701C CONGREGATE MEALS ASSESSMENT
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1 701C CONGREGATE MEALS ASSESSMENT Rick Scott, Governor Charles T. Corley, Secretary An Overview of the C Changes
2 Introduction - 701C The 701C is intended to be administered for congregate meal clients. The 701D Instructions (a companion manual for the 701B form) also apply to any questions from the 701B that also appear on the other assessment and screening forms, such as the 701C.
3 Overview of Changes to the DOEA 701C Includes changes in the following areas: Demographics Activities for Daily Living Instrumental Activities of Daily Living Nutrition
4 Changes in Demographics Item 10 - Limited English Proficiency (LEP) Mark the appropriate box to indicate whether the client has limited ability to read, write, or speak in the English language, or to understand spoken English ("No" or "Yes"). This can be due to the client's primary language being other than English, literacy issues, or physical impairments.
5 Changes in Demographics Item 11 Marital Status Select from the listed options. Obtain the client s response and mark the appropriate box to indicate the client s current marital status: Married: An individual who has a legal husband or wife. Partnered: An individual who is in a relationship with a person, other than a legal spouse. Single: An individual who has never been married. Separated: An individual who is legally married, but is living apart from their spouse. Divorced: An individual whose marriage has been legally dissolved. Widowed: An individual whose spouse died while they were still married.
6 Changes in Demographics Item 20 Living Situation Mark the appropriate box to indicate the client s current living situation ( With primary caregiver, With caregiver, With other, Alone ). If the client is in a facility, the response would be Alone. With Primary Caregiver (WC) - Consumer lives with the primary caregiver With Other Caregiver Consumer lives with a caregiver that is not the primary caregiver With Other (WO) - Consumer lives with anyone other than a caregiver. Alone (AL) - Consumer lives alone. This includes consumers living in an *ALF or nursing facility.
7 Changes in Demographics Item 26 Do You Need Other Assistance For Food? Mark the appropriate box to indicate whether the client needs other assistance for food ( No or Yes ). The client may not be eligible for S/NAP (Food Stamps) but still need help in obtaining food. Other sources of food assistance could be local food pantries, religious groups, or service organizations.
8 Changes in Demographics Item 27 ASSESSOR/CM: Client Answering Questions? Mark the appropriate box to indicate whether someone besides the client is providing answers to the questions in the assessment ( No or Yes ). If someone else is not providing answers ( No ), skip a-b. If someone else is providing answers ( Yes ), indicate the name of the person as well as their relationship to the client in spaces a. and b.
9 Changes in Demographics Item 28 Children the client lives with and provides care for Indicate the total number of children, besides the client s own children, under age 19 that live with and are cared for by the client by entering a number on the line provided. If the response is zero, skip a-c. If the response is one or more, enter the number and name(s) in items a- c. If any number response is zero in a-c, leave the name(s) blank.
10 Changes in Demographics Item 29 - Disabled adults the client lives with and provides care for Indicate the total number of disabled adults, aged 19 to 59 that live with and are cared for by the client by entering a number in the box provided. If the response is zero, skip a-c. If the response is one or more, enter the number and name(s) in items a- c. If any number response is zero in a-c, leave the name(s) blank
11 Changes in Activities of Daily Living (ADLs) Item 30 Activities of Daily Living Ask the client how much assistance s/he needs with completing the tasks listed on the form for activities a-c, and determine the amount of help needed.
12 Changes in Activities of Daily Living (ADLs) Item 30 Continued Determine the amount of help needed from the following range: No assistance needed: Indicates that client needs no help to perform any part of the activity. Uses assistive device: Indicates that the client needs an assistive device or technology to complete the activity. Needs supervision or prompt: Indicates that the client needs reminders or supervision during the activity. Otherwise s/he needs no physical help to perform the activity. Needs assistance (but not total help): Indicates that the client needs hands-on physical help during part of the activity. Needs total assistance (cannot do at all): Indicates that the client cannot complete activity without total physical assistance.
13 Changes in Instrumental Activities of Daily Living (IADL) Item 31 Instrumental Activities of Daily Living Assessing the frequency a client has assistance with a task is different from identifying how much assistance the client needs. You will ask the client how much assistance they have with completing the tasks listed on the form for activities a-c, and determine the frequency of help they have.
14 Changes in Instrumental Activities of Daily Living (IADL) Item 31 Continued Determine the frequency of help they have using the following range: No assistance needed: Indicates that client receives no help from others because they do not need any help to perform any part of the activity. Always has assistance: Indicates that the client always has an adequate level of help to meet their need in performing the activity. Has assistance most of the time: Indicates that the client usually has the help they need to perform the activity, or more often than not they have an adequate level of help for the activity. Rarely has assistance: Indicates that the client has unpredictable, unreliable or seldom has the amount of assistance they need to complete the activity. Never has assistance: Indicates that the client has absolutely no assistance to complete the activity.
15 Changes in Nutrition Item 34 Liquid Intake Ask the client how many cups of water, juice, or other liquid s/he drinks daily. If the response is more than eight, skip question a. If the response is less than eight, ask question a.
16 Changes in Nutrition Item 34 Fruits/Vegetable Intake Read the description of serving size and then ask the client how many servings of fruits and vegetables s/he eats every day, on average. Record the numerical response in the box.
17 Changes in Nutrition Item 36 Dairy Intake Read the description of serving size and then ask the client how many servings of dairy products s/he has every day, on average. Record the numerical response in the box.
18 Changes in Nutrition Item 38 Gained/Lost Weight Ask the client if s/he has lost or gained weight in the last few months and mark the appropriate response ( Unsure, No, or Yes ). a. Amount of Weight: Ask how much weight the client has lost or gained in the last few months and mark the appropriate response ( Less than 5 pounds, 5 to 10 pounds, or 10 pounds or more ). b. Purposeful Change: Ask the client whether the weight gain/loss was on purpose for example, whether they were trying to lose or gain weight, and record the response ( No or Yes ). An unintended weight change could indicate a health problem, and the client s doctor should be notified.
19 Changes in Nutrition Item 41 Working Appliances Indicate what working appliances, if any, the client has for storing/preparing food ( None, Refrigerator, Microwave, Toaster/Oven, Stove, or Other ). Be sure to note any other source that is not listed on the form in the space provided. More than one item can be checked; the intent is to capture all sources the client has for storing and preparing food. If the response is None, the Assessor/Case Manager needs to ask the client how they store and prepare food.
20 Changes in Nutrition Item 43 Alcohol Use Ask the client how many days in a typical week s/he drinks alcohol and record the response in the appropriate box ( Refused, None, 1 to 2, 3 to 5, or 6 to 7 ).
21 Contact Us Please send all questions to: Samantha Rhody (850)
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