Kentucky Form Map 351 PDF Details

Are you a Kentucky resident looking for an easy and convenient way to file your state taxes? Look no further than the Kentucky Form Map 351, which allows taxpayers to easily fill out their KY tax forms while reducing the likelihood of making costly errors. Whether you're filing taxes on behalf of yourself or someone else, this form provides all the necessary information needed to accurately complete tax returns. Learn how it works, how to obtain it and more in this comprehensive guide!

QuestionAnswer
Form NameKentucky Form Map 351
Form Length15 pages
Fillable?No
Fillable fields0
Avg. time to fill out3 min 45 sec
Other namesICD-9, DSM, map 351, ky map 351

Form Preview Example

MAP 351

Commonwealth of Kentucky

 

 

 

 

 

 

 

 

 

 

 

(Rev. 7/08)

Cabinet for Health and Family Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Department for Medicaid Services

 

 

 

 

 

 

 

 

 

 

 

 

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION I – MEMBER DEMOGRAPHICS

 

 

 

 

 

 

 

 

 

 

Name (last, first, middle)

 

Date of birth (mo., day, yr.)

 

 

Medicaid Member ID #

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address

 

County code

Sex (check one)

Marital status (check one)

 

 

 

 

 

 

 

 

Male

 

 

 

Divorced

Married

Separated

 

 

 

 

 

 

 

 

Female

 

 

 

Single

Widowed

 

 

 

City, state and zip code

 

Emergency contact (name)

 

 

Emergency contact (phone #)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member phone number

 

Is member able to read and

Member’s height

 

 

 

 

 

 

write

Yes

 

No

 

 

Member’s weight

 

 

 

 

 

SECTION II – MEMBER WAIVER ELIGIBILITY

 

 

 

 

 

 

 

Type of program applied for (CHECK ONE)

 

 

 

 

Adjudicated

 

 

/Nonadjudicated

 

_____

 

 

 

 

 

 

 

 

 

 

Home and Community Based Waiver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Type of application (check one)

 

 

 

 

 

 

 

Acquired Brain Injury Waiver

 

 

 

 

 

Certification

 

Re-certification Re-application

 

Acquired Brain Injury/Long Term Care Waiver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Supports for Community Living Waiver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Michelle P. Waiver

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Consumer Directed Option Blended

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Member admitted from (check one)

 

 

 

 

Certification period (enter dates below)

 

 

 

Home Hospital Nursing facility

ICF/MR/DD

 

 

Begin date

 

 

 

 

End date

 

 

 

Other:

 

 

 

 

Certification

number:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has member’s freedom of choice been explained and

 

 

Has member been informed of the process to make

 

verified by a signature on the MAP 350 Form Yes

No

 

a complaint

Yes

 

No (see instructions)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Physician’s name

Physician’s license number

Physician’s phone number

 

 

 

(enter 5 digit #)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Enter member’s primary diagnosis: HCB (ICD-9 code); SCL (DSM code); ABI (ICD-9 and/or DSM)

 

Enter all diagnoses including DSM or ICD-9 codes:

Is the member diagnosed with one of the following?

 

 

 

AXIS I: (mental illness)

 

Mental Retardation/ IQ=

 

 

(Date-of-onset

 

 

 

)

 

 

 

 

 

 

Developmental Disability

 

 

 

 

 

 

 

 

 

 

AXIS II: (MR/DD)

 

 

 

(Date-of-onset

 

 

 

 

)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Mental Illness

(Date-of-onset

)

 

AXIS III: (Medical)

 

 

 

Brain Injury

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Cause of Brain Injury:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date of Brain Injury:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Rancho Scale

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION III – ASSESSMENT PROVIDER INFORMATION

 

 

 

Assessment/Reassessment provider

Provider number

Provider phone number

 

 

 

name:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Street address

City, state and zip code

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Provider contact person

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1 of 15

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

 

 

Department for Medicaid Services

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

NAME (LAST, FIRST)

 

MEDICAID NUMBER

 

 

 

 

 

 

SECTION IV SELF ASSESSMENT

 

 

*For SCL, MP and ABI waivers only

*add additional pages as needed

Community Inclusion (what do you like to do or where would you like to go in the community, where do you go for recreation, do you not get to go somewhere that you would like to)

Relationships (How do you stay in contact with your friends and family, do you need assistance in making or keeping friends, who are your friends)

Rights (do you understand your rights, are any of your rights restricted, do you know what is abuse or neglect)

Dignity and Respect (how are you treated by staff, do you have a place you can go to be with friends or to be alone or have privacy)

Health (who are your doctors ,do you have any health concerns, what medicine do you take, how do they make you feel,)

Lifestyle (do you have a job, do you want to work, do you want to go to school, do you go to the bank, do you have spending money to carry)

Page 2 of 15

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

 

 

 

Department for Medicaid Services

 

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

 

Name (LAST, FIRST)

 

 

Medicaid Number

 

 

 

 

 

 

 

 

 

SECTION V – ACTIVITIES OF DAILY LIVING

 

1) Is member independent with

Comments:

 

dressing/undressing

 

 

 

Yes

No(If no, check below all that apply and comment)

 

 

 

Requires supervision or verbal cues

 

 

 

Requires hands-on assistance with upper body

 

 

 

Requires hands-on assistance with lower body

 

 

 

Requires total assistance

 

 

 

 

 

 

2) Is member independent with grooming

Comments:

 

Yes

No(If no, check below all that apply and comment)

 

 

 

Requires supervision or verbal cues

 

 

 

Requires hands-on assistance with

 

 

 

oral care

shaving

 

 

 

nail care

hair

 

 

 

Requires total assistance

 

 

 

 

 

 

3) Is member independent with bed mobility

Comments:

 

Yes

No (If no, check below all that apply and comment)

 

 

 

Requires supervision or verbal cues

 

 

 

Occasionally requires hands-on assistance

 

 

 

Always requires hands-on assistance

 

 

 

Bed-bound

 

 

 

 

Required bedrails

 

 

 

 

 

 

4) Is member independent with bathing

Comments:

 

Yes

No (If no, check below all that apply and comment)

 

 

 

Requires supervision or verbal cues

 

 

 

Requires hands-on assistance with upper body

 

 

 

Requires hands-on assistance with lower body

 

 

 

Requires Peri-Care

 

 

 

Requires total assistance

 

 

 

 

 

 

5) Is member independent with toileting

Comments:

 

Yes

No (If no, check below all that apply and comment)

 

 

 

Bladder incontinence

 

 

 

Bowel incontinence

 

 

 

Occasionally requires hands-on assistance

 

 

 

Always requires hands-on assistance

 

 

 

Requires total assistance

 

 

 

Bowel and bladder regimen

 

 

 

 

 

 

6) Is member independent with eating Yes No

Comments:

 

(If no, check below all that apply and comment)

 

 

 

Requires supervision or verbal cues

 

 

 

Requires assistance cutting meat or arranging food

 

 

 

Partial/occasional help

 

 

 

Totally fed (by mouth)

 

 

 

Tube feeding (type and tube location)

 

 

 

 

 

 

 

 

Page 3 of 15

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

 

 

 

 

Department for Medicaid Services

 

 

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

 

 

 

 

Name (LAST, FIRST)

 

 

 

Medicaid Number

 

 

 

 

 

 

 

 

7) Is member independent with ambulation

 

 

Comments:

 

Yes

No (If no, check below all that apply and comment)

 

 

 

 

Dependent on device

 

 

 

 

 

 

Requires aid of one person

 

 

 

 

 

 

Requires aid of two people

 

 

 

 

 

 

History of falls (number of falls, and date of last fall)

 

 

 

 

 

 

 

 

 

 

8) Is member independent with transferring

 

Comments:

 

Yes

No (If no, check below all that apply and comment)

 

 

 

 

Requires supervision or verbal cues

 

 

 

 

 

 

Hands-on assistance of one person

 

 

 

 

 

 

Hands-on assistance of two people

 

 

 

 

 

 

Requires mechanical device

 

 

 

 

 

 

Bedfast

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION VI - INSTRUMENTAL ACTIVITIES OF DAILY LIVING

 

1) Is member able to prepare meals

Yes

No

 

Comments:

 

(If no, check below all that apply and explain in the comments)

 

 

 

Arranges for meal preparation

 

 

 

 

 

 

Requires supervision or verbal cues

 

 

 

 

 

 

Requires assistance with meal preparation

 

 

 

 

 

Requires total meal preparation

 

 

 

 

 

 

2) Is member able to shop independently

Yes No

 

Comments:

 

(If no, check below all that apply and explain in the comments)

 

 

 

Arranges for shopping to be done

 

 

 

 

 

 

Requires supervision or verbal cues

 

 

 

 

 

 

Requires assistance with shopping

 

 

 

 

 

 

Unable to participate in shopping

 

 

 

 

 

 

 

 

 

 

3) Is member able to perform light housekeeping

 

Comments:

 

Yes

No

 

 

 

 

 

 

(If no, check below all that apply and explain in the comments)

 

 

 

Arranges for light housekeeping duties to be performed

 

 

 

Requires supervision or verbal cues

 

 

 

 

 

 

Requires assistance with light housekeeping

 

 

 

 

 

Unable to perform any light housekeeping

 

 

 

 

 

 

 

 

 

4) Is member able to perform heavy housework

 

Comments:

 

Yes

No

 

 

 

 

 

 

(If no, check below all that apply and explain in the comments)

 

 

 

Arranges for heavy housework to be performed

 

 

 

 

 

Requires supervision or verbal cues

 

 

 

 

 

 

Requires assistance with heavy housework

 

 

 

 

 

Unable to perform any heavy housework

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 4 of 15

MAP 351

Commonwealth of Kentucky

 

(Rev. 7/08)

Cabinet for Health and Family Services

 

 

 

 

Department for Medicaid Services

 

 

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

 

 

 

 

 

 

Name (LAST, FIRST)

 

 

 

Medicaid Number

 

 

 

 

 

 

 

 

 

 

5) Is member able to perform laundry tasks

 

Comments:

 

 

Yes

No

 

 

 

 

 

 

 

 

(If no, check below all that apply and explain in the comments)

 

 

 

 

 

 

Arranges for laundry to be done

 

 

 

 

 

 

 

 

Requires supervision or verbal cues

 

 

 

 

 

 

 

 

Requires assistance with laundry tasks

 

 

 

 

 

 

 

 

Unable to perform any laundry tasks

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

6) Is member able to plan/arrange for pick-up,

 

Comments:

 

 

delivery, or some means of gaining possession of

 

 

 

 

 

 

medication(s) and take them independently

 

 

 

 

 

 

Yes

No

 

 

 

 

 

 

 

 

(If no, check below all that apply and explain in the comments)

 

 

 

 

 

 

Arranges for medication to be obtained and taken correctly

 

 

 

 

 

 

Requires supervision or verbal cues

 

 

 

 

 

 

 

 

Requires assistance with obtaining and taking medication

 

 

 

 

 

 

correctly

 

 

 

 

 

 

 

 

Unable to obtain medication and take correctly

 

 

 

 

 

 

 

 

 

 

 

 

 

 

7) Is member able to handle finances independently

 

Comments:

 

 

Yes

No

 

 

 

 

 

 

 

 

(If no, check below all that apply and explain in the comments)

 

 

 

 

 

 

Arranges for someone else to handle finances

 

 

 

 

 

 

Requires supervision or verbal cues

 

 

 

 

 

 

 

 

Requires assistance with handling finances

 

 

 

 

 

 

Unable to handle finances

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

8) Is member able to use the telephone independently

 

Comments:

 

 

Yes

No

 

 

 

 

 

 

 

 

(If no, check below all that apply and explain in the comments)

 

 

 

 

 

 

Requires adaptive device to use telephone

 

 

 

 

 

 

Requires supervision or verbal cues

 

 

 

 

 

 

 

 

Requires assistance when using telephone

 

 

 

 

 

 

Unable to use telephone

 

 

 

 

 

 

 

 

 

SECTION VII-NEURO/EMOTIONAL/BEHAVIORAL

 

 

1) Does member exhibit behavior problems

 

Comments:

 

 

 

Yes

No (If yes, check below all that apply and explain

 

Date of functional analysis:

and/or

 

the frequency in comments)

 

 

Date of behavior support plan:

 

 

 

 

 

 

 

 

 

 

Disruptive behavior

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Agitated behavior

 

 

 

 

 

 

 

 

Assaultive behavior

 

 

 

 

 

 

 

 

Self-injurious behavior

 

 

 

 

 

 

 

 

Self-neglecting behavior

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 5 of 15

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

 

Department for Medicaid Services

 

MEDICAID WAIVER ASSESSMENT

 

 

 

Name (LAST, FIRST)

 

Medicaid Number

 

 

2) Is member oriented to person, place, time

Comments:

Yes No (If no, check below all that apply and comment)

 

Forgetful

 

 

Confused

 

 

Unresponsive

 

 

Impaired Judgment

 

 

 

 

3) Has member experienced a major change or

Description:

crisis within the past twelve months

Yes No

 

(If yes, describe)

 

 

 

 

4) Is the member actively participating in social

Description:

and/or community activities Yes

No

 

(If yes, describe)

 

 

 

 

5) Is the member experiencing any of the following

Comments:

(For each checked, explain the frequency and details in the

 

comments section)

 

 

Difficulty recognizing others

 

 

Loneliness

 

 

Sleeping problems

 

 

Anxiousness

 

 

Irritability

 

 

Lack of interest

 

 

Short-term memory loss

 

 

Long-term memory loss

 

 

Hopelessness

 

 

Suicidal behavior

 

 

Medication abuse

 

 

Substance abuse

 

 

Alcohol Abuse

 

 

Page 6 of 15

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

 

Department for Medicaid Services

 

MEDICAID WAIVER ASSESSMENT

 

 

Name (LAST, FIRST)

Medicaid Number

 

 

6) Cognitive functioning (Participant’s current

Comments:

level of alertness, orientation, comprehension,

 

concentration, and immediate memory for simple

 

commands)

 

 

Alert/oriented, able to focus and shift

 

attention, comprehends and recalls task

 

directions independently.

 

 

Requires prompting (cueing, repetition,

 

reminders) only under stressful or unfamiliar

 

conditions.

 

 

Requires assistance and some direction in

 

 

specific situations (e.g., on all tasks

 

 

involving shifting of attention), or

 

 

consistently requires low stimulus

 

 

environment due to distractibility.

 

 

Required considerable assistance in routine

 

 

situations. Is not alert and oriented or is

 

 

unable to shift attention and recall directions

 

 

more than half the time.

 

 

Totally dependent due to disturbances such

 

 

as constant disorientation, coma, persistent

 

 

vegetative state, or delirium.

 

 

 

7) When Confused (Reported or Observed):

Comments:

 

Never

 

 

In new or complex situations only

 

 

On awakening or at night only

 

 

During the day and evening, but not

 

constantly

 

 

Constantly

 

 

NA (non-responsive)

 

 

 

8) When Anxious (Reported or Observed):

Comments:

 

None of the time

 

 

Less often than daily

 

 

Daily, but not constantly

 

 

All of the time

 

 

NA (non-responsive)

 

 

 

9) Depressive Feelings (Reported or Observed):

Comments:

 

Depressed mood (e.g., feeling sad, tearful)

 

 

Sense of failure or self-reproach

 

 

Hopelessness

 

 

Recurrent thoughts of death

 

 

Thoughts of suicide

 

 

None of the above feelings reported or

 

observed

 

 

 

 

Page 7 of 15

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

 

Department for Medicaid Services

 

MEDICAID WAIVER ASSESSMENT

 

 

Name (LAST, FIRST)

Medicaid Number

 

 

10) Member Behaviors (Reported or Observed):

Comments:

 

Indecisiveness, lack of concentration

 

 

Diminished interest in most activities

 

 

Sleep disturbances

 

 

Recent changes in appetite or weight

 

 

Agitation

 

 

Suicide attempt

 

 

None of the above behaviors observed or

 

reported

 

 

 

11) Behaviors Demonstrated at Least Once a

Comments:

Week:

Memory deficit: failure to recognize

 

 

 

 

familiar persons/places, inability to recall

 

 

events of past 24-hours, significant memory

 

 

loss so that supervision is required.

 

 

Impaired decision-making: failure to

 

 

perform usual ADL’s, inability to

 

 

inappropriately stop activities, jeopardizes

 

 

safety through actions.

 

 

Verbal disruption: yelling, threatening,

 

 

excessive profanity, sexual references, etc.

 

 

Physical aggression: aggressive or

 

 

combative to self and others (e.g. hits self,

 

 

throws objects, punches, dangerous

 

 

maneuvers with wheelchair or other

 

 

objects).

 

 

Disruptive, infantile, or socially

 

 

inappropriate behavior (excludes verbal

 

 

actions).

 

 

Delusional, hallucinatory, or paranoid

 

 

behavior.

 

 

None of the above behaviors demonstrated.

 

 

 

12 ) Frequency of Behavior Problems (Reported or

Comments:

Observed) such as wandering episodes, self abuse,

 

verbal disruption, physical aggression, etc.:

 

 

Never

 

 

Less than once a month

 

 

Once a month

 

 

Several times each month

 

 

Several times a week

 

 

At least daily

 

 

 

 

Page 8 of 15

MAP 351

 

Commonwealth of Kentucky

(Rev. 7/08)

 

Cabinet for Health and Family Services

 

 

 

 

Department for Medicaid Services

 

 

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

Name (LAST, FIRST)

 

Medicaid Number

 

 

 

 

 

13)

Mental Status:

 

Comments:

 

 

 

Oriented

 

 

 

 

 

Forgetful

 

 

 

 

 

Depressed

 

 

 

 

 

Disoriented

 

 

 

 

Lethargic

 

 

 

 

 

Agitated

 

 

 

 

 

Other

 

 

 

 

 

 

14) Is this member receiving Psychiatric Nursing

Comments:

 

Services at home provided by a qualified psychiatric

 

 

nurse?

Yes

No

 

 

 

 

 

 

 

 

 

 

 

SECTION VIII-CLINICAL INFORMATION

 

1) Is member’s vision adequate (with or without

Comments:

 

glasses)

 

 

 

 

Yes

No

Undetermined

 

 

(If no, check below all that apply and comment)

 

 

Difficulty seeing print

 

 

Difficulty seeing objects

 

 

No useful vision

 

 

 

 

 

 

2) Is member’s hearing adequate (with or without

Comments:

 

hearing aid)

 

 

 

 

Yes

No

Undetermined

 

 

(If no, check below all that apply, and comment)

 

 

Difficulty with conversation level

 

 

Only hears loud sounds

 

 

No useful hearing

 

 

 

 

 

 

3) Is member able to communicate needs

Comments:

 

Yes

No (If no, check below all that apply and comment)

 

 

Speaks with difficulty but can be understood

 

 

Uses sign language and/or gestures/communication device

 

 

Inappropriate context

 

 

 

Unable to communicate

 

 

 

 

 

4) Does member maintain an adequate diet

Comments:

 

Yes

No (If no, check all that apply and comment)

 

 

Uses dietary supplements

 

 

Requires special diet (low salt, low fat, etc.)

 

 

Refuses to eat

 

 

 

Forgets to eat

 

 

 

Tube feeding required (Explain the brand, amount, and

 

 

frequency in the comments section)

 

 

Other dietary considerations (PICA, Prader-Willie, etc.)

 

 

 

 

 

 

 

Page 9 of 15

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

 

 

Department for Medicaid Services

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

Name (LAST, FIRST)

 

Medicaid Number

5) Does member require respiratory care and/or

Comments:

equipment

 

 

Yes

No (If yes, check all that apply and comment)

 

Oxygen therapy (Liters per minute and delivery device)

 

Nebulizer (Breathing treatments)

 

Management of respiratory infection

 

Nasopharyngeal airway

 

Tracheostomy care

 

 

Aspiration precautions

 

Suctioning

 

 

Pulse oximetry

 

 

Ventilator (list settings)

 

 

 

6) Does member have history of a stroke(s)

Comments:

Yes

No (If yes, check all that apply and comment)

 

Residual physical injury(ies)

 

Swallowing impairments

 

Functional limitations (Number of limbs affected)

 

 

 

7) Does member’s skin require additional,

Comments:

specialized care

Yes No

 

(If yes, check all that apply and comment)

 

Requires additional ointments/lotions

 

Requires simple dressing changes (i.e. band-aids,

 

occlusive dressings)

 

Requires complex dressing changes (i.e. sterile dressing)

 

Wounds requiring “packing” and/or measurements

 

Contagious skin infections

 

Ostomy care

 

 

8) Does member require routine lab work

Comments:

Yes

No (If yes, what type and how often)

 

 

 

9) Does member require specialized genital and/or

Comments:

urinary care Yes

No

 

(If yes, check all that apply and comment)

 

Management of reoccurring urinary tract infection

 

In-dwelling catheter

 

Bladder irrigation

 

 

In and out catheterization

 

 

 

10) Does member require specific, physician-

Comments:

ordered vital signs evaluation necessary in the

 

management of a condition(s) Yes No (If yes,

 

explain in the comments section)

 

11) Does member have total or partial paralysis

Comments:

Yes

No (If yes, list limbs affected and comment)

 

 

 

 

 

Page 10 of 15

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

 

 

Department for Medicaid Services

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

Name (LAST, FIRST)

 

 

 

Medicaid Number

 

 

 

 

12)

Does member require assistance with changes

 

Comments:

in body position Yes

No (If yes, check all that apply

 

and comment)

 

 

 

 

To maintain proper body alignment

 

 

 

To manage pain

 

 

 

 

To prevent further deterioration of muscle/joints/skin

 

 

 

 

 

 

 

13)

Does member require 24 hour caregiver

Yes

No

 

 

 

 

14)

Does member require respite services

Yes

No (If yes, how often)

 

 

15)

Does the member require intravenous fluids, intravenous medications or intravenous alimentation

Yes No (If yes, check below all that apply and list solution, location, amount, rate, frequency and prescribing physician)

Peripheral IV

Location

 

Amount/dosage

 

Rate

Solution:

 

 

 

 

 

 

Frequency:

 

 

 

Prescribing physician

 

 

 

 

 

 

 

 

Central line

Location

 

Amount/dosage

 

Rate

Solution:

 

 

 

 

 

 

Frequency

 

 

 

Prescribing physician

 

 

 

 

 

 

 

 

16)

Drug allergies (list)

 

 

 

17) Other allergies (list)

 

 

 

 

 

17)

Does the member use any medications Yes No (If

yes, list below) *add additional pages if needed

Name of medication

 

 

Dosage/Frequency/Route

Administered by

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 11 of 15

MAP 351

 

 

Commonwealth of Kentucky

(Rev. 7/08)

 

 

Cabinet for Health and Family Services

 

 

 

Department for Medicaid Services

 

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

Name (LAST, FIRST)

 

 

 

Medicaid Number

18) Is any of the following adaptive equipment Comments:

required (If needs, explain in the comments)

Dentures

Has

Needs

N/A

Hearing aid

Has

Needs

N/A

Glasses/lenses

Has

Needs

N/A

Hospital bed

Has

Needs

N/A

Bedpan

Has

Needs

N/A

Elevated toilet seat

Has

Needs

N/A

Bedside commode

Has

Needs

N/A

Prosthesis

Has

Needs

N/A

Ambulation aid

Has

Needs

N/A

Tub seat

Has

Needs

N/A

Lift chair

Has

Needs

N/A

Wheelchair

Has

Needs

N/A

Brace

Has

Needs

N/A

Hoyer lift

Has

Needs

N/A

19)Please describe in detail any information regarding health, safety and welfare/crisis issues:

Page 12 of 15

MAP 351

 

Commonwealth of Kentucky

(Rev. 7/08)

 

Cabinet for Health and Family Services

 

 

 

Department for Medicaid Services

 

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

 

 

 

Name (LAST, FIRST)

 

 

Medicaid Number

 

 

 

 

 

 

 

 

 

 

SECTION IX-ENVIRONMENT INFORMATION

 

1) Answer the following items relating to the

Comments:

 

member’s physical environment (Comment if

 

 

 

 

necessary)

 

 

 

 

 

 

Sound dwelling

Yes

No

 

 

 

 

Adequate furnishings

Yes

No

 

 

 

 

Indoor plumbing

Yes

No

 

 

 

 

Running water

Yes

No

 

 

 

 

Hot water

Yes

No

 

 

 

 

Adequate heating/cooling

Yes

No

 

 

 

 

Tub/shower

Yes

No

 

 

 

 

Stove

Yes

No

 

 

 

 

Refrigerator

Yes

No

 

 

 

 

Microwave

Yes

No

 

 

 

 

Telephone

Yes

No

 

 

 

 

TV/radio

Yes

No

 

 

 

 

Washer/dryer

Yes

No

 

 

 

 

Adequate lighting

Yes

No

 

 

 

 

Adequate locks

Yes

No

 

 

 

 

Adequate fire escape

Yes

No

 

 

 

 

Smoke alarms

Yes

No

 

 

 

 

Insect/rodent free

Yes

No

 

 

 

 

Accessible

Yes

No

 

 

 

 

Safe environment

Yes

No

 

 

 

 

Trash management

Yes

No

 

 

 

 

2) Provide an inventory of home adaptations already

present in the member’s dwelling. (Such as wheelchair ramp,

 

tub rails, etc.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION X – HOUSEHOLD INFORMATION

 

 

 

 

 

 

 

1) Does the member live alone

Yes No

 

Comments:

 

If yes, does the member receive any assistance from

 

 

 

 

others Yes No (Explain)

 

 

 

 

 

 

 

 

 

 

 

Page 13 of 15

MAP 351

Commonwealth of Kentucky

 

 

(Rev. 7/08)

Cabinet for Health and Family Services

 

 

 

 

Department for Medicaid Services

 

 

 

 

MEDICAID WAIVER ASSESSMENT

 

 

 

 

 

 

 

 

 

 

 

 

 

Name (LAST, FIRST)

 

 

Medicaid Number

 

 

 

 

 

 

 

 

 

 

 

 

2)Household Members (Fill in household member info below)

 

 

 

 

 

 

 

 

 

 

 

 

 

a) Name

 

Relationship

 

Age

Are they functionally able to provide care

 

 

 

 

 

 

 

 

Yes

No (If no, explain in the comments section)

 

Comments:

 

Care provided/frequency

 

 

 

 

 

 

 

 

 

 

 

 

b) Name

 

Relationship

 

Age

Are they functionally able to provide care

 

 

 

 

 

 

 

 

Yes

No (If no, explain in the comments section)

 

Comments:

 

Care provided/frequency

 

 

 

 

 

 

 

 

 

 

 

 

c) Name

 

Relationship

 

Age

Are they functionally able to provide care

 

 

 

 

 

 

 

 

Yes

No (If no, explain in the comments section)

 

Comments:

 

Care provided/frequency

 

 

 

 

 

 

 

 

 

 

 

 

d) Name

 

Relationship

 

Age

Are they functionally able to provide care

 

 

 

 

 

 

 

 

Yes

No (If no, explain in the comments section)

 

Comments:

 

 

 

 

 

Care

provided/frequency

 

 

 

 

 

 

 

 

SECTION XI-ADDITIONAL SERVICES

 

1) Has the member had any hospital, nursing facility or ICF/MR/DD admissions in the past 12 months?

 

Yes No (If yes, please list below)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

a-Facility name

 

 

 

 

Facility address

 

 

 

 

 

 

 

 

 

 

 

 

Reason for admission

 

 

 

 

Admission date

 

Discharge date

 

 

 

 

 

 

 

 

 

 

b-Facility name

 

 

 

 

Facility address

 

 

 

 

 

 

 

 

 

 

 

 

Reason for admission

 

 

 

 

Admission date

 

Discharge date

 

 

 

 

 

 

 

 

 

 

 

Page 14 of 15

MAP 351

Commonwealth of Kentucky

(Rev. 7/08)

Cabinet for Health and Family Services

 

Department for Medicaid Services

 

MEDICAID WAIVER ASSESSMENT

 

 

 

Name (LAST, FIRST)

 

Medicaid Number

 

 

 

2) Does the member receive services from other agencies (Example: Both Waiver and Non-waiver Services.) Yes No

(If yes, list services already provided and to be provided in accordance with a plan of care by an agency/organization, include Adult Day Health Care and traditional Home health services covered by Medicare/Third party insurance)

a-Service(s) received

 

Agency/worker name

Phone number

 

 

 

 

Agency address

 

Frequency

Number of units

 

 

 

 

b-Service(s) received

 

Agency/worker name

Phone number

 

 

 

 

Agency address

 

Frequency

Number of units

 

 

 

 

c-Service(s) received

 

Agency/worker name

Phone number

 

 

 

 

Agency address

 

Frequency

Number of units

 

 

 

 

 

SECTION XII-CONSUMER

DIRECTED OPTION

 

Has the member been provided information on Consumer Directed Option (CDO) and their right to choose

 

CDO, traditional or blended services?

Yes

No

If no, give reason:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Has the member chosen Consumer Direction Option?

 

 

Yes

No If yes, include form MAP 2000

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION XIII-SIGNATURES

 

 

 

 

 

 

Person(s) performing assessment or reassessment:

 

 

 

 

 

 

 

 

 

 

 

 

Signature:

 

 

 

 

 

 

Title:

 

 

 

 

 

Date

/

/

 

Signature:

 

 

 

 

 

 

Title:

 

 

 

 

 

Date

/

/

 

Verbal Level of Care Confirmation:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date: / /

 

 

 

 

 

 

Time:

am/pm

 

 

 

 

 

 

Assessment/Reassessment forwarded to Support Broker/Case Management provider:

 

 

 

Date Forwarded:

/

/

 

 

 

 

Time Forwarded:

am/pm

 

 

 

 

Name of Person Forwarding:

 

 

 

 

Title of Person Forwarding:

 

 

 

 

 

 

 

 

 

 

 

 

 

Receipt of assessment/reassessment by Support Broker/case management provider:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Date Received:

/

/

 

 

 

 

Time Received:

am/pm

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Name of Person Logging Receipt:

 

 

 

 

Title of Person Logging Receipt:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

QIO Signature:

 

 

 

Level of Care

 

 

Approval dates

 

 

 

 

 

 

 

 

Date

/ /

 

 

From:

/ /

 

To:

/

/

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 15 of 15

How to Edit Kentucky Form Map 351 Online for Free

DSM can be filled in online very easily. Just make use of FormsPal PDF tool to get the job done in a timely fashion. To make our editor better and simpler to use, we constantly work on new features, with our users' suggestions in mind. In case you are looking to get started, here's what it will take:

Step 1: First of all, access the tool by pressing the "Get Form Button" at the top of this webpage.

Step 2: With the help of our advanced PDF editing tool, you could do more than just fill out blank fields. Express yourself and make your docs appear high-quality with customized textual content added, or adjust the file's original content to excellence - all that accompanied by an ability to insert your personal pictures and sign it off.

This PDF form will require particular data to be filled out, thus you need to take whatever time to type in precisely what is asked:

1. When filling in the DSM, make certain to include all of the needed blank fields in its corresponding section. It will help speed up the process, allowing for your details to be handled without delay and properly.

map351 writing process explained (part 1)

2. Soon after filling in the previous section, go on to the next part and enter the necessary particulars in all these fields - Certification period enter dates, Physicians license number enter, Has members freedom of choice been, Mental Retardation IQ Dateofonset, Is the member diagnosed with one, Physicians phone number, Cause of Brain Injury Date of, SECTION III ASSESSMENT PROVIDER, AssessmentReassessment provider, Provider number, City state and zip code, Provider phone number, and Provider contact person.

Stage no. 2 in completing map351

3. The following segment is typically rather uncomplicated, Name last first, Medicaid Number, For SCL MP and ABI waivers only, SECTION IV SELF ASSESSMENT, and Community Inclusion what do you - all these fields will have to be completed here.

For SCL MP and ABI waivers only, Community Inclusion what do you, and Medicaid Number of map351

4. Completing Community Inclusion what do you is paramount in the next section - be sure to spend some time and take a close look at every single empty field!

Community Inclusion what do you, Community Inclusion what do you, and Community Inclusion what do you in map351

5. And finally, this last section is precisely what you need to wrap up before closing the document. The blank fields at this point are the following: Name last first, Medicaid Number, SECTION V ACTIVITIES OF DAILY, Comments, Is member independent with, dressingundressing Yes NoIf no, Is member independent with, Yes NoIf no check below all that, Requires handson assistance with, oral care nail care Requires total, shaving hair, Is member independent with bed, Yes No If no check below all that, Is member independent with bathing, and Yes No If no check below all that.

map351 conclusion process outlined (part 5)

Concerning oral care nail care Requires total and Is member independent with, be certain you do everything correctly here. Both these are the most significant ones in this form.

Step 3: Right after looking through the fields, hit "Done" and you are done and dusted! Download the DSM after you join for a free trial. Easily gain access to the pdf document inside your FormsPal account, along with any modifications and changes all saved! Here at FormsPal, we do our utmost to make sure that all your information is kept private.