Instructions for the Completion of the HCBS Comprehensive Assessment 525-05-60-10

(Revised 7/1/09 ML #3188)

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THIS ASSESSMENT IS FOR PERSONS 18 YEARS OF AGE OR OVER. The HCBS Comprehensive Assessment enables the HCBS case manager to record the applicant's/client's functional impairment level and correlate that to the need for in-home and community-based services. The HCBS Comprehensive Assessment is a web-based product of Synergy Technologies.

The HCBS Comprehensive Assessment Form is intended to collect information based on the client's response(s), information reported by significant other (such as family or friends), and the HCBS case manager's observation. In most cases, the applicant/client is the respondent of choice, and the HCBS case manager should make every attempt to conduct the interview with the applicant/client.

KEY FACTORS:

Cover Sheet

Assessment Information
Client Identification
Demographic
Informal Supports
Legal Representatives
Emergency Contacts
Medical Contact Information

Physical Health Information

Nutrition
Impairments
Current Health Status
Medication Use

Cognitive /Emotional Status

Cognition/Behavior
Emotional Well Being/Mental Health

Functional Assessment

Activities of Daily Living (ADL)
Instrumental Activities of Daily Living (IADL)
Supervision/Structured Environment
Special Needs
Home Environment Physical Environment

Physical Environment

Services/Economic Assistance Information

Services/Funding Sources

Narratives and Signatures/Dates

The HCBS case manager shall note the following information in the corresponding or relevant narratives and or notes which are available throughout the HCBS Comprehensive Assessment:

Record related comments which the applicant/client or family member offers. Document if comments are self reported, family reports, collateral contacts, or observation.
Does client have any difficulty preparing meals? Dental limitations? Cost? Are home delivered meals available? Special diet requirements?
Is applicant/client currently being treated for medical problems? If not, is the client refusing treatment?
Any medical condition not being treated may necessitate HCBS case management intervention in arranging for care.
Foot problems should be described in comments relating to client’s medical conditions/diagnosis
Vision, hearing and speech problems should describe and how they affect the applicant’s functioning.
Does the applicant/client experience difficulty in using adaptive devices? Note which devices are used inside and outside the home.
Details relating to history of falls, hospital, and emergency room visits.
Does client take dosage as prescribed?
Who administers the treatments and any problems the client is experiencing with medical treatments, particularly those which are self or family-administered?
Also, note any difficulty in remembering to take medication as well as side effects. If more than one doctor has prescribed the medications, ask if client’s primary physician is aware of all the medications client is taking.
Does client have any difficulty getting medicine refilled? Cost? Does pharmacy deliver? Is client still taking medications?
Other details may be recorded at the HCBS case manager’s discretion.

HCBS case managers are not expected or qualified to make medical diagnoses. Through observation and interviews, the HCBS case manager shall obtain pertinent medical information and any necessary medical documentation regarding the applicant's/client's physical health status.

All questions on the HCBS Comprehensive Assessment should be answered if they apply to the client in any way.

The HCBS Comprehensive Assessment Form and completion instructions are as follows:

Section 1. Cover Sheet. A HCBS case manager may have frequent need to refer to basic demographic information. HCBS case managers should be sure to confirm the accuracy of emergency and medical information.

Assessment Information
Client Identification
Demographic
Informal Supports
Legal Representatives
Emergency Contacts
Medical Contact Information

Section 2. Physical Health Information. An applicant's/client's physical health is an important indicator of overall well-being. The purpose of this section is three-fold:

It should enable the HCBS case manager to identify areas which require the attention of skilled medical personnel.
It will assist the HCBS case manager in assessing the client's rehabilitative potential and in establishing the goals of the service plan.
It will provide information that will be useful in indicating a need for personal care assistance.

Nutrition
Impairments
Current Health Status
Medication Use

Section 3. Cognitive/Emotional Status. This section collects basic information related to the applicant's/client's cognitive and emotional functioning. Both emotional health and cognitive capacity have an impact on ability to maintain a level of self care and consequently have an impact on the client's ability to remain at home.

Section 4. Functional Assessment

4-A. Activities of Daily Living

HCBS case managers require specific information regarding the activities a client can perform in order to arrange for services which enable the client to remain at home.

This section allows the HCBS case manager to determine the level of impairment an applicant/client is experiencing, based on specific medical, emotional and cognitive status. It is based on standard scales which have been tested and validated in programs serving the elderly.

The questions measure the degree to which an applicant/client can perform various tasks that are essential to independent living. These tasks, called Activities of Daily Living (ADLs), include: bathing, dressing/undressing, eating, toileting, continence, transfer in/out of bed or chair, and indoor mobility.

The scale used to measure independence in ADLs uses ratings from 0 to 3. A score of zero represents complete independence (no impairment), while 3 represents complete dependence (impairment). Each item measures the level of impairment of the client, regardless of how much help they might be receiving at present. In completing the section, the HCBS case manager should check the number which best corresponds to the applicant's/client's impairment level. The following general definitions shall determine the ratings.

Information on each of the ADLs can be collected by observation, by direct questioning of the applicant/client, or by interview with a significant other.

HCBS case managers will want to know how the applicant/client usually performs a task, i.e., most of the time. Applicants/clients who have occasional difficulty should be coded based on their usual performance. However, occasional difficulties should be noted in the corresponding narrative/note.

Barthel Scale Scoring (as defined by C.V. Granger, July, 1974)


0:	Completely Able - Activity completed under ordinary circumstances without modification, and within reasonable time. (A "reasonable time" involves an amount of time the client feels is acceptable to complete the task and an amount which does not interfere with completing other tasks, as well as the professional judgment of the Case Manager based on the client's age, health condition, (e.g. arthritis) and situation.
1:	Able with Aids/Difficulty - Activity completed with prior preparation or under special circumstances, or with assistive devices or aids, or beyond a reasonable time.
2:	Able with Helper - Activity completed only with help or assistance of another person, or under another person's supervision for safety, or by cuing. ANOTHER HUMAN IS INVOLVED IN ACTIVITY; but client performs at least half the effort him/herself.
3:	Unable - Client assists minimally (less than half of effort), or is totally dependent.

Some general concepts govern the manner in which a client is compared with the assessment criteria: The client is considered as a "whole entity." The Case Manager does not measure physical capacity or cognitive ability or affective state separately, but rather one's functioning as a whole. For example, if one has ample physical strength and skill to complete a task, but also has cognitive limitations which prevent him/her from doing so, that person cannot complete it. The Case Manager also measures the client's level of functioning in the present. What the client could or could not do in the past is not an issue nor is what the client, under hypothetical conditions, might be able to do in the future. Each task must be looked at as the sum of its parts. One must be able to complete all of the parts of a task in order to complete the task.

A Rating 2 OR 3 ON THE ASSESSMENT OF AN ADL INDICATES AN IMPAIRMENT

Since the ADL scale which follows will be used in determining a applicant's/client's functional impairment level, standard definitions for each ADL item are:

A-1. BATHE

This item measures the applicant's/client's ability to bathe or shower or take sponge baths independently for the purpose of maintaining adequate hygiene as needed for the client's circumstances. Consider minimum hygiene standards, medical prescription, or health related considerations such as incontinence, skin ulcer, lesions, frequent nose bleeds, and balance problems. Consider ability to turn faucets, regulate water temperature, wash and dry completely.


0.	Able to prepare and take a bath or shower independently within a reasonable time.
	NOTE:	If the only help an applicant/client requires is help with shampooing, score this item "0." Many elderly or disabled persons require help with shampooing but this scale does not include shampooing. The need for help with shampooing shall be recorded in the narrative.
1.	Requires the use of equipment (i.e., tub stool, grab bars, or handle bars) to bathe or shower him/herself. Small items such as mitten wash cloths, long-handled brushes or non-slip soap dishes are not considered special equipment.
2.	Needs another human to assist him/her through this activity. This may include supervision for safety or cuing. Able with Helper will be circled if the client performs at least half the effort him/herself.
3.	Unable to assist or assists minimally (less than half the effort) or is totally dependent on another human to complete the activity.

A-2 Comments/Notes on client’s ability to bathe self: The HCBS case manager shall record the following information in the narrative:

Reason client is not able to bathe self.
Does the applicant/client take showers, baths, or sponge baths? Indicate the reasons why this is or is not appropriate for the applicant/client’s circumstances. Indicate if client refuses assistance
Type of equipment used, if any. Any problems with equipment?
Who helps with bathing? How often? Type of Assistance?
Is applicant/client able to bathe as frequently as needed?
Service needed/approved, frequency, outcome desired.

A-3 Comments/Notes on client’s ability to groom and complete oral hygiene tasks: The HCBS case manager shall record the following information in the narrative:

Reason client is not able to groom or complete hygiene tasks per self.
Does the applicant/client groom and complete oral hygiene tasks? Indicate the reasons why this is or is not appropriate for the applicant/client’s circumstances. Indicate if client refuses assistance
Type of equipment used, if any. Any problems with equipment?
Who helps with grooming-hygiene? How often? Type of assistance?
Is applicant/client able to groom and complete hygiene as frequently as needed?
Service needed/approved, frequency, outcome desired.

A-4. DRESS/UNDRESS

This item measures the applicant's/client's ability to dress or undress. Consider applicant/client's needs of appropriate dress for weather or street attire. Consider ability to get clothes from closets and drawers as well as putting them on. Also include ability to put on prosthesis or assistive devices. Consider fine motor coordination for buttons and zippers, and strength for undergarments or winter coat. Do not include style or color coordination. Do not include tying shoes.


0:	Able to dress independently within a reasonable amount of time.
1:	Uses aids such as zipper pulls and specially designed clothing (e.g., velcro fasteners) or requires an inordinate amount of time to do so.
2:	Needs another human to assist with dressing and performs at least half the effort OR needs human assistance as a reminder to get dressed or for the laying out of clothes.
3:	Totally dependent due to physical or cognitive impairment or provides less than half the effort in dressing.

A-5 Comments/Notes: Comment on client’s ability to dress/undress in these fields

Reason client is not able to dress/undress self.
Type of help an applicant/client is getting, who assists?
Type of equipment?
Are arrangements satisfactory?
Inappropriateness of clients dress due to weather or street attire.
Service needed/approved, frequency, outcome desired.

A-6 EAT

This item refers to the applicant's/client's ability to feed him/herself including cutting meat and buttering bread. Consider client's ability to chew, swallow, cut food into manageable size pieces, and to chew and swallow hot and cold foods/beverages. It does NOT refer to meal preparation. (This is covered in Meal Preparation)


0:	Able to eat independently within a reasonable amount of time.
1:	Uses special grip utensils or plates or client takes an inordinate amount of time to eat.
2:	Performs at least half the effort required to eat, but receives some assistance from another human.
3:	Performs less than half the effort.

A-7 Comments/Notes: Comment on the client’s ability to eat

Reason client is not able to feed self.
Note aids applicant/client uses.
Who helps, which tasks?
Need for equipment or assistance?
Type of human assistance, if any.
Service needed/approved, frequency, outcome desired.

A-8. TOILET

This item deals with the applicant's/client's ability to get to the bathroom, get on/off the toilet, clean him/herself, manage clothes, and flush.

Consider frequency of need and need for reminders.


0:	Able to complete this activity independently or the client uses a urinal, bedpan or commode at night only and manages without assistance (including emptying the device).
1:	Uses grab bars, raised toilet seat or transfer board or client takes an inordinate amount of time.
2:	Requires human assistance in completing the activity but performs half the effort.
3:	Performs less than half the effort.

A-9 Comments/Notes: Comment on the client’s ability to complete toileting tasks.

Reason client is not able to toilet.
Note who the helper is and the extent of assistance.
Type of equipment.
Service needed/approved, frequency, outcome desired.

A-10 CONTINENCE

BLADDER/BOWEL


0:	Complete Control. Complete voluntary control of the bladder; never incontinent. Complete voluntary control of bowels; never incontinent.
1:	Self-care Devices, No Accidents. Applicant/client has a catheter or other urinary drainage device including absorbent pads. Applicant/client is able to empty, clean, and manage the use of the device without human assistance. Applicant/client has no accidents. Requires stool softeners, suppositories, laxatives, or enema, but does not require human assistance, or has colostomy, but can manage device without human assistance. No accidents.
2:	Helper. Occasional accidents. Applicant/client needs human assistance with a device, or has occasional accidents (with or without a device). . Requires human assistance with devices, medications, enemas, etc., or has occasional accidents.
3:	Incontinent. Cannot control urinary flow, despite aids or assistance. Applicant/client cannot control bowels despite aids or assistance.

A-11 Comments/Notes: Comment on the client’s ability to manage incontinence needs/activities.

Reason for bladder or bowel continence problem.
Type of device. How long has it been used? Any problems?
Who helps?
Tasks performed by helper.
Any problems?
Service needed/approved, frequency, outcome desired.

A-12. TRANSFER IN AND OUT OF BED OR CHAIR

This item measures the level of assistance the client needs in transfers.

Include the ability to reach assistive devices and appliances necessary to ambulate, and the ability to transfer (to/from) between bed and wheelchair, walker, etc.; the ability to adjust the bed or place/remove handrails, if applicable and necessary. Do not consider ambulation, itself, as this is considered under Get Around Inside.


0:	Able to transfer independently within a reasonable amount of time.
1:	Special equipment is used in transfers such as lifts, hospital beds, sliding boards, "trapezes" or pulleys or client takes an inordinate amount of time to transfer in and out of the bed or chair.
2:	Is supported by human help in getting in/out of bed/chair or performs half the effort.
3:	Must be lifted in/out of bed/chair.

A-13 Comments/Notes: Comment on the client’s ability to complete transfer in and out of bed/chair.

Reason client is not able to transfer self.
Types of aids.
Who helps-tasks performed by helper.
Service needed/approved, frequency, outcome desired.

A-14. GET AROUND INSIDE

This item measures an applicant's/client's indoor mobility. The HCBS case manager may ask an applicant/client, "How do you usually get around inside?"

Do not consider transferring in and out of bed or chair.


0:	Able to get around inside independently within a reasonable amount of time.
1:	An aid such as walker, wheelchair, cane, crutches, or furniture is used to get around.
2:	Needs human assistance to get around.
3:	Bedbound client.

A-15 Comments/Notes: Comment on the client’s ability to get around inside.

Reason client is not able to get around inside.
Types of aids.
Who is helping? Tasks performed by helper.
Service needed/approved, frequency, outcome desired.

4-B INSTRUMENTAL ACTIVITIES OF DAILY LIVING

This section deals with an applicant's/client's ability to carry out tasks which may not need to be done everyday (like ADLs), but which nevertheless are important for living independently. Intervention may be required to help an applicant/client adapt to difficulties experienced in performing IADL activities. IADL items include meal preparation, housework, laundry, shopping, taking medicines, getting around outside, transportation, money management, and telephone use. Performance of IADL items requires mental as well as physical capacity. For example, taking medications and managing money require memory, judgment, and intellectual ability. The IADL scale measures the functional impact of emotional, intellectual, and physical impairments.

Not all applicants/clients have the opportunity to perform IADL tasks. For example, an applicant/client who lives with a relative or spouse might not prepare meals simply because another person routinely does this task. Similarly, some applicants/clients do not manage their own money because a spouse does it. However, the IADL scale is designed to measure an applicant's/client's ability both physical and cognitive to perform these tasks, regardless of the individual's opportunity to perform them. Thus, in asking applicant's/client's about IADL tasks, HCBS case managers must stress what the person can do rather than what he/she is doing, for example: "Can you prepare meals, do housework, shop, etc.?"

As with ADL ratings, the HCBS Case Manager will want to know how the applicant/client usually performs a task, i.e., most of the time. Applicants/clients who have occasional difficulty should be scored based on their usual performance, noting occasional difficulties in the narrative/note.

Like ADL scores, the HCBS case manager can obtain information regarding IADL impairments by observation, interview with family or friends, or by direct self-report of the client. The scale used to rate each IADL task differs slightly from the ADL scale. It includes three basic categories of functioning:


0:	Without help. Applicant/client is able to perform task independently, without supervision, reminder or assistance.
1:	With help. Applicant/client is able to perform task only with assistance, reminder, cuing or supervision.
2:	Can't do at all. Applicant/client is not able to perform task at all, even with assistance.

In IADL score it is especially valuable to look at each task as the sum of its parts. Doing the laundry, for example, includes requirements of the physical ability to carry the wash to the washing machine, the cognitive ability to operate the washing machine including the measuring of soap and setting of controls, the physical ability to move clothes from washer to dryer, the cognitive ability to operate the dryer, the skill to fold and physical ability to carry the clean laundry back from the machine. If one can operate the washer and dryer, but cannot carry the clothes to or from the machines, this person rates a #1, "with help."

SCORES OF 1 OR 2 IN ASSESSMENT OF AN IADL INDICATES AN IMPAIRMENT

Standard Definitions for each IADL item are as follows:

B-1. MEAL PREPARATION

The HCBS case manager may ask the applicant/client, "Can you prepare your own meals?" Regardless of whether the applicant/client actually does prepare meals, ask whether he/she can.

Consider the applicant's/client's ability to prepare hot and/or cold meals that are nutritionally able to sustain the client or therapeutic, as necessary. Consider applicant's/client's cognitive ability, such as ability to remember to prepare meals, applicant's/client's ability to prepare foodstuffs, to open containers, to properly store and maintain foodstuffs, and to use kitchen appliances. Do not consider clean up because it is part of Housework. Do not include canning of produce or baking of such items as cookies, cakes, and bread.


0:	Able to prepare and cook meals or client does not usually cook but is able to.
1:	Needs assistance from another person, i.e., client is unable to prepare a meal but is able to reheat a prepared meal.
2:	Unable to prepare or cook meals.

B-2 Comments/Notes: Comment on the client’s ability to prepare meals.

Who helps with preparation?
Frequency and type of assistance.
Reason for inability to cook.
If applicable, inadequacy of present diet to extent that it would not sustain applicant/client nutritionally, or does not meet therapeutic needs.
Service needed/approved, frequency, outcome desired.

B-3. HOUSEWORK

This item refers to the applicant's/client's ability to do routine housework.

The HCBS case manager might ask the applicant/client "Are you able to do routine housework (such as dusting)?" and "Are you able to do heavy housework (such as washing floors)?" Again, be sure to stress ability, physical and cognitive, rather than actual performance.

Consider minimum hygienic conditions required for applicant's/client's health and safety. Do not include laundry. Do not include refusal to do tasks if refusal is unrelated to the impairment.


0:	Completely able.
1:	Can do some housework, but not all housework.
2:	Can not do any housework.

B-4 Comments/Notes: Comment on the client’s ability to do ordinary housework.

Reason client is unable to complete housework
Who helps with housework?
Frequency and type of assistance (i.e., family does spring cleaning)
Why is the client unable to do housework? (i.e., severe arthritis or cognitive problem.)
What types of routine housework client is unable to do.
Service needed/approved, frequency, outcome desired.

B-5. LAUNDRY

This item measures the applicant's/client's ability to do his/her laundry.

Can the applicant/client sort, carry, load and unload, fold and put away clothes? Consider the need to use coins for pay machines. Do not score if the only problem is that laundry facilities are located outside the home as the need for transportation is covered in Transportation. Consider the applicant's/client's cognitive ability to complete these tasks. Consider applicant's/client's physical and cognitive ability to complete these tasks even if applicant/client lives with others who do them for the applicant/client.


0:	Completely able to do laundry.
1:	Requires human assistance (i.e., facility is in the basement and a family member carries the laundry up the basement stairs).
2:	Cannot do laundry at all.

B-6 Comments/Notes: Comment on the client’s ability do laundry.

Reason client is not able to do laundry.
Who helps with laundry?
Frequency of assistance.
Note where laundry facilities are located (i.e., in home or laundromat.
Service needed/approved, frequency, outcome desired.

B-7. SHOPPING

This item measures the client's ability to shop for groceries and other essentials assuming transportation or delivery is available.

Consider ability to make shopping lists, to function within the store, to locate and select items, to reach and carry purchases, to handle shopping carts, to communicate with store clerks, and to put purchases away. Do not consider banking, posting mail, monetary exchanges, or availability of transportation in scoring this item. Applicant/clients ability to access transportation is measured under Transportation and ability to manage money is measured under Management of Money.


0:	Able to shop but needs help with transportation (note this under Transportation).
1:	Needs human assistance (i.e., carrying bundles).
2:	Unable to shop.

B-8 Comments/Notes: Comment on the client’s ability to do shopping.

Reason client is not able to complete shopping.
Who helps with shopping?
Frequency of assistance.
Also note proximity of shopping facilities.
Service needed/approved, frequency, outcome desired.

B-9. TAKING MEDICINE

This item measures the ability of the applicant/client to take medicine by oneself. This is defined as: remembering to take medicine; getting the medicine from the place it is kept within the home; measuring the proper amounts; actually swallowing the pill; applying the ointment; or giving oneself injections (including the filling of syringe).

Score 0 for applicant/client who has no needs for medication or who perform tasks independently. Score according to client's ability to perform the task even if commonly done by others. Score need for service monitoring of medications due to possibility of overdose as a 2. Do not include obtaining of medication from pharmacy as this is covered under Transportation.


0:	Completely able including giving injections.
1:	Needs human assistance (i.e., reminder or RN to give injection).
2:	Unable (either physically or cognitively unable).


B-10	Comments/Notes: In these fields if an applicant/client cannot take his/her own medicine.

It is important to ask the reason and record this in the narrative. For service planning purposes, an applicant/client who forgets to take medications may require different types of services and supports than an applicant/client who is physically unable to take medication.

Who helps with medicine?
Reason client is not able to take his/her medication independently.
Frequency of assistance.
Service needed/approved, frequency, outcome desired.

B-11 GET AROUND OUTSIDE

This item refers to the applicant's/client's ability to move around outside, to walk or get around by some other means (i.e., wheelchair), and to do so without assistance.

Consider ability to negotiate stairs, streets, porches, sidewalks, and entrances and exits of residence and destination.


0:	Completely able to get around outside (even if he/she uses a wheelchair/walker).
1:	Requires an escort to push a wheelchair, hold his/her arm for stability or to assist in event of disorientation.
2:	Completely unable to go outdoors due to physical or mental disability.

B-12 Comments/Notes: Comment on the client’s ability to be mobile outside.

Reason client is not able to move around outside
Who helps?
How often does client get outside.
Service needed/approved, frequency, outcome desired.

B-13 TRANSPORTATION

This item measures an applicant's/client's ability to use transportation. For this question only, ability to use transportation includes access to a means of transportation.

Consider ability to negotiate entering and exiting of vehicle. Consider the ability to secure appropriate and available transportation and to know locations of home and essential places. Lack of appropriate and available transportation as needed, will increase the score. Consider cognitive as well as physical ability to use transportation.


0:	Completely able to travel in a car, bus, or senior van without assistance and has access to at least one of these methods on a regular basis.
1:	Needs assistance arranging for or using transportation either due to mental/physical impairment or has limited access.
2:	Completely unable to travel. This type of client is usually severely impaired and requires occasional specialized or medical transportation to doctor's appointments.

B-14 Comments/Notes: Comment on the client’s ability to use transportation

Reason client is not able to use/access transportation.
Who helps with transportation?
Frequency.
Service needed/approved, frequency, outcome desired.

B-15 MANAGEMENT OF MONEY

This item refers to the applicant's/client's ability to handle money and pay bills.

Consider client's ability to plan, budget, write checks or money orders, and exchange currency and coins. Include the ability to count and to open and post mail. Do not increase the score based on insufficient funds.

Some applicants/clients may have a legal representative (guardian, conservator or representative payee).


0:	Able to manage his/her money independently.
1:	Cannot write checks and pay bills without help, but makes day to day purchases and handles cash.
2:	Has a legal guardian or conservator or client is unable to manage money.

B-16 Comments/Notes: Comment on the client’s ability to manage money.

Reason why client is not able to manage money.
Explain why applicant/client has legal representative or representative payee (for social security payments).
How long has this arrangement been in effect.
Service needed/approved, frequency, outcome desired.

B-17 USE TELEPHONE (Communication)

This item refers to the applicant's/client's ability to use the telephone. Include getting telephone numbers and placing calls by him/herself. The applicant/client must be able to reach and use the telephone, answer the telephone, dial, articulate and comprehend. If the client uses special adaptive telephone equipment, score the client based on the ability to perform this activity with that equipment.

Special equipment in common use includes:

amplifiers for people with speech and hearing impairments;
enlarged dials or number stickers for the visually impaired;
modified telephones for those with hearing aids;
telephones hooked up to teletypewriters for those with speech impairments.
signals (tone ringers, loud bells or lights) to indicate that the telephone is ringing.
speaker telephones and head sets for persons who cannot hold receivers.

(NOTE: The use of an emergency response system device should not be considered when scoring this item because it can only be used for emergencies and does not enable its user to make or receive other essential calls such as arranging physician appointments or grocery deliveries.)

The tasks of routine writing/reading fall within the scope of the IADL of telephone. If the applicant/client needs a routine regimen of assistance with routine writing or reading of correspondence, this functional impairment may be documented within the scope of the IADL of telephone.

If an applicant/client has no telephone, ask about his/her ability to use a telephone elsewhere (i.e., at a neighbor's home).


0:	Completely able.
1:	Requires human assistance (i.e., someone else must dial).
2:	Cannot answer the telephone or dial the operator.

B-18 Comments/Notes: Comment on the client’s ability to use the telephone.

Reason why the client is not able to use the telephone
Types of equipment.
Who provides help?
Service needed/approved, frequency, outcome desired.

4-C SUPERVISED STRUCTURED ENVIRONMENT

A rating of yes in assessment indicates an impairment

C-1 Does the client/applicant require supervision or a structured environment on a continuous basis with the exception of brief periods of time?

This item measures the client ‘s need for supervision or a structured environment on a continuous basis except for brief periods of time.

Supervised Or Structured Environment Scoring

Determine the individual’s need for supervision or a structured environment to prevent or reduce health and safety risks. Information can be collected by observation, by direct questioning of the individual, or by interview with a significant other. Documentation must specifically include the reason(s) for the need of a supervised or structured environment.


	No:	The client does not require supervision or a structured environment.
	Yes:	The client does require supervision or a structured environment.

C-2. Summary of the client/applicants need for structured environment/supervision.

What impairment or need qualifies client/applicant to be determined eligible?

Reason why this impairment presents a health/welfare/ or safety risk
Explain why the health/welfare/or safety risk will be met by residing in a basic care facility or adult family foster care residence.
Explain why an alternative setting which is not a structured environment will not meet the individual’s needs
Service needed/approved, frequency, outcome desired.

4-D SPECIAL NEEDS

D-1 Include in this section special needs and services required to maintain clients independency and safety.

D-2 Enter any additional comments regarding special needs.

Reason client is not able to complete task.
Who helps with the identified tasks?
Frequency.
Service needed/approved, frequency, outcome desired.

Section 5. Home Environment. Physical environment may impact positively or negatively on an applicant's/client's overall well-being, and thus, an evaluation of physical environment is an essential portion of the assessment process. This section presents some key areas which require the HCBS case manager's evaluation. It should elicit information useful in determining whether specialized housing, relocation, or home repair are necessary.

Section 6. Services/Economic Assistance Information. The HCBS case manager records information about benefits and Services the applicant/client currently receives as well as those for which the client may be eligible.

Narratives: Include all information relevant to the client obtained during the assessment process that was not entered in a comment or note field.

All contacts relating to a client must be noted in the narrative section of the comprehensive assessment. Notes maintained in any other format are not considered valid.

Date
Reason for contact. (initial, annual, six month, quarterly, collateral, returned call, received call, etc)
Location of visit (home visit, care conference, hospital visit, office visit, telephone contact, letter sent, etc)
A description of the exchange between yourself and the client or the collateral contact.
A listing of identified needs
Service delivery options
Summary of care plan
Identify client stated goals, progress, change in goals, etc at the initial, annual and six month contact in this narrative note or in question #1.H.1. Describe the client's stated goals and results or progress
Review the Individual Service Plan developed by the Adult Residential Provider (who provides services primarily to individual with TBI) or the Transitional Care Provider at the annual and semi-annual interdisciplinary team meeting and document the results of the Individual Program Plan
Client satisfaction and follow-up plan
Case Managers initials

Signature: A signed and dated hard copy of the assessment including the narrative must be kept in the client file.

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