Instructions for Form NMO-7073 "Nevada Medicaid: Functional Assessment Service Plan" - Nevada

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Nevada Medicaid: Functional Assessment Service Plan
Instructions
These instructions will assist you when completing a Nevada Medicaid Functional Assessment Service Plan form.
Required form:
Functional Assessment Service Plan Tool – Form NMO-7073
1.
Recipient information:
a.
Enter the recipient's name, last name and first name. Entry into this field will auto populate into the header
of the form.
b.
Enter the Recipient ID number - Entry into this field will auto populate into the header of the form.
c.
Enter the recipient's date of birth.
d.
Indicate Yes or No by selecting the button if a translator is required. If Yes is marked, indicate the
language.
e.
Enter the recipient's current address, city, state, zip code, and phone.
f.
Identify Male or Female by selecting the appropriate button.
g.
Enter the recipient's height, weight, and age.
h.
Have the recipient read and complete the rest of page 1 of your tool.
i.
At the end of your assessment, enter the begin and end time of your assessment. Have the recipient,
their legally responsible individual, personal care rep, or other sign the attestation page.
ii.
If “other” is marked, indicate the relationship.
2.
Legally Responsible Individual (LRI) information: Complete this section only if the recipient has an LRI. LRI include
spouses, legal guardians, and parent(s), stepparent(s), foster parent(s) and adoptive parent(s) of minor children. An
LRI is required to provide medical support. A power of attorney (POA) is not the same as guardianship.
a.
Enter LRI's name and relationship to recipient.
b.
Indicate if the LRI resides in the home or outside the home by selecting the appropriate button.
c.
If the LRI does not reside with the recipient, enter their phone number.
d.
Indicate if the LRI is disabled or works/attends school outside the home.
i.
If the LRI works outside the home or attends school outside the home, indicate the work/school
schedule.
Services can only be provided to cover activities of daily living (ADLs) and meals when the LRI is not available
due to their work or school schedule. The LRI remains responsible for other instrumental activities of daily
living (IADLs) such as housekeeping, laundry, and shopping.
If the LRI has proof of disability, allow for services for which the LRI is incapable of doing due to their disability.
Example: The LRI may not be able to lift or bend, but is still able to prepare meals and feed recipient. You can
provide bathing, transfer, toileting, and mobility time, but not feeding and meal preparation.
If the LRI is totally disabled, approach the plan as if the LRI is completely unavailable/incapable.
3.
Emergency contact information: If the recipient has no guardian but has a POA, a personal care representative
(PCR), or would like us to have permission to speak to another individual:
a.
Enter the contact name of this person.
b.
Indicate POA, PCR, and/or relationship type (friend, sister, daughter, etc.).
c.
Enter the contact's phone number.
Page 1 of 13
Functional Assessment and Service Plan Instructions
NMO-7073 (10-15)
Nevada Medicaid: Functional Assessment Service Plan
Instructions
These instructions will assist you when completing a Nevada Medicaid Functional Assessment Service Plan form.
Required form:
Functional Assessment Service Plan Tool – Form NMO-7073
1.
Recipient information:
a.
Enter the recipient's name, last name and first name. Entry into this field will auto populate into the header
of the form.
b.
Enter the Recipient ID number - Entry into this field will auto populate into the header of the form.
c.
Enter the recipient's date of birth.
d.
Indicate Yes or No by selecting the button if a translator is required. If Yes is marked, indicate the
language.
e.
Enter the recipient's current address, city, state, zip code, and phone.
f.
Identify Male or Female by selecting the appropriate button.
g.
Enter the recipient's height, weight, and age.
h.
Have the recipient read and complete the rest of page 1 of your tool.
i.
At the end of your assessment, enter the begin and end time of your assessment. Have the recipient,
their legally responsible individual, personal care rep, or other sign the attestation page.
ii.
If “other” is marked, indicate the relationship.
2.
Legally Responsible Individual (LRI) information: Complete this section only if the recipient has an LRI. LRI include
spouses, legal guardians, and parent(s), stepparent(s), foster parent(s) and adoptive parent(s) of minor children. An
LRI is required to provide medical support. A power of attorney (POA) is not the same as guardianship.
a.
Enter LRI's name and relationship to recipient.
b.
Indicate if the LRI resides in the home or outside the home by selecting the appropriate button.
c.
If the LRI does not reside with the recipient, enter their phone number.
d.
Indicate if the LRI is disabled or works/attends school outside the home.
i.
If the LRI works outside the home or attends school outside the home, indicate the work/school
schedule.
Services can only be provided to cover activities of daily living (ADLs) and meals when the LRI is not available
due to their work or school schedule. The LRI remains responsible for other instrumental activities of daily
living (IADLs) such as housekeeping, laundry, and shopping.
If the LRI has proof of disability, allow for services for which the LRI is incapable of doing due to their disability.
Example: The LRI may not be able to lift or bend, but is still able to prepare meals and feed recipient. You can
provide bathing, transfer, toileting, and mobility time, but not feeding and meal preparation.
If the LRI is totally disabled, approach the plan as if the LRI is completely unavailable/incapable.
3.
Emergency contact information: If the recipient has no guardian but has a POA, a personal care representative
(PCR), or would like us to have permission to speak to another individual:
a.
Enter the contact name of this person.
b.
Indicate POA, PCR, and/or relationship type (friend, sister, daughter, etc.).
c.
Enter the contact's phone number.
Page 1 of 13
Functional Assessment and Service Plan Instructions
NMO-7073 (10-15)
Nevada Medicaid: Functional Assessment Service Plan
Instructions
4.
Daily routine: This is also used to determine the recipient’s needs and is helpful to the PCS agency in determining
the PCS schedule.
Example 1: Recipient indicates he gets up and showers; then the personal care attendant (PCA) arrives and
cleans and cooks. This recipient is not going to meet criteria for the program.
Example 2: Recipient states that he goes to ADHC Monday through Friday and needs assistance to be ready in
time to be picked up. The agency will then know one visit in the early a.m. on those days is required.
5.
Assessment information:
a.
Purpose of request - Select the appropriate item. This will be indicated on the prior authorization form you
receive.
b.
Location - Select the appropriate item.
c.
Indicate the primary person relaying the information. If it is not the recipient, indicate who it is and their
relationship to the recipient.
d.
You may indicate the name of the actual PCS agency if known and the name of the PCA if known.
e.
Enter others in the household. If they are children, enter the ages of the children.
f.
Enter any allergies the recipient may have including medications, food, or seasonal allergies.
6.
Diagnosis:
a.
While recipients may have multiple diagnoses, it is most important to indicate:
i.
the primary diagnosis(s).
ii.
the diagnosis that affects their ability to complete their ADL/IADL activities.
7.
Medications:
a.
Indicate the recipient's medications, dosage, and frequency.
NOTE:
The client will receive a copy of this assessment. This tool can be used to assist emergency
personnel, should they be called.
8.
Objective observations:
a.
Add in the results of your hands on clinical assessment, including your objective observations of the
recipient's ability or inability to complete their ADLs/IADLs. Include the recipient's demonstrated functional
ability to accomplish ADLs.
For example, ask the recipient to bring you their medications, while observing their ability to walk, bend,
or reach, or the amount of assistance or technique used with transfers.
NOTE:
This section is for the documentation of your clinical observations of the recipient’s functional
assistance needs directly related to the authorization of personal care services. Should you need
to document anything non clinical for the QIO-like vendor or a future PT/OT would need to
know, such as a vicious dog on the premises or that the recipient is combative, please use a
separate progress note and attach to your review.
The following sections: Functional deficits (9) through IADLs (15) are used to paint a picture of the recipient’s abilities
and inabilities to complete ADL/IADLs.
9.
Functional deficits:
a.
Select the items that most describes the recipient in the area of Mobility/Range of motion: Gait, Dominant
Side, Right and Left Arm, and Right and Left Leg.
b.
Use the comment box to elaborate on what the actual deficit is.
Page 2 of 13
Functional Assessment and Service Plan Instructions
NMO-7073 (10-15)
Nevada Medicaid: Functional Assessment Service Plan
Instructions
10.
Sensory deficits:
a.
Select the items that most describes the recipient’s sensory deficits in the areas of Vision, Auditory, and
Touch/Sensation. For Pain, use a rating from 0 to 10. If a positive response is received regarding pain, the
location and type of pain must be entered. An additional area for 'Other/Comment' is also available. For
example, if sensory deficit is neuropathy, you might indicate that under 'Other/Comment', but might also
see something indicated under the areas of diagnosis or functional deficit.
11.
Cognitive deficits:
a.
Indicate Memory/Cognitive status to the best of your ability during the interview.
i.
Choosing ‘within normal limits’ will indicate they are oriented to person, place, time, and purpose. If
only a partial orientation, you must indicate which area the client is oriented to.
b.
Indicate the Speech/Language ability.
c.
If you chose 'Other/Comment', a description must be entered.
12.
Endurance deficits:
a.
If endurance is the primary issue, indicate the item that most meets the recipient’s condition.
b.
If you chose 'Other', a description must be entered.
13.
Assistance devices and other services:
a.
In the left hand column, indicate if the client “Has”, “Uses”, or “Needs” equipment. Recipients may have
equipment, but are not using it; so if they are using the equipment, make sure to check both the “H” for
‘Has’ and the ‘U’ for Uses.
b.
The right hand column is for services. If any of the services are being received, check the box(es) under ‘R’.
If the services are needed, check the boxes under ‘N’. If the service is N/A, do not check.
c.
If the recipient is attending Adult Day Health Care (ADHC), a work program, or school, indicate the
schedule. The PCS Provider agency will need this to create their schedule with the recipient.
NOTE:
Any box on either side marked with an “N” will be referred by the Quality Improvement
Organization (QIO)-like vendor to the Nevada Medicaid District Office or the appropriate waiver
case manager for follow up.
14.
Activities of Daily Living (ADLs):
For each task, you will identify the level of independence/dependence and the number of days per week that
assistance is needed. For example, in bathing you determine the client to be a Level 2 and that help is needed
4 days per week. In the bathing row, you would enter a “4” in the 'Days per week' column and a “2” in the 'Score'
column.
NOTE:
Do not provide time for tasks that in the absence of a disability a person would not be able to perform.
For example, do not provide bath time when the only assistance required is assistance with washing the
back.
To score each task, use the descriptions below. Strict adherence to the descriptions is required so that all
assessments have the same result regardless of the therapist completing the review.
NOTE:
Time is in minutes per day.
Page 3 of 13
Functional Assessment and Service Plan Instructions
NMO-7073 (10-15)
Nevada Medicaid: Functional Assessment Service Plan
Instructions
Bathing/Dressing/Grooming:
Score
Time
Description
0
0
Independent:
Able to bathe, dress, and groom without assistance of another person, with or
without assistive devices. Able to bathe, dress, and groom with a simple reminder
from in home supports, but does not otherwise require cueing or physical assistance
throughout the task(s) to complete. Bathing is done by an alternate source (non-
paid care giver, LRI, family, or friend). The recipient only requests assistance washing
a body part that in the absence of a disability, the recipient would not be able to
reach/wash.
1
30
Minimum assist:
Able to manage bathing, dressing, and grooming without physical assist, but needs
standby assist or cueing to complete the task. May require only assistance in/out of
shower or tub, clothes laid out, and grooming supplies set up.
2
45
Moderate assist:
Requires physical assistance to complete bathing, dressing, and grooming, but
recipient is able to participate. Requires assist in/out of shower, to wash part of
body, and/or to assist with shampoo, to set up, and partial physical assistance with
dressing and grooming.
3
60
Maximum assist:
Requires maximum assist or is dependent on others to complete bathing, dressing,
and grooming. Upper and lower body physical assistance is required.
Toileting:
Score
Time
Description
0
0
Independent:
Can self-toilet without physical assistance or supervision with or without assistive
devices. Task is completed by other non-paid resources. Can empty own urinary or
bowel drainage systems.
1
15
Minimum assist:
Standby assistance or cueing needed for safety or task completion. Physical
assistance such as clothing adjustment or washing hands. Includes emptying
commode or urinal when the recipient otherwise self-toilets. Occasional help with
adult briefs or pull-ups.
2
15
Moderate assist:
Physical assistance required with hygiene, clothing, and assistance on/off toilet or
commode. Includes assistance with adult briefs/incontinence products.
3
30
Maximum assist:
Unable to use the toilet unassisted. Requires continuous observation and total assist
for hygiene and clothing. Includes changing of diapers (not briefs). Includes
emptying urinary/bowel drainage bags.
Page 4 of 13
Functional Assessment and Service Plan Instructions
NMO-7073 (10-15)
Nevada Medicaid: Functional Assessment Service Plan
Instructions
Transferring:
NOTE:
Assisting on/off the toilet is under Toileting time. Assisting a person to stand up to begin
ambulating is under Mobility time. Do not mark Transferring time unless it is a separately
identified task as indicated in each level description. Transferring may include assistance on or
off handicapped transportation if the need is consistent and not intermittent.
Score
Time
Description
0
0
Independent:
Is ambulatory with or without assistive devices. Is able to reposition self in chair or
bed.
1
15
Minimum assist:
Is ambulatory with or without assistive devices, but requires some repositioning in
bed or chair (positioning of legs, elevating a body limb, propping with pillows).
2
15
Moderate assist:
Is non-ambulatory or minimally ambulatory and requires simple pivot transfers to
wheelchair or household furniture (wheelchair to recliner). May or may not also
need repositioning in bed, wheelchair, or chair.
3
30
Maximum assist:
Is non-ambulatory and dependent for all transfers and/or repositioning. Includes
use of Hoyer lift.
Mobility/Ambulation:
NOTE:
For purpose of the PCS program, Mobility refers to within the residence. Do NOT indicate a
level of need when the need is in the community only.
Score
Time
Description
0
0
Independent:
Is able to ambulate independently within the residence. Includes independent
ambulation with a cane.
1
15
Minimum assist:
Stand-by or intermittent assist to stand and/or ambulate. Positioning of a cane to
ambulate.
2
15
Moderate assist:
Contact guard/hands-on assist to stand and/or ambulate, with or without assistive
devices. Positioning of a walker or wheelchair to ambulate. Includes stand-by assist
for power wheel chair when doors must be opened or closed or obstacles moved
within the residence. Plug in power wheelchair battery.
3
15
Maximum assist:
Dependent. Unable to move within residence or propel wheelchair.
4
0
Does not require hands on assistance. No PCA time required. If PCA time is
required, score appropriately as a level 1, 2, or 3. Independent in manual or power
wheelchair, bed-bound and non-ambulatory, or is two hand dependent on an
assistive device to ambulate independently within the residence. Qualifies as a 2 or
higher when determining IADLs.
Page 5 of 13
Functional Assessment and Service Plan Instructions
NMO-7073 (10-15)
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