To document the assessor s conclusions after synthesizing all information learned about the individual during the assessment process.

Transcription

1 Assessor Conclusions About this Domain (Assessor Conclusions) To document the assessor s conclusions after synthesizing all information learned about the individual during the assessment process. Level of Supervision & Support Is the person able to participate in the interview? Who provided the information? (Displays if No is selected above) Current Housing Type: Homeless Institution ICF/DD Institution Hospital Board & Lodge Foster Care Own Home, Apt. Institution, NF/Certified boarding care ncertified boarding care Correctional Facility Planned Housing Type: Homeless Institution ICF/DD Institution Hospital Board & Lodge Foster Care Own Home, Apt. Institution, NF/Certified boarding care ncertified boarding care Correctional facility Last update: 6/12/2017 Page 1 of 6

2 (Displays when any combination of Institution ICF/DD or Institution Hospital or Institution NF/Certified boarding care under Current Housing AND Foster Care or Own Home, Apt, under Planned Housing Type is selected) In regard to the person s potential eligibility for Moving Home Minnesota (MHM): A DHS review is not required because other criteria are not met A DHS review is required, MHM intake has been submitted or will be submitted A DHS review is complete (Displays when A DHS review is complete is selected) The Minnesota Department of Human Services (DHS) has reviewed the MHM criteria of stay duration, stay setting and payment criteria and determined that: The person meets these criteria for participation in MHM The person does not meet these criteria for participation in MHM Planned Living Arrangement Living Alone Living with spouse Living with parents Living with family Living with friend/significant other Living in a congregate setting Homeless (Displays only if any choice BUT Living alone or Homeless is selected above) Would live alone/be homeless without current/planned housing type? Informed the person of the choice between receiving services in the home/community or in an institution? Unsure or Not Applicable Last update: 6/12/2017 Page 2 of 6

3 Be assessed to need a residential habilitation service that must be included in the person s care plan? Is the person unable to function independently in the community without Semi- Independent Living Services (SILS)? SILS does not provide enough supports SILS provides the appropriate supports N/A Person does not require SILS supports Unknown Vocational - Supports: Independent - requires typical training; may use adaptations Needs on the job training - time limited Needs minimal support - with or without adaptations Needs moderate support - with or without adaptations Needs intensive support - with or without adaptations N/A (explain in notes) Unknown (specify notes) Orientation: Orientation is defined as the awareness of an individual to his/her present environment in relation to time, place and person. Oriented Minor forgetfulness Partial or intermittent periods of disorientation Totally disoriented; does not know time, place, identity Comatose t determined Is the individual appropriate to share home care services with another? Last update: 6/12/2017 Page 3 of 6

4 (Displays if Yes is selected above) Comments: The person is generally frail? The person has a complicated condition? Does the person have an assessed need for supports and services over and above those available through the MA State plan? Per physician order, needs skilled assessment and intervention multiple times during a 24-hour period to maintain health and prevent deterioration? Physician order pending Without the provision of services under the CAC Waiver, the person would require frequent or continuous care in a hospital? Pending Certified by the primary physician to meet the level of care provided in a hospital? Pending Does the individual have a brain injury that requires a level of care and behavioral supports available in a specialized nursing facility or neurobehavioral hospital? Last update: 6/12/2017 Page 4 of 6

5 Please select one: (Displays when Yes is selected above) Requires level of specialized cognitive and behavioral support(s) available in a nursing facility that provides brain injury services Requires level of care and behavioral support available in a neurobehavioral hospital; available intensive behavior intervention Note a person does NOT have to be a resident of a nursing facility or neurobehavioral hospital to require this level of care. Requires specialized brain injury services and/or supports that exceed services available in BIW-NF? The person requires one or more waiver/ac services to meet their needs? Unknown Has financial eligibility for Family Support Grant been determined per Minn. Stat ? no intention to determine financial eligibility Pending intend to determine financial eligibility Select the appropriate response: (Displays when Yes is selected above) t financially eligible for FSG Financially eligible for FSG Last update: 6/12/2017 Page 5 of 6

6 WAIVER/PROGRAM (Displayed only for Age is 65 +) Has the Alternative Care Program Eligibility Worksheet been completed and eligibility determined? no intention to complete Pending intend to complete and determine eligibility t applicable, currently on EW Please select the appropriate response: (Displays when Yes is selected above) t financially eligible for AC Financially eligible for AC services Financially eligible for choice of AC or EW (may be eligible for Temporary AC) t eligible for AC (may be eligible for Temporary AC) Is this a New Assessment or Reassessment? (Displayed if Age is 65 +) New Reassessment Has the person exited the BI, CAC or CADI waiver for institutional care or trial of non-waiver home care and is choosing to return to the same waiver within 180 days? (Displayed if New is selected above) BI CAC - CADI Is the person currently on a program? (Displayed if Reassessment is selected 2 questions above) BI CAC - CADI - Other Notes/Comments: Level of Supervision & Support has been reviewed and updated? Yes Last update: 6/12/2017 Page 6 of 6