Free ForwardHealth Personal Care Screening Tool (PCST), F11133 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Health Care Access and Accountability F-11133 (10/08)

STATE OF WISCONSIN HFS 107.13(2), Wis. Admin. Code

FORWARDHEALTH

PERSONAL CARE SCREENING TOOL (PCST)
Instructions: Print or type clearly. Refer to the Personal Care Screening Tool (PCST) Completion Instructions, F-11133A, for information on completing this form. SCREENING INFORMATION 1a. Name -- Screening Agency 1b. Telephone Number 3a. Name -- Screener 3b. Qualifications -- Screener APPLICANT INFORMATION 4. Name -- Applicant (Last, First, Middle Initial) Registered Nurse Certified Adult LTC Functional Screener Other 2. Screen Completion Date

5.

Gender -- Applicant Male Female

6. Social Security Number -- Applicant

7.

Address -- Applicant (Street, City, State, ZIP Code)

8. Date of Birth -- Applicant

9. Telephone Number -- Applicant (Optional) 10. County / Tribe of Residence -- Applicant 12. Directions (Optional) 11. County / Tribe of Responsibility -- Applicant

13. Medical Insurance Check all that apply: Medicare (Specify Identification Number) Part A Part B Effective Date (If Known) Effective Date (If Known) . . .

Medicare Managed Care. ForwardHealth (Specify Member Number) Private Insurance (Includes Employer-Sponsored [Job Benefit] Insurance). Private Long Term Care Number Railroad Retirement (Specify Number) Other Insurance. No medical insurance at this time. Continued . . .

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APPLICANT INFORMATION (Continued) 14. Race (Optional) Check all boxes that apply. Black or African American White Other 15. Ethnicity (Optional) Spanish / Hispanic / Latino 16. Interpreter Services (Optional) Is an interpreter required? If so, in what language? 01 American Sign Language 02 Spanish 03 Vietnamese 17. Responsible Party Contact Type (Optional) Adult Child Ex-spouse Guardian of Person Parent / Stepparent Power of Attorney Sibling Spouse Other Informal Caregiver / Support 04 Hmong 05 Russian 06 Other 07 A Native American Language Yes No Asian or Pacific Islander American Indian or Alaskan Native

18. Name -- Responsible Party (Last, First, Middle Initial) (Optional)

19. Telephone Number(s) -- Responsible Party (Optional) Home: Work: Cell: Best time to call: 20. Address -- Responsible Party (Street, City, State, ZIP Code) (Optional)

21. Comments (Optional)

22. Scheduled Activities Outside the Residence (Include a schedule of activities in the applicant's medical file.) Does the applicant regularly attend scheduled activities outside the residence? If yes, how many days per week do regularly scheduled activities occur? 23. Diagnosis Codes List up to three International Classification of Diseases, Ninth Revision, Clinical Modification (ICD-9-CM) codes that most directly relate to the applicant's need for personal care. At least one ICD-9-CM code is required. ICD-9-CM Code 1 Yes No

ICD-9-CM Code 2

ICD-9-CM Code 3 Continued

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APPLICANT INFORMATION (Continued) 24. Living Situation (Indicate where the applicant currently lives.) Own Home or Apartment Alone includes person living alone who receives in-home services. With Spouse / Partner / Family. With Nonrelative / Roommates includes dormitory, convent, or other communal setting. With Live-in Paid Caregiver(s) includes service in exchange for room and board. Someone Else's Home or Apartment Family. Nonrelative. 1-2 Bed Adult Family Home (Certified) or Other. Paid Caregiver's Home. Home / Apartment for Which Lease is Held by Support Services Provider. Apartment with Services Residential Care Apartment Complex. Independent Apartment Community-Based Residential Facility. Group Residential Care Setting Licensed Adult Family Home (three to four-bed home). Community-Based Residential Facility with 1-20 Beds. Community-Based Residential Facility with More than 20 Beds. Children's Group Home. Health Care Facility / Institution Nursing Home includes rehabilitation facility. Intermediate Care Facility for Mental Retardation. Developmental Disability Center / State Institution for Developmental Disabilities. Mental Health Institute / State Psychiatric Institution. Other Institution for Mental Disease. Child Caring Institution. Hospice No Permanent Residence (e.g., a homeless shelter). Other Specify (e.g., jail): ACTIVITIES OF DAILY LIVING 25. Bathing "Bathing" means the ability to wash the entire body (excludes grooming, washing hands and face only, and bathing related to incontinence care) in the shower, tub, or with a sponge or bed bath for the purpose of maintaining adequate hygiene. This includes the ability to get in and out of the tub or shower, turning faucets on and off, regulating water temperature, wetting, soaping, and rinsing skin, shampooing hair, drying body, applying lotion to skin, and routine catheter care. Bathing includes all transfers related to bathing. Select the response, A-F, that best describes the level of function the applicant possesses when bathing. A. B. C. D. E. F. Applicant is able to bathe him- or herself in the shower or tub, with or without an assistive device. Applicant is able to bathe him- or herself in the shower or tub, but requires the presence of another person intermittently for supervision or cueing. Applicant is able to bathe him- or herself in shower or tub, but requires the presence of another person throughout the task for constant supervision to provide immediate intervention to ensure completion of the task. Applicant is able to bathe in shower, tub, or bed with partial physical assistance from another person. Applicant is unable to effectively participate in bathing and is totally bathed by another person. Applicant's ability is age appropriate for a child age five or younger.

Indicate how many days per week personal care worker assistance is needed with bathing: ____________________________ Comments

Continued

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ACTIVITIES OF DAILY LIVING (Continued) 26. Dressing "Dressing" means the ability to dress and undress (with or without an assistive device) as necessary. This includes fine motor coordination for buttons and zippers. Difficulties with a zipper or buttons at the back of a dress or blouse do not constitute a functional deficit. Upper Body Select the response, A-F, that best describes the level of function the applicant possesses when dressing his or her upper body. A. B. C. D. E. F. Applicant is able to dress the upper body without assistance or is able to dress him- or herself if clothing is laid out or handed to him or her. Applicant is able to dress the upper body by him- or herself, but requires the presence of another person intermittently for supervision or cueing. Applicant is able to dress the upper body by him- or herself, but requires the presence of another person throughout the task for constant supervision to provide immediate intervention to ensure completion of the task. Applicant needs partial physical assistance from another person to dress the upper body. Applicant depends entirely upon another person to dress the upper body. Applicant's ability is age appropriate for a child age five or younger.

Indicate when PCW assistance with dressing the upper body is needed: AM PM Both

Indicate how many days per week PCW assistance is needed with dressing the upper body: __________________________ Lower Body Select the response, A-F, that best describes the level of function the applicant possesses when dressing his or her lower body. A. Applicant is able to dress the lower body without assistance or is able to dress him- or herself if clothing is laid out or handed to him or her. B. Applicant is able to dress the lower body by him- or herself, but requires the presence of another person intermittently for supervision or cueing. C. Applicant is able to dress lower body by him- or herself, but requires the presence of another person throughout the task for constant supervision to provide immediate intervention to ensure completion of the task. D. Applicant needs partial physical assistance from another person to dress the lower body. E. Applicant depends entirely upon another person to dress the lower body. F. Applicant's ability is age appropriate for a child age five or younger.

Indicate when PCW assistance with dressing the lower body is needed: AM PM Both

Indicate how many days per week PCW assistance is needed with dressing the lower body: __________________________

Prosthetics, Braces, Splints and/or Anti-Embolism Hose Indicate whether or not PCW assistance is needed with placement and/or removal of a prosthetic, brace, splint, or antiembolism hose: Yes No

Indicate how many days per week PCW assistance is needed with placement and/or removal of a prosthetic, brace, splint, or anti-embolism hose: __________________________ Comments

___________________________________________________________________________________________________________

Continued

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ACTIVITIES OF DAILY LIVING (Continued) 27. Grooming "Grooming" means the ability to tend to personal hygiene needs (i.e., washing face and hands, combing or brushing hair, shaving, nail care, applying deodorant, and oral or denture care). Select the response, A-G, that best describes the level of function the applicant possesses when grooming. A. B. C. D. E. F. G. Applicant is able to groom him- or herself, with or without the use of assistive devices or adapted methods. Applicant is able to groom him- or herself, but requires the presence of another person intermittently for supervision or cueing. Applicant is able to groom him- or herself, but requires the presence of another person throughout the task for constant supervision to provide immediate intervention to ensure completion of the task. Applicant needs physical assistance to set up grooming supplies, but can groom him or her self. Applicant needs partial physical assistance to groom him- or herself. Applicant depends entirely upon another person for grooming. Applicant's ability is age appropriate for a child age five or younger.

Indicate when PCW assistance with grooming is needed: AM PM Both

Indicate how many days per week PCW assistance is needed with grooming: ________ Comments

28. Eating "Eating" means the ability to eat and drink using routine or adaptive utensils. This also includes the ability to cut, chew, and swallow food. Select the response, 0 or A-H, that best describes the level of function the applicant possesses when eating. If member is fed orally and via tube feedings, select the most appropriate response A through F for the oral feedings. Complete the daily tube feedings under Element 34 as appropriate. 0. A. B. C. D. E. F. G. H. Applicant is fed exclusively via tube feedings or intravenously. Applicant is able to feed him- or herself, with or without use of assistive device or adapted methods. Applicant is able to feed him- or herself, but requires the presence of another person intermittently for supervision or cueing. Applicant needs physical assistance at meal time to cut meat, arrange food, butter bread, etc. Applicant is able to feed him- or herself, but requires the presence of another person throughout the task for constant supervision to provide immediate intervention to ensure completion of the task. Applicant has recent history of choking or potential for choking, based on documentation. Applicant needs partial physical feeding from another person. Applicant needs total feeding from another person. Applicant's ability is age appropriate for a child age three or younger.

Indicate the meals for which PCW assistance is needed: Breakfast Lunch Dinner None

Indicate how many days per week PCW assistance is needed for each meal: Breakfast _____ Comments Lunch _____ Dinner _____ Not Required

Continued

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ACTIVITIES OF DAILY LIVING (Continued) 29. Mobility in the Home "Mobility in the home" means the ability to move between locations (i.e., ambulate) in the applicant's living environment, including the kitchen, living room, bathroom, and sleeping area. This excludes basements, attics, yards, and any equipment used outside the home. Select the response, 0 or A-E, that best describes the level of function the applicant possesses when moving between locations in the home with or without an assistive device. Assistive devices include, but are not limited to, canes, crutches, walkers, scooters, and wheelchairs. 0. A. B. C. D. E. Applicant remains bedfast. Applicant is able to ambulate by him- or herself. Applicant is able to ambulate by him- or herself, but requires the presence of another person intermittently for supervision or cueing. Applicant is able to ambulate by him- or herself, but requires the constant presence of PCW to provide immediate physical intervention. Applicant needs physical help from another person. Applicant's ability is age appropriate for a child 18 months or younger.

Indicate how many days per week PCW assistance is needed with mobility in the home: ____ Comments

30. Toileting Toileting includes transferring on and off the toilet, cleansing of self, changing of personal hygiene product, emptying an ostomy or catheter bag, and adjusting clothes. Toileting includes all transfers related to toileting. Select the responses, A-G, that best describe the level of function the applicant possesses when toileting. Select all responses that apply and, as requested, include the frequency per day. A. Applicant is able to toilet him- or herself or provide his or her own incontinence care, with or without an assistive device. B. Applicant is able to toilet him- or herself or provide his or her own incontinence care, with or without an assistive device, but requires the presence of another person intermittently for supervision or cueing. C. Applicant is able to toilet him- or herself or provide his or her own incontinence care, but requires the presence of another person throughout the task for constant supervision to provide immediate intervention to ensure completion of the task. _____Estimated frequency per day that PCW assistance is needed with toileting. D. Applicant needs physical help from another person to use the toilet and/or change a personal hygiene product. _____Estimated frequency per day that PCW assistance is needed with toileting. E. Applicant needs physical help from another person for incontinence care. (Does not include stress incontinence.) F. _____Estimated frequency per day that PCW assistance is needed with incontinence care. Applicant needs physical help from another person to empty an ostomy or catheter bag.

_____Estimated frequency per day that PCW assistance is needed with ostomy or catheter care. G. Applicant's ability is age appropriate for a child age four or younger. Indicate how many days per week PCW assistance is needed for toileting: ____ Comments

Continued

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ACTIVITIES OF DAILY LIVING (Continued) 31. Transferring "Transferring" means the physical ability to move between surfaces (e.g., from bed/chair to wheelchair or walker), the ability to get in and out of bed or usual sleeping place, and the ability to use assistive devices for transfers. Transferring excludes transfers related to bathing and toileting.

Select the response, A-G, that best describes the level of function the applicant possesses when transferring. A. B. C. D. E. F. G. Applicant is able to transfer him- or herself, with or without an assistive device. Applicant is able to transfer him- or herself, with or without an assistive device, but requires the presence of another person intermittently for supervision or cueing. Applicant is able to transfer him- or herself, with or without an assistive device, but requires the presence of another person throughout the task for constant supervision to provide immediate intervention to ensure completion of the task. Applicant needs the physical help of another person, but is able to participate (e.g., applicant can stand and bear weight). Applicant needs constant physical help from another person and is unable to participate (e.g., applicant is unable to stand and pivot or is unable to bear weight). Applicant needs help from another person with the use of a mechanical lift (e.g., Hoyer) when transferring. Applicant's ability is age appropriate for a child age three or younger.

Indicate how many days per week PCW assistance is needed with transferring: ____ Comments

MEDICALLY ORIENTED TASKS 32. (Part I) Medication Assistance Select the appropriate response. 0. A. B. C. D. Not applicable. Independent with medications, with or without the use of a device. Needs reminders. Needs the physical help of another person, not a PCW. Needs the physical help of a PCW. Frequency per day: _____ Indicate how many days per week PCW assistance is needed with medication assistance: _____ Comments

33. (Part II) Tasks to be Performed by a PCW Select the tasks to be completed by a PCW. Indicate the frequency per day and days per week each task will be performed. Glucometer Readings (Allowed when medical condition supports the need for ongoing, frequent monitoring and the physician has established parameters.) PCW Frequency Per Day __________ PCW Days Per Week __________

Continued

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MEDICALLY ORIENTED TASKS (Continued) 33. (Part II) Tasks to be Performed by a PCW (Continued) Skin Care (Application of prescription ointments.) Name of prescription medication ________________________________________________________________________ Frequency prescribed ________________________________________________________________________________ PCW Frequency Per Day __________ Catheter Site Care (Only for suprapubic catheters.) PCW Frequency Per Day __________ Gastrointestinal Tube Site Care PCW Frequency Per Day __________ Complex Positioning PCW Frequency Per Day __________ Comments PCW Days Per Week __________ PCW Days Per Week __________ PCW Days Per Week __________ PCW Days Per Week __________

34.

(Part III) Tasks to Be Performed by a PCW -- ForwardHealth Review and Manual Approval May Be Required Select the tasks to be completed by a PCW as delegated by the registered nurse. Indicate the frequency per day and days per week each task will be performed. For tasks indicated in this element, manual review of the prior authorization (PA) request will be required only when the total amount of time computed by the PCST is insufficient for a PCW also to provide the delegated medical tasks identified in this element and additional time is being requested for those delegated medical tasks. Include the Personal Care Addendum, F-11136, the plan of care, and other documentation as directed when submitting the PA request. Daily Tube Feedings (Nasogastric or Gastrostomy) Continuous Feeding Intermittent (Bolus) Feeding PCW Frequency Per Day __________ PCW Frequency Per Day __________ PCW Days Per Week __________ PCW Days Per Week __________

Respiratory Assistance (Check all that apply.) Tracheostomy Care Suctioning Chest Physiotherapy Nebulizer Bowel Program (Check all that apply.) Suppository Enema Digital Stimulation PCW Frequency Per Day __________ PCW Frequency Per Day __________ PCW Frequency Per Day __________ PCW Days Per Week __________ PCW Days Per Week __________ PCW Days Per Week __________ PCW Frequency Per Day __________ PCW Frequency Per Day __________ PCW Frequency Per Day __________ PCW Frequency Per Day __________ PCW Days Per Week __________ PCW Days Per Week __________ PCW Days Per Week __________ PCW Days Per Week __________

Continued

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MEDICALLY ORIENTED TASKS (Continued) 34. (Part III) Tasks to Be Performed by a PCW -- ForwardHealth Review and Manual Approval May Be Required (Continued) Other Program (Check all that apply.) Wound or Decubiti Care (Excludes Basic Skin Care) PCW Frequency Per Day __________

PCW Days Per Week __________

Therapy Program (Therapy plan prescribed by a physical therapist, occupational therapist, or speech-language pathologist within the last 12 month period.) PCW Frequency Per Day __________ PCW Days Per Week __________

Range of Motion (Ordered by a physician, but not part of a prescribed therapy program.) PCW Frequency Per Day __________ PCW Days Per Week __________

Vital Signs (Allowed when medical condition supports the need for ongoing, frequent monitoring, and the physician has established parameters.) PCW Frequency Per Day__________ PCW Days Per Week __________

Other (Specify all tasks that apply.) _____________________________ _____________________________ Comments PCW Frequency Per Day __________ PCW Frequency Per Day __________ PCW Days Per Week __________ PCW Days Per Week __________

INCIDENTAL SERVICES 35. Will services incidental to the ADL and MOTs, be performed by the PCW? Incidental services include changing the applicant's bed, laundering the applicant's bed linens and personal clothing, care of eyeglasses (also contact lenses) and hearing aides, light cleaning in essential areas of the home used during personal care services, purchasing food, preparing the applicant's meals, and cleaning the applicant's dishes. (Refer to the Personal Care page of the Online Handbook section of the Provider area of the ForwardHealth Portal.) Yes No

BEHAVIORS AND MEDICAL CONDITIONS 36. Behaviors Does the applicant exhibit more often than once per week behavior that makes ADL and MOTs more time consuming for the PCW to complete? Yes No

If "Yes," list the behavior(s) and describe how the behavior(s) makes the ADL and MOTs more time consuming for the PCW to complete:

Continued

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BEHAVIORS AND MEDICAL CONDITIONS (Continued) 37. Medical Conditions Does the applicant have any medical conditions that make ADL and MOTs more time consuming for a PCW to complete? Yes No

If "Yes," list the medical condition(s) (e.g., severe contractures, hemiplegia, severe shortness of breath) and describe how the condition(s) makes the ADL and MOTs more time consuming for the PCW to complete.

38. Seizures Does the applicant have a diagnosis of seizures? If "Yes," complete the following. Date of last seizure was: A. B. C. 0 - 90 days ago. 91 - 180 days ago. More than 180 days ago. Yes No

Specific Seizure Type ____________________________________________________________________________________ Frequency of Seizures ___________________________________________________________________________________ Date of Last Seizure _____________________________________________________________________________________ Does the PCW provide interventions? If "Yes," list interventions. Yes No

PRO RE NATA, INCLUDING MEDICAL APPOINTMENTS 39. Pro Re Nata (PRN), Including Time to Accompany Applicant to Medical Appointments Does the applicant need PRN for a PCW to accompany him or her to medical appointments and/or for assistance during short duration episodes of acute need for PC services? Yes No

BILLING PROVIDER INFORMATION 40. Name -- Billing Provider Check if case sharing. Names -- Other Agencies Sharing the Case: 41. Billing Provider Number

42. Address -- Billing Provider (Street, City, State, ZIP+4 Code) SIGNATURE As the authorized screener completing this PCST, I confirm the following: All information entered on this form is complete and accurate, and I am familiar with all of the information entered on this form. 43. SIGNATURE -- Authorized Screener 44. Date Signed -- Authorized Screener