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COMMONWEALTH OF MASSACHUSETTS

EXECUTIVE OFFICE OF HEALTH AND HUMAN SERVICES

DIVISION OF MEDICAL ASSISTANCE

600 Washington Street Boston, MA 02111 www.mass.gov/dma

MassHealth

Chronic Disease and

Rehabilitation Hospital Bulletin 83

January 2003

TO: Chronic Disease and Rehabilitation Hospitals Participating in MassHealth

FROM: Wendy E. Warring, Commissioner

RE:	Changes in Clinical Assessment Forms

Background	The Division determines clinical eligibility for MassHealth long-term-care
	services based upon documentation submitted by the provider. The Long
	Term Care Assessment form has been replaced by two new forms in
	order to facilitate communication between providers and the Division.

New Forms	Attached to this bulletin are copies of the two new forms required for
	approving referrals for long-term-care services, including, but not limited
	to, nursing-facility and adult-day-health services.
	• Request for Services (RFS-1) (formerly called the MassHealth
	Long Term Care Assessment form)
	• Minimum Data Set – Home Care (MDS-HC)
	Chronic disease and rehabilitation hospitals must begin using these new
	forms by February 1, 2003. Please discard all previous versions of the Long
	Term Care Assessment form.

Who May Complete	The MDS-HC must be completed by an assessment coordinator. The
the MDS-HC	assessment coordinator must be a registered nurse who certifies the
	accuracy and completeness of the MDS-HC.
	The following sections of the MDS-HC may be completed by a licensed
	social worker (LSW, LCSW, or LICSW).
	AA – Name and Identification Numbers
	BB – Personal Items
	CC – Referral Items
	B – Cognitive Patterns
	C – Communication/Hearing Patterns
	E – Mood and Behavior Patterns
	F – Social Functioning
	G – Informal Support Services
	O – Environmental Assessment

	CONTINUED ON BACK

MassHealth

Chronic Disease and

Rehabilitation Hospital Bulletin 83

January 2003

Page 2

Who May Complete	Each person who completes a portion of the MDS-HC must sign and
the MDS-HC	certify the sections he or she completes in Section R – Assessment
(cont.)	Information (Other Signatures, Title, Sections, Date).

Qualifications for	The registered nurse or social worker must be licensed by the
Completing the Forms	Massachusetts Board of Registration.

ICD-9-CM Codes	The MDS-HC assessment requires the use of the ICD-9-CM codes for
	medical diagnoses.

Trainings	The Division holds periodic trainings for providers. You will receive notice
	of trainings when they are scheduled.

Supplies of the Forms	You may photocopy the forms as needed. To obtain supplies of the
	forms, use the information below to mail or fax your request. Include your
	provider number, address, telephone number, the exact title of the form,
	and the desired quantity.
	MassHealth Forms Distribution
	P.O. Box 9101
	Somerville, MA 02145
	Fax: 703-917-4087

Questions	If you have any questions about this bulletin, please contact MassHealth
	Provider Services at 617-628-4141 or 1-800-325-5231.

(With hearing appliance if used)

MINIMUM DATA SET - HOME CARE (MDS-HC)©

•Unless otherwise noted, score for last 3 days

•Examples of exceptions include IADLs/Continence/Services/Treatments where status scored over last 7 days

SECTION AA. NAME AND IDENTIFICATION NUMBERS

NAME OF

CLIENT

a. (Last/Family Name)

b. (First Name)

c. (Middle Initial)

CASE

RECORD

NO.

GOVERN-

a. Pension (Social Security) Number

MENT

PENSION

AND HEALTH

Health

insurance

number

(or

other comparable insurance number)

INSURANCE

NUMBERS

SECTION BB. PERSONAL ITEMS (Complete at Intake Only)

GENDER

1. Male

2. Female

BIRTHDATE

Month

Day

Year

RACE/

(Check all that apply)

ETHNICITY

RACE

Native Hawaiian or other Pacific

American Indian/Alaskan

Islander

White

Native

Asian

ETHNICITY:

Black or African American

Hispanic or Latino

MARITAL

1. Never married

3. Widowed

5. Divorced

STATUS

2. Married

4. Separated

6. Other

5.LANGUAGE Primary Language

*		0. English	1. Spanish	2. French	3. Other
		0. English	1. Spanish	2. French	3. Other
6.	EDUCATION	1. No schooling		5. Technical or trade school
	(Highest	2. 8th grade/less		6. Some college
	Level	3. 9-11 grades		7. Bachelor's degree
	Completed)	4. High school		8. Graduate degree

7.RESPONSI- (Code for responsibility/advanced directives)

BILITY/	0. No	1. Yes
ADVANCED
DIRECTIVES a. Client has a legal guardian

b. Client has advanced medical directives in place (for example, a do not hospitalize order)

SECTION CC. REFERRAL ITEMS (Complete at Intake Only)

1.DATE CASE

OPENED/

	REOPENED
	REOPENED		Month		Day	Year
			Month		Day	Year
2.	REASON	1. Post hospital care				4. Eligibility for home care
	FOR	2. Community chronic care				5. Day care
	REFERRAL	3. Home placement screen				6. Other
3.	GOALS OF	(Code for client/family understanding of goals of care)
	CARE	0. No		1. Yes
		a. Skilled nursing treatments				d. Client/family education
		b. Monitoring to avoid clinical				e. Family respite


		complications
		complications
		c. Rehabilitation				f. Palliative care
		c. Rehabilitation				f. Palliative care

4.TIME SINCE Time since discharge from last in-patient setting (Code for most

LAST recent instance in LAST 180 DAYS)

HOSPITAL	0. No hospitalization within 180 days	3. Within 15 to 30 days
STAY	1. Within last week	4. More than 30 days ago
	2. Within 8 to 14 days

5. WHERE	1. Private home/apt. with no home care services
LIVED AT	2. Private home/apt. with home care services
TIME OF	3. Board and care/assisted living/group home
REFERRAL	4. Nursing home
	5. Other
6. WHO LIVED	1. Lived alone
WITH AT	2. Lived with spouse only
REFERRAL	3. Lived with spouse and other(s)
	4. Lived with child (not spouse)
	5. Lived with other(s) (not spouse or children)
	6. Lived in group setting with non-relative(s)

7.PRIOR NH Resided in a nursing home at anytime during 5 YEARS prior to case

PLACEMENT opening
0. No	1. Yes

8.RESIDENTIAL Moved to current residence within last two years

HISTORY

0. No

1. Yes

SECTION A. ASSESSMENT INFORMATION

1.ASSESSMENT Date of assessment

REFERENCE

DATE

Month

Day

Year

2.REASONS Type of assessment

FOR 1. Initial assessment

ASSESS- 2. Follow-up assessment

MENT 3. Routine assessment at fixed intervals

4.Review within 30-day period prior to discharge from the program

5.Review at return from hospital

6.Change in status

7.Other

SECTION B. COGNITIVE PATTERNS

1.MEMORY (Code for recall of what was learned or known)

RECALL	0. Memory OK	1. Memory problem
ABILITY	a. Short-term memory OK — seems/appears to recall after 5 minutes

	b. Procedural memory OK—Can perform all or almost all steps in a
	multitask sequence without cues for initiation

2.	COGNITIVE	a. How well client made decisions about organizing the day (e.g., when
	SKILLS FOR	to get up or have meals, which clothes to wear or activities to do)
	DAILY	0.	INDEPENDENT—Decisions consistent/reasonable/safe
	DECISION-	0.	INDEPENDENT—Decisions consistent/reasonable/safe
	MAKING	1.	MODIFIED INDEPENDENCE—Some difficulty in new situations
			only
		2.	MINIMALLY IMPAIRED—In specific situations, decisions become
			poor or unsafe and cues/supervision necessary at those times
		3.	MODERATELY IMPAIRED—Decisions consistently poor or un-
			safe, cues/supervision required at all times
		4.	SEVERELY IMPAIRED—Never/rarely made decisions

		b. Worsening of decision making as compared to status of 90 DAYS
		AGO (or since last assessment if less than 90 days)
		0. No		1. Yes

3.INDICATORS a. Sudden or new onset/change in mental function over LAST 7 DAYS

OF DELIRIUM (including ability to pay attention, awareness of surroundings, being
coherent, unpredictable variation over course of day)
0. No	1. Yes
b. In the LAST 90 DAYS (or since last assessment if less than 90
days), client has become agitated or disoriented such that his or
her safety is endangered or client requires protection by others
0. No	1. Yes

SECTION C. COMMUNICATION/HEARING PATTERNS

1. HEARING

0.HEARS ADEQUATELY—Normal talk, TV, phone, doorbell

1.MINIMAL DIFFICULTY—When not in quiet setting

2.HEARS IN SPECIAL SITUATIONS ONLY—Speaker has to adjust tonal quality and speak distinctly

3.HIGHLY IMPAIRED —Absence of useful hearing

2.MAKING (Expressing information content—however able)

SELF	0. UNDERSTOOD—Expresses ideas without difficulty
UNDERSTOOD	0. UNDERSTOOD—Expresses ideas without difficulty
	1. USUALLY UNDERSTOOD—Difficulty finding words or finishing thoughts
(Expression)	BUT if given time, little or no prompting required
(Expression)	2. OFTEN UNDERSTOOD—Difficulty finding words or finishing thoughts,
	prompting usuallly required
	3. SOMETIMES UNDERSTOOD—Ability is limited to making concrete
	requests
	4. RARELY/NEVERUNDERSTOOD

3.ABILITY TO (Understands verbal information—however able)

	UNDER-	0. UNDERSTANDS—Clear comprehension
	STAND	0. UNDERSTANDS—Clear comprehension
	STAND	1. USUALLY UNDERSTANDS—Misses some part/intent of message,
	OTHERS	1. USUALLY UNDERSTANDS—Misses some part/intent of message,
	OTHERS	BUT comprehends most conversation with little or no prompting

	(Comprehen-	2. OFTEN UNDERSTANDS—Misses some part/intent of message;with
	sion)	prompting can often comprehend conversation
	sion)	3. SOMETIMES UNDERSTANDS—Responds adequately to simple, di-
		3. SOMETIMES UNDERSTANDS—Responds adequately to simple, di-
		rect communication
		4. RARELY/NEVERUNDERSTANDS

4.	COMMUNICA-	Worsening in communication (making self understood or understand-
	TION	ing others) as compared to status of 90 DAYS AGO (or since last
	DECLINE	assessment if less than 90 days)
	DECLINE	assessment if less than 90 days)
		0. No	1. Yes

SECTION D. VISION PATTERNS

1.VISION (Ability to see in adequate light and with glasses if used)

0.ADEQUATE—Sees fine detail, including regular print in newspapers/ books

1.IMPAIRED—Sees large print, but not regular print in newspapers/ books

2.MODERATELY IMPAIRED—Limited vision; not able to see newspa- per headlines, but can identify objects

3.HIGHLY IMPAIRED—Object identification in question, but eyes ap- pear to follow objects

4.SEVERELY IMPAIRED—No vision or sees only light, colors, or shapes; eyes do not appear to follow objects

2.VISUAL Saw halos or rings around lights, curtains over eyes, or flashes of LIMITATION/ lights

	DIFFICUL-	0. No	1. Yes
	DIFFICUL-	0. No	1. Yes
	TIES
3.	VISION	Worsening of vision as compared to status of 90 DAYS AGO (or since
	DECLINE	last assessment if less than 90 days)
		0. No	1. Yes
	MDS-HC Version 2.0 — July 21, 1999			MDS-HC - Pg 1

(A) (B)

SECTION E. MOOD AND BEHAVIOR PATTERNS

1. INDICATORS OF

DEPRES-

SION,

ANXIETY,

(Code for observed indicators irrespective of the assumed cause)

0.Indicator not exhibited in last 3 days

1.Exhibited 1-2 of last 3 days

2.Exhibited on each of last 3 days

1. TWO KEY			(A)	(B)
INFORMAL			PrIm	Secn
HELPERS	If needed, willingness (with ability) to increase help:
	If needed, willingness (with ability) to increase help:
Primary (A)	0. More than 2 hours 1. 1-2 hours per day	2. No
Primary (A)

SAD MOOD

a. A FEELING OF SADNESS OR BEING DEPRESSED, that life is not worth living, that nothing matters, that he or she is of no use to anyone or would rather be dead

b.PERSISTENTANGER WITH SELF OR OTHERS— e.g., easily annoyed, anger at care received

c.EXPRESSIONS OF WHAT APPEARTO BE UNREAL- ISTIC FEARS—e.g., fear of being abandoned, left alone, being with others

d.REPETITIVEHEALTHCOM- PLAINTS—e.g., persistently seeks medical attention, obsessive concern with body functions

e.REPETITIVEANXIOUSCOM- PLAINTS,CONCERNS—e.g., persistently seeks attention/ reassurance regarding sched- ules, meals, laundry, clothing, relationship issues

f.SAD,PAINED,WORRIED FA- CIAL EXPRESSIONS — e.g.,

furrowed brows

g.RECURRENTCRYING,TEAR- FULNESS

h.WITHDRAWALFROMACTIVI- TIES OF INTEREST—e.g., no interest in long standing ac- tivities or being with family/ friends

i . REDUCED SOCIAL INTER-

ACTION

	and	j . — Advice or emotional support
	Secondary (B)
	Secondary (B)	k. — IADL care
		k. — IADL care
	(cont)
	(cont)	l. — ADL care
		l. — ADL care

2.	CAREGIVER	(Check all that apply)
	STATUS	A caregiver is unable to continue in caring activities—e.g., decline in

		the health of the caregiver makes it difficult to continue		a.
		Primary caregiver is not satisfied with support received from family		b.
		and friends (e.g., other children of client)		b.
		and friends (e.g., other children of client)		c.
		Primary caregiver expresses feelings of distress, anger or depression		c.
		NONE OF ABOVE		d.
				d.
3.	EXTENT OF	For instrumental and personal activities of daily living received over the
	INFORMAL	LAST 7 DAYS, indicate extent of help from family, friends, and
	INFORMAL	neighbors	HOURS
	HELP	neighbors
	HELP
	(HOURS	a. Sum of time across five weekdays
	OF CARE,	a. Sum of time across five weekdays
	OF CARE,
	ROUNDED)	b. Sum of time across two weekend days
		b. Sum of time across two weekend days

2.MOOD Mood indicators have become worse as compared to status of 90

DECLINE days ago (or since last assessment if less than 90 days)
0. No	1. Yes

3.BEHAVIORAL Instances when client exhibited behavioral symptoms. If EXHIBITED, ease of SYMPTOMS altering the symptom when it occurred.

0.Did not occur in last 3 days

1.Occurred, easily altered

2.Occurred, not easily altered

a.WANDERING—Moved with no rational purpose, seemingly oblivious to needs or safety

b.VERBALLY ABUSIVE BEHAVIORAL SYMPTOMS—Threatened, screamed at, cursed at others

c.PHYSICALLY ABUSIVE BEHAVIORAL SYMPTOMS—Hit, shoved, scratched, sexually abused others

d.SOCIALLY INAPPROPRIATE/DISRUPTIVE BEHAVIORAL SYMP- TOMS—Disruptive sounds, noisiness, screaming, self-abusive acts, sexual behavior or disrobing in public, smears/throws food/feces, rummaging, repetitive behavior, rises early and causes disruption

e.RESISTS CARE—Resisted taking medications/injections, ADL as- sistance, eating, or changes in position

4.CHANGES IN Behavioral symptoms have become worse or are less well tolerated BEHAVIOR by family as compared to 90 DAYS AGO (or since last assessment if

SYMPTOMS less than 90 days)
0. No, or no change in behavioral symptoms	1. Yes

SECTION F. SOCIAL FUNCTIONING

1.INVOLVE- a. At ease interacting with others (e.g., likes to spend time with others)

MENT	0. At ease	1. Not at ease
	b. Openly expresses conflict or anger with family/friends
	0. No	1. Yes

2.CHANGE IN As compared to 90 DAYS AGO (or since last assessment if less than

SOCIAL 90 days ago), decline in the client's level of participation in social,

ACTIVITIES religious, occupational or other preferred activities. IF THERE WAS A
DECLINE, client distressed by this fact
0. No decline
1. Decline, not distressed
2. Decline, distressed
3. ISOLATION a. Length of time client is alone during the day (morning and afternoon)
0. Never or hardly ever
1. About one hour
2. Long periods of time—e.g., all morning
3. All of the time
b. Client says or indicates that he/she feels lonely
0. No	1. Yes

SECTION G. INFORMAL SUPPORT SERVICES

SECTION H. PHYSICAL FUNCTIONING:

•IADL PERFORMANCE IN 7 DAYS

•ADL PERFORMANCE IN 3 DAYS

1.IADL SELF PERFORMANCE—Code for functioning in routine activities around the home or in the community during the LAST 7 DAYS,

(A)IADL SELF PERFORMANCE CODE (Code for client's performance during LAST 7 DAYS)

0.INDEPENDENT—did on own

1.SOME HELP—help some of the time

2.FULL HELP—performed with help all of the time

3.BY OTHERS—performed by others

8.ACTIVITY DID NOT OCCUR

(B)IADL DIFFICULTY CODE How difficult it is (or would it be) for client to do

activity on ownPerformance

0.NO DIFFICULTY

1.SOME DIFFICULTY—e.g., needs some help, is very slow, or fatiguesDifficulty

2.GREAT DIFFICULTY—e.g., little or no involvement in the activity is possible

a.MEAL PREPARATION—How meals are prepared (e.g., planning meals, cooking, assembling ingredients, setting out food and utensils)

b.ORDINARY HOUSEWORK—How ordinary work around the house is performed (e.g., doing dishes, dusting, making bed, tidying up, laundry)

c.MANAGING FINANCE—How bills are paid, checkbook is balanced, household expenses are balanced

d.MANAGING MEDICATIONS—How medications are managed (e.g., remembering to take medicines, opening bottles, taking correct drug dosages, giving injections, applying ointments)

e.PHONE USE—How telephone calls are made or received (with assistive devices such as large numbers on telephone, amplification as needed)

f.SHOPPING—How shopping is performed for food and household items (e.g., selecting items, managing money)

g.TRANSPORTATION—How client travels by vehicle (e.g., gets to places beyond walk- ing distance)

2.ADL SELF-PERFORMANCE—The following address the client's physical functioning in routine personal activities of daily life, for example, dressing, eating, etc. during the LAST 3 DAYS, considering all episodes of these activities. For clients who performed an activity indepen- dently, be sure to determine and record whether others encouraged the activity or were present to supervise or oversee the activity [Note—For bathing, code for most dependent single episode in LAST 7 DAYS]

0.INDEPENDENT—No help, setup, or oversight —OR— Help, setup, oversight provided only 1 or 2 times (with any task or subtask)

1.SETUP HELP ONLY—Article or device provided within reach of client 3 or more times

2.SUPERVISION—Oversight, encouragement or cueing provided 3 or more times during last 3 days —OR— Supervision (1 or more times) plus physical assistance provided only 1 or

TWO KEY

INFORMAL HELPERS

Primary (A)

and

Secondary

(B)

NAME OF PRIMARY AND SECONDARY HELPERS

a. (Last/Family Name)		b. (First)

c. (Last/Family Name)		d. (First)

			(A)	(B)
			PrIm	Secn

e. Lives with client
0. Yes	1. No	2. No such helper [skip other items in
		the appropriate column]

f.Relationship to client

0. Child or child-in-law 2. Other Relative

1. Spouse	3. Friend/neighbor

Areas of help:	0. Yes	1. No

g. — Advice or emotional support h. — IADL care

i. — ADL care

2 times (for a total of 3 or more episodes of help or supervision)

3.LIMITED ASSISTANCE—Client highly involved in activity;received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3 or more times —OR— Combination of non-weight bearing help with more help provided only 1 or 2 times during period (for a total of 3 or more episodes of physical help)

4.EXTENSIVE ASSISTANCE—Client performed part of activity on own (50% or more of subtasks), but help of following type(s) were provided 3 or more times:

—Weight-bearing support —OR—

—Full performance by another during part (but not all) of last 3 days

5.MAXIMAL ASSISTANCE—Client involved and completed less than 50% of subtasks on own (includes 2+ person assist), received weight bearing help or full performance of certain subtasks 3 or more times

6.TOTAL DEPENDENCE—Full performance of activity by another

8. ACTIVITY DID NOT OCCUR (regardless of ability)

MDS-HC Version 2.0 — July 21, 1999

MDS-HC - Pg 2

2. ADLSELF-PERFORMANCE(cont)

a. MOBILITY IN BED—Including moving to and from lying position, turning side to side, and

positioning body while in bed.

b. TRANSFER—Including moving to and between surfaces—to/from bed, chair, wheelchair,

standing position. [Note—Excludes to/from bath/toilet]

c. LOCOMOTION IN HOME—[Note—If in wheelchair, self-sufficiency once in chair]

d. LOCOMOTION OUTSIDE OF HOME—[Note—If in wheelchair, self-sufficiency once in

chair]

e. DRESSING UPPER BODY—How client dresses and undresses (street clothes,under-

wear) above the waist, includes prostheses, orthotics, fasteners, pullovers, etc.

f. DRESSING LOWER BODY—How client dresses and undresses (street clothes, under-

wear) from the waist down, includes prostheses, orthotics, belts, pants, skirts, shoes,

and fasteners

3.BOWEL CONTI- NENCE

In LAST 7 DAYS, control of bowel movement (with appliance or bowel continence program if employed)

0.CONTINENT—Complete control; DOES NOT USE ostomy device

1.CONTINENT WITH OSTOMY—Complete control with use of ostomy device that does not leak stool

2.USUALLY CONTINENT—Bowel incontinent episodes less than weekly

3.OCCASIONALLY INCONTINENT—Bowel incontinent episode once a week

4.FREQUENTLY INCONTINENT—Bowel incontinent episodes 2-3 times a week

5.INCONTINENT—Bowel incontinent all (or almost all) of the time

8.DID NOT OCCUR—No bowel movement during entire 7 day assessment period

g. EATING—Including taking in food by any method, including tube feedings.

h. TOILET USE—Including using the toilet room or commode, bedpan, urinal, transferring

on/off toilet, cleaning self after toilet use or incontinent episode, changing pad, managing

any special devices required (ostomy or catheter), and adjusting clothes.

i . PERSONAL HYGIENE—Including combing hair, brushing teeth, shaving, applying makeup, washing/drying face and hands (EXCLUDE baths and showers)

j . BATHING—How client takes full-body bath/shower or sponge bath (EXCLUDE washing of back and hair). Includes how each part of body is bathed: arms, upper and lower legs, chest, abdomen, perineal area. Code for most dependent episode in LAST 7 DAYS

3.ADLDECLINE ADL status has become worse (i.e., now more impaired in self perfor- mance) as compared to status 90 days ago (or since last assessment

		if less than 90 days)
		if less than 90 days)
		0. No	1. Yes
4.	PRIMARY	0. No assistive device	3. Scooter (e.g., Amigo)
	MODES OF	1. Cane	4. Wheelchair
	LOCOMO-	2. Walker/crutch	8. ACTIVITY DID NOT OCCUR
	TION	a. Indoors
		a. Indoors
		b. Outdoors
		b. Outdoors

5.	STAIR	In the last 3 days, how client went up and down stairs (e.g., single or
	CLIMBING	multiple steps, using handrail as needed)
		0. Up and down stairs without help
		1. Up and down stairs with help
		2. Not go up and down stairs

6.	STAMINA	a. In a typical week, during the LAST 30 DAYS (or since last assess-
		ment), code the number of days client usually went out of the house
		or building in which client lives (no matter how short a time period )
		0. Every day	2. 1 day a week
		1. 2-6 days a week	3. No days
		b. Hours of physical activities in the last 3 days (e.g., walking, cleaning

		house, exercise)
		0. Two or more hours	1. Less than two hours
		0. Two or more hours	1. Less than two hours
	7.FUNCTIONAL	Client believes he/she capable of increased functional independence
	POTENTIAL	(ADL, IADL, mobility)		a.
				a.
		Caregivers believe client is capable of increased functional indepen-
		dence (ADL, IADL, mobility)		b.
		Good prospects of recovery from current disease or conditions, im-
		proved health status expected		c.
		NONE OF ABOVE		d.

SECTION I. CONTINENCE IN LAST 7 DAYS

1. BLADDER	a. In LAST 7 DAYS control of urinary bladder function (with appliances
CONTI-	such as catheters or incontinence program employed) [Note—if
NENCE	dribbles, volume insufficient to soak through underpants]

0.CONTINENT —Complete control; DOES NOT USE any type of catheter or other urinary collection device

1.CONTINENTWITH CATHETER—Complete control with use of any type of catheter or urinary collection device that does not leak urine

2.USUALLY CONTINENT—Incontinent episodes once a week or less

3.OCCASIONALLY INCONTINENT—Incontinent episodes 2 or more times a week but not daily

4.FREQUENTLY INCONTINENT—Tends to be incontinent daily, but some control present

5.INCONTINENT—Inadequate control, multiple daily episodes

8. DID NOT OCCUR —No urine output from bladder

b.Worsening of bladder incontinence as compared to status 90 DAYS AGO (or since last assessment if less than 90 days)

0. No1. Yes

2.	BLADDER	(Check all that apply in LAST 7 DAYS)
	DEVICES	Use of pads or briefs to protect against wetness	a.
		Use of pads or briefs to protect against wetness	a.
		Use of an indwelling urinary catheter	b.
			b.
		NONE OF ABOVE	c.
			c.

SECTION J. DISEASE DIAGNOSES

Disease/infection that doctor has indicated is present and affects client's status, requires treat- ment, or symptom management. Also include if disease is monitored by a home care professional or is the reason for a hospitalization in LAST 90 DAYS (or since last assessment if less than 90 days)

[blank]. Not present

1.Present—not subject to focused treatment or monitoring by home care professional

2.Present—monitored or treated by home care professional

[If no disease in list, check J1ac, None of Above]

DISEASES

HEART/CIRCULATION

p. Osteoporosis

a. Cerebrovascular accident

SENSES

(stroke)

q. Cataract

b. Congestive heart failure

r. Glaucoma

c. Coronary artery disease

PSYCHIATRIC/MOOD

d. Hypertension

s. Any psychiatric diagnosis

e. Irregularly irregular pulse

INFECTIONS

f. Peripheral vascular disease

t. HIV infection

NEUROLOGICAL

u. Pneumonia

g. Alzheimer's

v. Tuberculosis

h. Dementia other than

w. Urinary tract infection (in

Alzheimer's disease

LAST 30 DAYS)

i . Head trauma

OTHER DISEASES

j . Hemiplegia/hemiparesis

x. Cancer—(in past 5 years)

k. Multiple sclerosis

not including skin cancer

l . Parkinsonism

y. Diabetes

MUSCULO-SKELETAL

z . Emphysema/COPD/asthma

m.Arthritis

aa. Renal Failure

n. Hip fracture

ab.Thyroid disease (hyper or

o. Other fractures (e.g., wrist,

hypo)

vertebral)

ac. NONE OF ABOVE

ac.

OTHER

•

CURRENT

OR MORE

•

DETAILED

DIAGNOSES

•

AND ICD-9

CODES

•

SECTION K. HEALTH CONDITIONS AND PREVENTIVE HEALTH

MEASURES

PREVENTIVE

(Check all that apply—in PAST 2YEARS)

HEALTH

Blood pressure measured

(PAST TWO

Received influenza vaccination

YEARS)

Test for blood in stool or screening endoscopy

IF FEMALE: Received breast examination or mammography

NONE OF ABOVE

PROBLEM

(Check all that were present on at least 2 of the last 3 days)

CONDITIONS

Diarrhea

Loss of appetite

PRESENT ON

2 OR MORE

Difficulty urinating or urinating

Vomiting

DAYS

3 or more times at night

Fever

NONE OF ABOVE

PROBLEM

(Check all present at any point during last 3 days)

CONDITIONS

PHYSICAL HEALTH

Shortness of breath

Chest pain/pressure at rest or

MENTAL HEALTH

on exertion

Delusions

No bowel movement in 3 days

Hallucinations

Dizziness or lightheadedness

NONE OF ABOVE

Edema

MDS-HC Version 2.0 — July 21, 1999

MDS-HC - Pg 3

4.	PAIN	a. Frequency with which client complains or shows evidence of pain
		0. No pain (score b-e as 0)		2. Daily - one period
		1. Less than daily		3. Daily - multiple periods
				(e.g., morning and evening)
		b. Intensity of pain
		b. Intensity of pain
		0. No pain	2. Moderate	4. Times when pain is horrible
		1. Mild	3. Severe	or excruciating

		c. From client's point of view, pain intensity disrupts usual activities
		0. No	1. Yes
		d. Character of pain
		0. No pain	1. Localized - single site		2. Multiple sites
		e. From client's point of view, medications adequately control pain
		0. Yes or no pain	1. Medications do not		2. Pain present,
			adequately control pain		medication not
			adequately control pain		medication not
					taken

5.FALLS Number of times fell in LAST 90 DAYS (or since last assessment if FREQUENCY less than 90 days) If none, code "0"; if more than 9, code "9"

6.	DANGER OF	(Code for danger of falling)
	FALL	0. No	1. Yes

		a. Unsteady gait
		b. Client limits going outdoors due to fear of falling (e.g., stopped

		using bus, goes out only with others)

7.	LIFE STYLE	(Code for drinking or smoking)
	(Drinking/	0. No	1. Yes
	Smoking)
	Smoking)	a. In the LAST 90 DAYS (or since last assessment if less than 90 days),

		client felt the need or was told by others to cut down on drinking, or
		others were concerned with client's drinking
		b. In the LAST 90 DAYS (or since last assessment if less than 90 days),

		client had to have a drink first thing in the morning to steady nerves
		(i.e., an "eye opener") or has been in trouble because of drinking
		c. Smoked or chewed tobacco daily

8.HEALTH (Check all that apply)

STATUS	Client feels he/she has poor health (when asked)	a.
INDICATORS	Client feels he/she has poor health (when asked)	a.
INDICATORS	Has conditions or diseases that make cognition, ADL, mood, or

	behavior patterns unstable (fluctuations, precarious, or deteriorating)	b.
	Experiencing a flare-up of a recurrent or chronic problem	c.
	Treatments changed in LAST 30 DAYS (or since last assessment if
	less than 30 days) because of a new acute episode or condition	d.
	Prognosis of less than six months to live—e.g., physician has told
	client or client's family that client has end-stage disease	e.
	NONE OF ABOVE	f.

9.OTHER (Check all that apply)

STATUS	Fearful of a family member or caregiver	a.
INDICATORS	Fearful of a family member or caregiver	a.
INDICATORS	Unusually poor hygiene	b.
	Unusually poor hygiene

	Unexplained injuries, broken bones, or burns	c.
		c.
	Neglected, abused, or mistreated	d.
		d.
	Physically restrained (e.g., limbs restrained, used bed rails,
	constrained to chair when sitting)	e.
	NONE OF ABOVE	f.

SECTION L. NUTRITION/HYDRATION STATUS

1.	WEIGHT	(Code for weight items)	1. Yes
		0. No	1. Yes
		a. Unintended weight loss of 5% or more in the LAST 30 DAYS [or 10%
		or more in the LAST 180 DAYS]

		b. Severe malnutrion (cachexia)
		c. Morbid obesity
		c. Morbid obesity
2.	CONSUMP-	(Code for consumption)
2.	CONSUMP-	0. No	1. Yes
	TION	0. No	1. Yes
	TION
		a. In at least 2 of the last 3 days, ate one or fewer meals a day

		b. In last 3 days, noticeable decrease in the amount of food client
		usually eats or fluids usually consumes

c. Insufficient fluid—did not consume all/almost all fluids during last

3 days

d.Enteral tube feeding

3.SWALLOWING 0. NORMAL—Safe and efficient swallowing of all diet consistencies

1.REQUIRES DIET MODIFICATION TO SWALLOW SOLID FOODS (mechanical diet or able to ingest specific foods only)

2.REQUIRES MODIFICATION TO SWALLOW SOLID FOODS AND LIQUIDS (puree, thickened liquids)

3.COMBINED ORAL AND TUBE FEEDING

4.NO ORAL INTAKE (NPO)

SECTION M. DENTAL STATUS (ORAL HEALTH)

1.	ORAL	(Check all that apply)
	STATUS	Problem chewing (e.g., poor mastication, immobile jaw, surgical resec-
	STATUS

		tion, decreased sensation/motor control, pain while eating)	a.
			a.
		Mouth is "dry" when eating a meal	b.
		Problem brushing teeth or dentures	c.
		NONE OF ABOVE	d.

SECTION N. SKIN CONDITION

1.	SKIN	Any troubling skin conditions or changes in skin condition (e.g., burns,
	PROBLEMS	bruises, rashes, itchiness, body lice, scabies)
		0. No	1. Yes
2.	ULCERS	Presence of an ulcer anywhere on the body. Ulcers include any area of
	(Pressure/	persistent skin redness (Stage 1); partial loss of skin layers (Stage 2);
	(Pressure/	deep craters in the skin (Stage 3); breaks in skin exposing muscle or
	Stasis)
	Stasis)	bone (Stage 4).[Code 0 if no ulcer,otherwise record the highest ulcer

		stage (Stage 1-4).]

		a. Pressure ulcer—any lesion caused by pressure, shear forces,
		resulting in damage of underlying tissues
		b. Stasis ulcer—open lesion caused by poor circulation in the lower

		extremities
3.	OTHERSKIN	(Check all that apply)
	PROBLEMS	Burns (second or third			Surgical wound
	PROBLEMS
	REQUIRING					d.
	REQUIRING	degree)
	TREATMENT	degree)
	TREATMENT			a.	Corns, calluses, structural prob-
				a.
		Open lesions other than
		Open lesions other than			lems, infections, fungi	e.
		ulcers, rashes, cuts (e.g.,			lems, infections, fungi


		cancer)		b.	NONE OF ABOVE	f.
				b.	NONE OF ABOVE	f.
		Skin tears or cuts		c.
				c.
4.	HISTORY OF	Client previously had (at any time) or has an ulcer anywhere on the
	RESOLVED	body
	RESOLVED
	PRESSURE	0. No	1. Yes
	ULCERS	0. No	1. Yes
	ULCERS
5.	WOUND/	(Check for formal care in LAST 7 DAYS)
	ULCER	Antibiotics, systemic or topical				a.
	CARE	Antibiotics, systemic or topical
	CARE
		Dressings				b.
						b.
		Surgical wound care				c.
						c.
		Other wound/ulcer care (e.g., pressure relieving device, nutrition, turn-
		ing, debridement)				d.
						d.
		NONE OF ABOVE				e.

SECTION O. ENVIRONMENTAL ASSESSMENT

1.	HOME	Lighting in evening (including inadequate or no lighting in living room,
	ENVIRON-	sleeping room, kitchen, toilet, corridors)		a.
	MENT	Flooring and carpeting (e.g., holes in floor, electric wires where client
	[Check any
	[Check any	walks, scatter rugs)
	of following	walks, scatter rugs)		b.
	of following			b.
	that make	Bathroom and toiletroom (e.g., non-operating toilet, leaking pipes, no
	home
	home	rails though needed, slippery bathtub, outside toilet)		c.
	environment	rails though needed, slippery bathtub, outside toilet)		c.
	hazardous or	Kitchen (e.g., dangerous stove, inoperative refrigerator, infestation by
	uninhabit-	rats or bugs)		d.
	able (if none	rats or bugs)		d.
	apply, check	Heating and cooling (e.g., too hot in summer, too cold in winter, wood
	NONE OF
	NONE OF	stove in a home with an asthmatic)		e.
	ABOVE; if	stove in a home with an asthmatic)


	temporarily	Personal safety (e.g., fear of violence, safety problem in going to
	in institution,	mailbox or visiting neighbors, heavy traffic in street)		f.
	base			f.
	base	Access to home (e.g., difficulty entering/leaving home)
	assessment	Access to home (e.g., difficulty entering/leaving home)		g.
	on home	Access to rooms in house (e.g., unable to climb stairs)		h.
	visit)]	Access to rooms in house (e.g., unable to climb stairs)		h.
		NONE OF ABOVE		i.
2.	LIVING	a. As compared to 90 DAYS AGO (or since last assessment), client
	ARRANGE-	now lives with other persons—e.g., moved in with another person,
	ARRANGE-	other moved in with client
	MENT	other moved in with client
	MENT	0. No	1. Yes
		0. No	1. Yes
		b. Client or primary caregiver feels that client would be better off in

		another living environment
		0. No 1. Client only	2. Caregiver only 3. Client and caregiver
		0. No 1. Client only	2. Caregiver only 3. Client and caregiver

SECTION P. SERVICE UTILIZATION (IN LAST 7 DAYS)

1.	FORMAL	Extent of care or care management in LAST 7 DAYS (or since last
	CARE	assessment if less than 7 days) involving	(A)		(B)	(C)
			(A)		(B)	(C)
	(Minutes		# of
	(Minutes		Days	Hours		Mins
	rounded to	a. Home health aides
	rounded to
	even 10
	even 10
	minutes)	b. Visiting nurses
		b. Visiting nurses
		c. Homemaking services
		c. Homemaking services
		d. Meals
		d. Meals
		e. Volunteer services


		f. Physical therapy
		g. Occupational therapy


		h. Speech therapy
		i. Day care or day hospital
		j. Social worker in home

MDS-HC Version 2.0 — July 21, 1999

MDS-HC - Pg 4

2. SPECIAL	Special treatments, therapies, and programs received or scheduled during the
TREAT-	LAST 7 DAYS (or since last assessment if less than 7 days) and adherence to
MENTS,	the required schedule. Includes services received in the home or on an
THERAPIES,	outpatient basis.
PROGRAMS	[Blank]. Not applicable	2. Scheduled, partial adherence

1.Scheduled, full adherence as prescribed 3. Scheduled, not received [If no treatments provided, check NONE OF ABOVE P2aa]

RESPIRATORYTREATMENTS		o. Occupational therapy
		p. Physical therapy
a. Oxygen		p. Physical therapy
b. Respirator for assistive		PROGRAMS
b. Respirator for assistive		PROGRAMS
	breathing	q. Day center
		q. Day center
c. All other respiratory treat-		r.	Day hospital
	ments	s. Hospice care
	ments
OTHERTREATMENTS
		t. Physician or clinic visit

d. Alcohol/drug treatment

		u. Respite care

	program
e. Blood transfusion(s)		SPECIAL PROCEDURES DONE
e. Blood transfusion(s)		IN HOME

f.	Chemotherapy
		v. Daily nurse monitoring (e.g.,

g. Dialysis

			EKG, urinary output)
h. IV infusion - central		w. Nurse monitoring less than
h. IV infusion - central

i .	IV infusion - peripheral		daily
j .	Medication by injection	x. Medical alert bracelet or elec-
j .	Medication by injection	x. Medical alert bracelet or elec-
k. Ostomy care			tronic security alert
			tronic security alert
		y.	Skin treatment
l .	Radiation


m. Tracheostomy care		z .	Special diet
		z .	Special diet

THERAPIES		aa. NONE OF ABOVE		aa.
		aa. NONE OF ABOVE

n. Exercise therapy

3.MANAGE- Management codes:

MENT OF	0. Not used
EQUIPMENT	1. Managed on own
(In Last 3	2. Managed on own if laid out or with verbal reminders
Days)	3. Partially performed by others
	4. Fully performed by others

	a. Oxygen	c. Catheter
	b. IV	d. Ostomy
	b. IV	d. Ostomy

4.VISITS IN Enter 0 if none, if more than 9, code "9" LAST90

DAYS	a. Number of times ADMITTED TO HOSPITAL with an overnight stay
OR
SINCELAST	b. Number of times VISITED EMERGENCY ROOM without an overnight
ASSESSMENT	stay

c. EMERGENT CARE—including unscheduled nursing, physician, or therapeutic visits to office or home

5.TREATMENT Any treatment goals that have been met in the LAST 90 DAYS (or since

GOALS last assessment if less than 90 days)

0. No

1. Yes

6.OVERALL Overall self sufficiency has changed significantly as compared to

CHANGE IN status of 90 DAYS AGO (or since last assessment if less than 90 days)
CARE NEEDS 0. No change 1. Improved—receives	2. Deteriorated—
fewer supports	receives more support

7.TRADE OFFS Because of limited funds, during the last month, client made trade-offs among purchasing any of the following: prescribed medications, suffi- cient home heat, necessary physician care, adequate food, home care

0. No

1. Yes

SECTION Q. MEDICATIONS

1.NUMBER OF Record the number of different medicines (prescriptions and over the

	MEDICA-	counter), including eye drops, taken regularly or on an occasional basis
		in the LAST 7 DAYS (or since last assessment)[If none, code "0", if
	TIONS
		more than 9, code "9"]

2.RECEIPT OF Psychotropic medications taken in the LAST 7 DAYS (or since last PSYCHO- assesssment) [Note—Review client's medications with the list that

TROPIC applies to the following categories]		0. No	1. Yes
MEDICATION
MEDICATION	a. Antipsychotic/neuroleptic	c. Antidepressant
	b. Anxiolytic	d. Hypnotic
	b. Anxiolytic	d. Hypnotic

3.MEDICAL Physician reviewed client's medications as a whole in LAST 180 DAYS OVERSIGHT (or since last assessment)

0.Discussed with at least one physician (or no medication taken)

1.No single physician reviewed all medications

4.COMPLI- Compliant all or most of time with medications prescribed by physician

ANCE/ (both during and between therapy visits) in LAST 7 DAYS
ADHERENCE
WITH	0. Always compliant
MEDICA-	1. Compliant 80% of time or more
TIONS	2. Compliant less than 80% of time, including failure to purchase
	prescribed medications

3.NO MEDICATIONS PRESCRIBED

=When box blank, must enter number or letter a. = When letter in box, check if condition applies

MDS-HC Version 2.0 — July 21, 1999

5.LIST OF ALL List prescribed and nonprescribed medications taken in LAST 7 DAYS (or since MEDICATIONS last assessment)

a.Name and Dose—Record the name of the medication and dose ordered.

b.Form: Code the route of Administration using the following list:

1.		By mouth (PO)		5. Subcutaneous (SQ)			9. Enteral tube
2.		Sub lingual (SL)		6. Rectal (R)			10. Other
3.		Intramuscular (IM)		7.	Topical
4.		Intravenous (IV)		8. Inhalation
	c. Number taken—Record the amount of medication administered each time
	the medication is given
	d. Freq: Code the number of times per day, week, or month the medication is
	administered using the following list:
	PRN. As necessary				5D.	Five times daily
	QH.		Every hour		QOD. Every other day
	Q2H.		Every two hours		QW.	Once each wk
	Q3H.		Every three hours		2W.	Two times every week
	Q4H.		Every four hours		3W.	Three times every week
	Q6H.		Every six hours		4W.	Four times each week
	Q8H.		Every eight hours		5W.	Five times each week
	QD.		Once daily		6W.	Six times each week
	BID.		Two times daily		1M.	Once every month
			(includes every 12 hrs)		2M.	Twice every month
	TID.		Three times daily		C.	Continuous
	QID.		Four times daily		O.	Other

a. Name and Dose						b. Form	c. Number d. Freq.
							Taken

a._________________________________________________________________________

b._________________________________________________________________________

c._________________________________________________________________________

d._________________________________________________________________________

e._________________________________________________________________________

f._________________________________________________________________________

g._________________________________________________________________________

h._________________________________________________________________________

i._________________________________________________________________________

j._________________________________________________________________________

k._________________________________________________________________________

SECTION R. ASSESSMENT INFORMATION

1.SIGNATURES OF PERSONS COMPLETINGTHE ASSESSMENT:

a.Signature of Assessment Coordinator

b.Title of Assessment Coordinator

c.Date Assessment Coordinator signed as complete

Month	Day	Year

d. Other Signatures	Title	Sections	Date

e.			Date

f.			Date

g.			Date

h.			Date

i .			Date

* Country specific
MDS-HC Version 2.0 — July 21, 1999	MDS-HC - Pg 5

Request for Services

Type of clinical eligibility determination all requested services.

Service(s) requested

Pre-admission nursing facility (NF)

Home and community

based services (HCBS) waiver

Adult day health (ADH)

Adult foster care (AFC)

Program for All-inclusive Care

for the Elderly (PACE)

Group adult foster care (GAFC)

Other

Date

Nursing facility use only

Conversion

Continued stay

Short term review

Transfer NF to NF

Retrospective

Member information

Member/applicant

Last name

First name

Telephone

Address

City

Zip

Check one
	MassHealth			MassHealth	GAFC/


	member			application pending	Assisted living residence

		MassHealth ID number	Date application iled		Date SSI-G application iled
Next of kin/Responsible party

Last name

First name

Telephone

Address

City

Zip

Physician

Last name

First name

Telephone

Address

City

Zip

Screening for mental illness, mental retardation, and developmental disability

Does the member/applicant have any of the following diagnoses/conditions? Check all that apply.

Mental illness

Specify:

Mental retardation without related condition

Developmental disability with related condition that occurred prior to age 22.

Check all that apply.

Autism

Deafness/severe hearing impairment

Multiple sclerosis

Severe learning disability

Blindness/severe visual impairment

Epilepsy/seizure disorder

Muscular dystrophy

Spina biida

Cerebral palsy

Head/brain injury

Orthopedic impairment

Spinal cord injury

Major mental illness

Cystic ibrosis

Speech/language impairment

RFS-1 (Rev. 10/02)

OVER

Name of member/applicant

Community services recommended

Check all that apply.

Skilled nursing

HCBS waiver

Rest home

Homemaker

Physical therapy

Elderly housing

Personal emergency response system

Meals

Occupational therapy

Adult foster care

Adult day health

Transportation

Speech therapy

Group adult foster care

PACE

Chore service

Mental health services

Home health aide

Grocery shopping/delivery

Assisted living

Social worker services

Congregate housing

Personal care/homemaker

Other:

Additional information

1. Is the home or apartment available for the member or applicant?

yes

Is there a caregiver to assist the member in the community?

yes

Has the member or applicant experienced unexplained weight gain in the last 30 days?

yes

Does the member or applicant receive personal care/homemaker services?

If yes:

days per week

hours per week

yes

Has the member or applicant experienced a signiicant change in condition in the last 30 days?

If yes:

improvement

deterioration

Indicate the changes below.

For nursing facility requests only

1.Does the nursing facility member/applicant express an interest to remain in or return to the community?

2.Is the nursing facility stay expected to be short-term (up to 90 days)?

3.Is the nursing facility stay expected to be long-term (more than 90 days)?

Referral source Name of registered nurse completing this form

Signature			Print name

yes	no
yes	no
yes	no

Title

Name of organization

Telephone

Address

City

Zip

For community providers:

For nursing facility providers:

Attach the MDS-HC and Physician’s Summary form according to provider’s regulations/guidelines.

Attach the most recent comprehensive MDS, current quarterly MDS, and current physician orders.

Question	Answer
Form Name	Mds Hc Form
Form Length	9 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	2 min 15 sec
Other names	mds hc manual, mds hc edit, mds hc form, mds hc rfs template

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