Form 470 3502 PDF Details

Electronic filing for Form 470 3502 is now available through the ICANN web site. This form must be filed electronically each year by all registrars who are seeking to renew their accreditation with ICANN. The deadline for submission is September 1st, and penalties may apply for late filing. The form can be found on the ICANN website under Forms and Applications - Registrar Accreditation Agreement. Instructions on how to file electronically can also be found on this page.

QuestionAnswer
Form NameForm 470 3502
Form Length36 pages
Fillable?No
Fillable fields0
Avg. time to fill out9 min
Other names470 3502 physical disability waiver assesment tools form

Form Preview Example

Iowa Department of Human Services

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

PART A VERIFICATION OF HCBS CONSUMER CHOICE

Home- and Community-Based Services (HCBS)

My right to choose a home- and community-based program has been explained to me.

I have been advised that I may choose: (1) Home- and Community-Based Services or (2) Medical Institutional Services.

I choose:

HCBS

Medical Institutional Services

Signature of Consumer or Guardian or Durable Power of Attorney for Health Care

Date

PART B ASSESSMENT

Initial Review

Continued Stay Review

Social Security Number

 

 

 

 

Payment Source

 

 

 

 

 

 

 

 

 

 

 

 

Medicaid

Medicaid Pending

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Consumer’s Name

 

 

 

 

 

 

 

 

Medicaid Number

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

City

 

 

State

 

 

 

Zip Code

County Name

 

 

 

County No.

 

 

 

 

 

 

 

 

 

 

 

 

 

Legal Guardian or Conservator:

Yes

No

 

Birth Date

 

 

Sex:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Male

 

Female

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Race/Ethnic:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

American Indian

Asian or Pacific

Black

 

Hispanic

White

 

Other

 

Unknown

or Alaskan Indian

Islander

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Service Worker, Case Manager, or Discharge Planner Completing Form

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

City

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

Attending Physician’s Name

 

 

 

 

 

 

 

 

Telephone Number

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

City

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Living Arrangement

 

 

 

 

Date of Facility

 

Date of Facility

 

 

 

 

 

 

Entry

 

Discharge

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Home

 

Acute Care/Hospital

 

 

 

 

 

 

 

Nursing Facility, Skilled Care

Acute Care/Psychiatric

 

 

 

 

 

 

 

Nursing Facility, ICF LOC

Specialty

 

 

 

 

 

 

 

 

 

 

 

ICF/MR

 

Speciality/MHI

 

 

 

 

 

 

 

 

 

ICF/MI

 

CSALA

 

 

 

 

 

 

 

 

 

 

 

RCF

 

Group Home

 

 

 

 

 

 

 

 

 

RCF/MI

 

Other

 

 

 

 

 

 

 

 

 

 

 

RCF/MR

 

Unknown

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Agency Providing Physical Disability Waiver Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Address

 

 

 

 

 

City

 

State

 

 

Zip Code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Diagnoses

470-3502 (Rev. 2/03)

Medications

 

 

 

 

Route

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Therapies

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of

Receives

 

Reason

Hours / Month

Hours / Month

Hours / Month

Therapy

 

AEA Therapist

Priv. Therapist

Caregiver

 

 

 

 

 

 

 

 

 

 

 

Speech

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Occupational

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Physical

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Psychological

Yes

No

 

 

 

 

 

Counseling

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

The purpose of this assessment is to provide information for the required determination and redetermination of the level of care certified by the Iowa Foundation for Medical Care (IFMC) for the Iowa Department of Human Services (DHS) HCBS Physical Disability Waiver program. Each assessment needs to be signed by the person completing the assessment to certify that the information was accurate when the assessment was signed and dated. This person is accountable for accuracy of all the information stated in the assessment.

Assessment #1

Name

Title

Date

 

 

 

Assessment #2

 

 

Name

Title

Date

 

 

 

Assessment #3

 

 

Name

Title

Date

 

 

 

Assessment #4

 

 

Name

Title

Date

 

 

 

470-3502 (Rev. 2/03)

2

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

1.COGNITIVE/MENTAL STATUS

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Alert and fully oriented

 

 

 

 

 

 

Alert and oriented with significant

 

 

 

 

 

 

alteration in self-concept or mood

 

 

 

 

 

 

Generally oriented through the use of

 

 

 

 

 

 

assistive techniques

 

 

 

 

 

 

Cognitive impairment

 

 

 

 

 

 

(e.g., orientation, attention,

 

 

 

 

 

 

concentration, perception, memory,

 

 

 

 

 

 

reasoning, self-direction)

 

 

 

 

 

 

Exhibits mental status changes

 

 

 

 

 

 

consistent with an acute psychiatric

 

 

 

 

 

 

disorder

 

 

 

 

 

 

Comatose but responsive

 

 

 

 

 

 

Comatose (unresponsive)

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

1

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

1.COGNITIVE/MENTAL STATUS (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

2

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

2. BEHAVIOR

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Exhibits socially acceptable behavior

 

 

 

 

 

 

Behaviors have been modified to

 

 

 

 

 

 

socially acceptable levels or occur

 

 

 

 

 

 

infrequently

 

 

 

 

 

 

Displays behaviors requiring physical

 

 

 

 

 

 

intervention

 

 

 

 

 

 

Displays behaviors requiring verbal

 

 

 

 

 

 

intervention

 

 

 

 

 

 

Check behaviors displayed which

 

 

 

 

 

 

require verbal or physical intervention:

 

 

 

 

 

 

Self-injurious behavior

 

 

 

 

 

 

Verbal aggression

 

 

 

 

 

 

Physical aggression

 

 

 

 

 

 

Destruction

 

 

 

 

 

 

Stereotypical, repetitive behavior

 

 

 

 

 

 

Antisocial behavior

 

 

 

 

 

 

(See attachment on back.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

3

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

2. BEHAVIOR (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

4

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

2. BEHAVIOR (Page 2)

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Noncompliance

 

 

 

 

 

 

Disruption

 

 

 

 

 

 

Depressive symptoms

 

 

 

 

 

 

Elopement

 

 

 

 

 

 

Illegal sexual behavior

 

 

 

 

 

 

Mood swings

 

 

 

 

 

 

Eating disorders

 

 

 

 

 

 

Inappropriate or excessive liquid

 

 

 

 

 

 

consumption

 

 

 

 

 

 

Abuse of chemicals or alcohol

 

 

 

 

 

 

Obsessive-compulsive behavior

 

 

 

 

 

 

Anxiety

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

5

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

2.BEHAVIOR (Page 2 Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

6

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

2.INTELLECTUAL, VOCATIONAL, AND SOCIAL SKILLS

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Intellectual and cognitive:

 

 

 

 

 

 

No impairments are present, or

 

 

 

 

 

 

consumer is able to function with

 

 

 

 

 

 

adaptive means

 

 

 

 

 

 

Intellectual and cognitive:

 

 

 

 

 

 

Impairments are present which

 

 

 

 

 

 

require assistance (Check the areas

 

 

 

 

 

 

requiring assistance.)

 

 

 

 

 

 

Telling time

 

 

 

 

 

 

Survival words or signs

 

 

 

 

 

 

Reading

 

 

 

 

 

 

Writing

 

 

 

 

 

 

Number skills

 

 

 

 

 

 

Problem solving, reasoning

 

 

 

 

 

 

Memory

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

7

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

3.INTELLECTUAL, VOCATIONAL, AND SOCIAL SKILLS (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

8

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

3.INTELLECTUAL, VOCATIONAL, AND SOCIAL SKILLS (Page 2)

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Vocational: No impairments are

 

 

 

 

 

 

present, or consumer is able to

 

 

 

 

 

 

function with adaptive means

 

 

 

 

 

 

Vocational: Impairments are present

 

 

 

 

 

 

which require assistance (Check the

 

 

 

 

 

 

areas requiring assistance.)

 

 

 

 

 

 

Travel to and from work

 

 

 

 

 

 

Attending work as scheduled

 

 

 

 

 

 

Using time clock

 

 

 

 

 

 

Following directions and rules

 

 

 

 

 

 

Maintains attention to task

 

 

 

 

 

 

Accepts changes in schedule or

 

 

 

 

 

 

routine

 

 

 

 

 

 

Maintains production rate

 

 

 

 

 

 

Communicates wants and needs

 

 

 

 

 

 

Performs 1-step task

 

 

 

 

 

 

Performs 2- or 3-step task

 

 

 

 

 

 

Follows written direction

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

9

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

3.INTELLECTUAL, VOCATIONAL, AND SOCIAL SKILLS (Page 2 Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

10

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

3.INTELLECTUAL, VOCATIONAL, AND SOCIAL SKILLS (Page 3)

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Community and Social Skills:

 

 

 

 

 

 

No impairments are present, or

 

 

 

 

 

 

consumer is able to function with

 

 

 

 

 

 

adaptive means

 

 

 

 

 

 

Community and Social Skills:

 

 

 

 

 

 

Impairments are present which

 

 

 

 

 

 

require assistance (Check the areas

 

 

 

 

 

 

requiring assistance.)

 

 

 

 

 

 

Transportation and mobility *

 

 

 

 

 

 

Community skills *

 

 

 

 

 

 

Shopping *

 

 

 

 

 

 

Safety *

 

 

 

 

 

 

Money skills *

 

 

 

 

 

 

Social and interpersonal skills

 

 

 

 

 

 

Leisure and recreation skills *

 

 

 

 

 

 

Telephone use

 

 

 

 

 

 

Sexuality: knowledge and self-

 

 

 

 

 

 

concept

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

* See attachment on back.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

11

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

3.INTELLECTUAL, VOCATIONAL, AND SOCIAL SKILLS (Page 3 Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

12

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

4.MOBILITY AND EXTREMITY FUNCTION

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

#1

#2

#3

#4

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

Ambulatory; independent

 

 

 

 

 

Ambulatory; independent but with

 

 

 

 

 

problems of ataxia, balance, or

 

 

 

 

 

sensorimotor deficiencies

 

 

 

 

 

Independent with assistive device

 

 

 

 

 

Ambulatory with assistance in using

 

 

 

 

 

an assistive or mechanical device

 

 

 

 

 

Ambulates with human assistance

 

 

 

 

 

Manual wheelchair with assistance

 

 

 

 

 

Manual wheelchair without assistance

 

 

 

 

 

Power wheelchair with assistance

 

 

 

 

 

Power wheelchair without assistance

 

 

 

 

 

Consumer has no musculoskeletal or

 

 

 

 

 

fine or gross motor impairments

 

 

 

 

 

Paralysis

 

 

 

 

 

Hemiplegia

 

 

 

 

 

Paraplegia

 

 

 

 

 

Quadriplegia

 

 

 

 

 

Impaired muscle tone

 

 

 

 

 

Contractures

 

 

 

 

 

Scoliosis

 

 

 

 

 

Other fine motor impairments

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

13

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

4.MOBILITY AND EXTREMITY FUNCTION (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

14

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

5. HEALTH CARE

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

No health care problems

 

 

 

 

 

 

Health care problems are present but

 

 

 

 

 

 

consumer is able to manage self care

 

 

 

 

 

 

Health care problems are present and

 

 

 

 

 

 

consumer requires assistance to

 

 

 

 

 

 

manage their care (Check areas in

 

 

 

 

 

 

which consumer has health

 

 

 

 

 

 

problems.)

 

 

 

 

 

 

Seizure disorder

 

 

 

 

 

 

Cardiac disorder

 

 

 

 

 

 

Gastrointestinal disorders

 

 

 

 

 

 

Urinary tract disorder

 

 

 

 

 

 

Weight problems

 

 

 

 

 

 

Evidence of communicable

 

 

 

 

 

 

disease

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

15

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

5.HEALTH CARE (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

16

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

5. HEALTH CARE (Page 2)

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Respiratory

 

 

 

 

 

 

Experiences no respiratory

 

 

 

 

 

 

distress

 

 

 

 

 

 

Experiences shortness of breath

 

 

 

 

 

 

and oxygen administered on an

 

 

 

 

 

 

as-needed basis or at specified

 

 

 

 

 

 

time intervals

 

 

 

 

 

 

Experiences shortness of breath

 

 

 

 

 

 

and oxygen administered on a

 

 

 

 

 

 

continuous basis

 

 

 

 

 

 

Suctioning required on an as-

 

 

 

 

 

 

needed basis (less than daily)

 

 

 

 

 

 

Suctioning required at least daily

 

 

 

 

 

 

Acorn nebulizer, incentive

 

 

 

 

 

 

spirometer, IPPB treatments,

 

 

 

 

 

 

chest percussion therapy, or

 

 

 

 

 

 

inhalers administered

 

 

 

 

 

 

Other respiratory problems which

 

 

 

 

 

 

require assistance

 

 

 

 

 

 

Ventilator

 

 

 

 

 

 

Tracheotomy

 

 

 

 

 

 

Cardiorespiratory monitor

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

17

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

5.HEALTH CARE (Page 2 Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

18

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

5. HEALTH CARE (Page 3)

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Skin Care

 

 

 

 

 

 

No skin problems

 

 

 

 

 

 

Stasis ulcer or pressure ulcer

 

 

 

 

 

 

present requiring treatment or

 

 

 

 

 

 

dressing changes at least daily

 

 

 

 

 

 

Stasis ulcer or pressure ulcer

 

 

 

 

 

 

present requiring treatment or

 

 

 

 

 

 

dressing changes less than daily

 

 

 

 

 

 

Stasis ulcer or pressure ulcer

 

 

 

 

 

 

present but no assistance with

 

 

 

 

 

 

treatment or dressing changes is

 

 

 

 

 

 

needed

 

 

 

 

 

 

Other skin problems requiring

 

 

 

 

 

 

treatment or dressing changes at

 

 

 

 

 

 

least daily required (may include

 

 

 

 

 

 

drainage tubes, incisions, etc.)

 

 

 

 

 

 

Other skin problems that do not

 

 

 

 

 

 

require assistance with treatment

 

 

 

 

 

 

or dressing (Specify in additional

 

 

 

 

 

 

notes.)

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

19

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

5.HEALTH CARE (Page 3 Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

20

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

6. ELIMINATION

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Continent in bowel and bladder; does

 

 

 

 

 

 

not require assistance

 

 

 

 

 

 

Continent with verbal or physical

 

 

 

 

 

 

assistance

 

 

 

 

 

 

Continent except for occasional

 

 

 

 

 

 

periods of incontinence

 

 

 

 

 

 

Inappropriate toileting habits

 

 

 

 

 

 

Incontinent for bladder; requires

 

 

 

 

 

 

assistance

 

 

 

 

 

 

Incontinent for bowel; requires

 

 

 

 

 

 

assistance

 

 

 

 

 

 

Incontinent but independent

 

 

 

 

 

 

Catheter (permanent, temporary, or

 

 

 

 

 

 

intermittent)

 

 

 

 

 

 

Suprapubic catheter

 

 

 

 

 

 

Colostomy

 

 

 

 

 

 

Ileostomy

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

21

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

6.ELIMINATION (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

22

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

7. ACTIVITIES OF DAILY LIVING

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Self-Help Skills: Independent or is

 

 

 

 

 

 

able to function independently with

 

 

 

 

 

 

adaptive devices

 

 

 

 

 

 

Self-Help Skills: Deficits are present

 

 

 

 

 

 

(Check areas which require direct

 

 

 

 

 

 

personal assistance.)

 

 

 

 

 

 

Dressing or undressing

 

 

 

 

 

 

Washing or bathing

 

 

 

 

 

 

Oral hygiene

 

 

 

 

 

 

Hair care

 

 

 

 

 

 

Shaving

 

 

 

 

 

 

Menses care

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

23

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

7.ACTIVITIES OF DAILY LIVING (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

24

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

7.ACTIVITIES OF DAILY LIVING (Page 2)

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Domestic Skills: No deficits or deficits

 

 

 

 

 

 

are present but consumer is able to

 

 

 

 

 

 

function with adaptive device

 

 

 

 

 

 

independently

 

 

 

 

 

 

Domestic Skills: Impairments are

 

 

 

 

 

 

present (Check areas where

 

 

 

 

 

 

consumer needs assistance.)

 

 

 

 

 

 

Home Skills *

 

 

 

 

 

 

Food Preparation *

 

 

 

 

 

 

Clothes/Laundry Care *

 

 

 

 

 

 

* See attachment on back.

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

25

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

7.ACTIVITIES OF DAILY LIVING (Page 2 Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

26

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

8. EATING SKILLS

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

#1

#2

#3

#4

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

Independent

 

 

 

 

 

Independent with adaptive equipment

 

 

 

 

 

Semi-independent; requires physical

 

 

 

 

 

assistance

 

 

 

 

 

Able to take some nourishment orally,

 

 

 

 

 

but also fed via NG-tube, G-tube,

 

 

 

 

 

J-tube, or hyperalimentation to

 

 

 

 

 

maintain nutritional status

 

 

 

 

 

Unable to take nourishment orally,

 

 

 

 

 

fed via NG-tube, G-tube, or

 

 

 

 

 

hyperalimentation

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

27

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

8.EATING SKILLS (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

28

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

9. DRUG THERAPY

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

No medications have been prescribed

 

 

 

 

 

 

Oral medications; takes independently

 

 

 

 

 

 

Oral medications; assistance needed

 

 

 

 

 

 

Insulin is administered by set dosages

 

 

 

 

 

 

Blood glucose is regulated by sliding

 

 

 

 

 

 

scale at least 2-4 times daily

 

 

 

 

 

 

Medications are given via intravenous

 

 

 

 

 

 

(IV) route

 

 

 

 

 

 

Intramuscular (IM) or subcutaneous

 

 

 

 

 

 

medications administered at least

 

 

 

 

 

 

daily, and consumer is unable to self-

 

 

 

 

 

 

administer

 

 

 

 

 

 

Insulin administered requiring at least

 

 

 

 

 

 

daily adjustment in dosage, deter-

 

 

 

 

 

 

mined by blood glucose levels as

 

 

 

 

 

 

ordered by the physician

 

 

 

 

 

 

Medications requiring physician

 

 

 

 

 

 

monitoring and frequent lab values

 

 

 

 

 

 

(if appropriate) are administered

 

 

 

 

 

 

Central venous lines or ports for

 

 

 

 

 

 

infusion of IV medication,

 

 

 

 

 

 

chemotherapy, or blood products

 

 

 

 

 

 

Central venous lines or ports in place

 

 

 

 

 

 

and irrigated less than daily

 

 

 

 

 

 

Other: Specify in additional notes.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

29

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

9.DRUG THERAPY (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

30

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

10.SENSORY PERCEPTION AND COMMUNICATION

 

Functional Assessment

Assessment

Assessment

Assessment

Assessment

Additional Notes

 

#1

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Check the category that most

 

 

 

 

 

 

accurately describes the consumer

Date:

Date:

Date:

Date:

Assessment #1

 

 

 

 

 

 

 

 

Vision is not impaired or has been

 

 

 

 

 

 

corrected or compensated

 

 

 

 

 

 

Vision is impaired

 

 

 

 

 

 

Hearing is not impaired or has been

 

 

 

 

 

 

corrected or compensated

 

 

 

 

 

 

Hearing is impaired

 

 

 

 

 

 

Sensory perception (i.e., taste, smell,

 

 

 

 

 

 

tactile, spatial) is not impaired or has

 

 

 

 

 

 

been compensated

 

 

 

 

 

 

Sensory perception is impaired

 

 

 

 

 

 

Speech is not impaired or has been

 

 

 

 

 

 

corrected or compensated

 

 

 

 

 

 

Speech is impaired, but no therapy

 

 

 

 

 

 

services required

 

 

 

 

 

 

Speech therapy needed to retrain or

 

 

 

 

 

 

establish new skills in communication

 

 

 

 

 

 

is provided daily by a speech therapist

 

 

 

 

 

 

Speech therapy program provided

 

 

 

 

 

 

less than daily by or under the

 

 

 

 

 

 

direction or supervision of a licensed

 

 

 

 

 

 

speech therapist

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

470-3502 (Rev. 2/03)

31

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

10.SENSORY PERCEPTION AND COMMUNICATION (Cont.)

Functional Assessment

Assessment

Assessment

Assessment

Additional Notes

#2

#3

#4

 

 

 

 

 

 

 

 

 

 

 

Assessment #2

Assessment #3

Assessment #4

470-3502 (Rev. 2/03)

32

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

Self-Injurious Behavior

♦Hitting or slapping self

♦Head banging

♦Biting self

♦Pulling own hair

♦Scratching self

Destruction

♦Tearing

♦Burning

♦Throwing

♦Cutting

Disruption

♦Pestering, teasing

♦Arguing, complaining

♦Interrupting

♦Yelling, screaming

♦Laughing or crying for no reason

Behavior Attachment

Stereotypical, Repetitive

♦Pacing

♦Rocking

♦Grinding teeth

♦Twirling fingers or objects

♦Eating disorders

♦Smearing feces

♦Rectal digging

♦Wandering

Antisocial Behavior

♦Swearing

♦Inappropriate touching

♦Lying

♦Inappropriate body noises

♦Cheating

♦Stealing

♦Inappropriate elimination

Noncompliance

♦Refusal to comply

♦Braking established rules

Inappropriate sexual behavior

♦Inappropriate masturbation

♦Inappropriate heterosexual or homosexual behavior

♦Other socially unacceptable sexual behavior

Home Skills

Cleans house as follows:

♦Dusts

♦Sweeps

♦Mops

♦Cleans bath, kitchen

♦Cleans windows

♦Knows when something is broken and needs repair

Activities of Daily Living Attachment

Clothes Care/Laundry

♦Sorts clothes

♦Uses washer, dryer, detergent

♦Folds and places clothes in closet and drawers

Food Preparation

♦Determines what to eat

♦Determines what is needed at grocery store

♦Goes to store and makes grocery purchases

♦Prepares food

♦Sets table and clears

♦Stores food

♦Cleans up cooking area

470-3502 (Rev. 2/03)

33

PHYSICAL DISABILITY WAIVER ASSESSMENT TOOL

Transportation

♦Schedules, makes travel arrangements

♦Uses bus, cab, etc.

Community Skills

♦Accesses police

♦Accesses fire, ambulance, hospital

♦Uses restaurants, community organizations, clubs, etc.

Shopping

♦Identifies items needed for purchase

♦Identifies location of store

♦Knows amount of money needed

♦Makes purchases

♦Takes items home and puts them away

Community and Social Skills Attachment

Safety

♦Uses keys

♦Knows emergency situations of strangers, fire, theft, and medical, and knows procedures for each

♦Gets up in morning and gets ready for the day

♦Goes to bed at night

Leisure and Recreation

♦Identifies enjoyable activities

♦Initiates and participates in individual activities

♦Initiates and participates in group activities

♦Schedules and uses community resources for activities

Money Skills

♦Understands use of money

♦Makes purchases

♦Obtains change

•Knows correct amount of money needed

•Knows change to be received

♦Receives bills for services, e.g., rent, utilities, phone, etc.

♦Understands need for payment

♦Arranges payment of bills

♦Takes paycheck to bank, cashes and/or deposits check

Social and Interpersonal Skills

♦Cooperates with others

♦Offers to help others

♦Greets and responds to others

470-3502 (Rev. 2/03)

34

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