13) Mental Status: Comments:

     Oriented Forgetful Depressed

     Disoriented

     Lethargic

     Agitated Other

     14) Is this member receiving Psychiatric Nursing Comments: Services at home provided by a qualified psychiatric nurse? No

     Yes

    1) Is member’s vision adequate (with or without Comments: glasses) Yes No Undetermined (If no, check below all that apply and comment) Difficulty seeing print Difficulty seeing objects

     No useful vision

    2) Is member’s hearing adequate (with or without Comments: hearing aid) Yes No Undetermined (If no, check below all that apply, and comment) Difficulty with conversation level Only hears loud sounds

     No useful hearing

    3) Is member able to communicate needs Comments: Yes No (If no, check below all that apply and comment) Speaks with difficulty but can be understood Uses sign language and/or gestures/communication device Inappropriate context Unable to communicate

MAP 351 Page 9 of 15 (Rev. 3/07)

    Commonwealth of Kentucky

    Cabinet for Health and Family Services

    Department for Medicaid Services

    Name (last, first) Medicaid Number 4) Does member maintain an adequate diet Comments: Yes No (If no, check all that apply and comment) Uses dietary supplements Requires special diet (low salt, low fat, etc.) Refuses to eat Forgets to eat

     Tube feeding required (Explain the brand, amount, and frequency in the comments section) Other dietary considerations (PICA, Prader-Willie, etc.)

    5) Does member require respiratory care and/or Comments: equipment Yes No (If yes, check all that apply and comment) Oxygen therapy (Liters per minute and delivery device) Nebulizer (Breathing treatments) Management of respiratory infection Nasopharyngeal airway

     Tracheostomy care

     Aspiration precautions Suctioning Pulse oximetry

     Ventilator (list settings)

    6) Does member have history of a stroke(s) Comments: Yes No (If yes, check all that apply and comment) Residual physical injury(ies) Swallowing impairments Functional limitations (Number of limbs affected)

    7) Does member’s skin require additional, Comments: specialized care Yes No (If yes, check all that apply and comment) Requires additional ointments/lotions Requires simple dressing changes (i.e. band-aids, occlusive dressings) Requires complex dressing changes (i.e. sterile dressing)

     Wounds requiring “packing” and/or measurements

     Contagious skin infections Ostomy care

    8) Does member require routine lab work Comments: Yes No (If yes, what type and how often)

    9) Does member require specialized genital and/or Comments: urinary care Yes No (If yes, check all that apply and comment) Management of reoccurring urinary tract infection In-dwelling catheter Bladder irrigation In and out catheterization

MAP 351 Page 10 of 15 (Rev. 3/07)

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