(Revised 9/1/18 ML #3543)
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Purpose: To provide evidence an applicant is eligible for the Expanded SPED (ExSPED) program. This form, SFN 56, is forwarded to the Aging Services Division, along with the SFN 676, in order to enter the applicant into the ExSPED pool and to assign a recipient identification number.
Steps of Completion:
Name: Complete the name of the applicant
Social Security Number: Enter applicant’s SSN
Does the Person Live Alone: If the person lives alone or has minor children or the other family member(s) in the house that are physically or mentally unable to assist the client, check "yes".
ADLs: Based on the functional assessment, transfer the scores from the assessment document to the applicable score box. ADLs scored in this section include bathing, eating, mobility inside, transfer bed/chair, dressing, toileting, and continence.
The scoring criteria for ADLs is as follows:
0 = completely able
1 = able with aids/difficulty
2 = able with help
3 = unable
IADLs: Based on the functional assessment, transfer the scores from the assessment document to the applicable score box. IADLs scored in this section include meal preparation, communication, laundry, taking medication, shopping, mobility outside, transportation, housework, and management of money.
The scoring criteria for IADLs is as follows:
0 = without help
1 = with help
2 = unable to do at all
If the applicant is eligible for the Ex-SPED program, the following criteria must be met:
Impaired (score is 1 or 2) in at least three of the following four IADLs meal preparation, laundry, taking medication, or housework.
Case Manager, County, and County Number: Record the HCBS Case Manager’s name, county in which the client resides, and county number.
The original is to be filed in the applicant’s case file. A copy must be sent to Aging Services/HCBS.
An electronic copy is available through the state e-forms (SFN 56).