DEPARTMENT OF HEALTH SERVICES Division of Long Term Care F-21167 (08/2008)
STATE OF WISCONSIN
CLTS WAIVERS LEVEL OF CARE CHANGE
PROCESS WHEN A FUNCTIONAL SCREEN CHANGES THE CHILD'S TARGET GROUP
Completion of this form is voluntary; however, it is necessary to allow a waiver agency to continue to verify waiver eligibility criteria as it relates to Level of Care determination for a child participating in the CLTS Waivers. Failure to complete this form will result in the county being out of compliance in meeting the CLTS Waiver eligibility requirements and state county contract requirements.
As explained in the Children's Functional Screen Training Manual, a screener is a knowledgeable professional who has met the child and reviewed valuable information about the child. The screener is responsible for confirming that the results of the CLTS Functional Screen meet with their professional judgment. If the outcome is not what the screener expected, the screener should contact State clinical staff to request a screen review. When the verified result of a Functional Screen changes the Target Group in which a child is participating, the following steps must be taken: 1. If the screen was calculated as part of the annual recertification process, use the CLTS Recertification Checklist (form F-21078) to report the change in Target Group and to have HSRS updated. If the screen calculation was not part of the annual recertification, complete the following:
2.
Name Child (Last, First, MI) Child's Current HSRS Slot Number Date Updated Functional Screen Completed Current Target Group
Responsible County
DD SED PD New Target Group Determined None* DD SED *If none, proceed with the Waiver Termination process.
PD
Check the box to indicate that you have closed the child's HSRS slot effective (date may be up to the end of the calendar month in which the Functional Screen was completed). A new HSRS slot will be assigned on that same date and you will be notified of the new slot number. Your county or agency must have a contract with DHS for the new Target Group. Name Individual completing this form Email address Date completed Telephone Number
Submit completed form to: Connie Vehlow DHS/DLTC/Children's Services Section PO Box 7851 Madison WI 53707-7851