Free ForwardHealth Personal Care Screening Tool (PCST), F11133A - Wisconsin

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

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

FORWARDHEALTH

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS
ForwardHealth requires certain information to enable the programs to authorize and pay for medical services provided to eligible members. Members of ForwardHealth are required to give providers full, correct, and truthful information for the submission of correct and complete claims for reimbursement. This information should include, but is not limited to, information concerning enrollment status, accurate name, address, and member identification number (HFS 104.02[4], Wis. Admin. Code). Under s. 49.45(4), Wis. Stats., personally identifiable information about program applicants and members is confidential and is used for purposes directly related to ForwardHealth administration such as determining eligibility of the applicant, processing prior authorization (PA) requests, or processing provider claims for reimbursement. Failure to supply the information requested by the form may result in denial of PA or payment for the services. ForwardHealth requires persons who are requesting authorization for personal care services to complete and submit the Personal Care Screening Tool (PCST) as instructed. The PCST may be completed using a Web-based format that may be accessed at https://www.dwd.state.wi.us/desltc/, or providers may print and complete the paper format (F-11133) from the Forms page of the ForwardHealth Portal. The use of this form is mandatory when requesting PA for personal care (PC) services. If more space is needed than is provided in the comment section, include the additional information on the Personal Care Addendum, F-11136 (09/06). Provide enough information for ForwardHealth to make a determination about the request. Providers are required to submit either the PCST Summary Sheet, F-11137, or a completed paper version of the PCST and other documents as directed by ForwardHealth personal care policy when requesting PA for personal care services. Providers may submit PA documents by fax to ForwardHealth at (608) 221-8616 or by mail to the following address: ForwardHealth Prior Authorization Ste 88 6406 Bridge Rd Madison WI 53784-0088 Providers should make duplicate copies of all paper documents mailed to ForwardHealth. The provision of services that are greater in number or significantly different from those authorized may result in nonpayment of the billing claim(s). GENERAL INSTRUCTIONS The PCST is a tool that collects information on an individual's ability to accomplish activities of daily living (ADL), instrumental ADL (IADL), medically oriented tasks (MOT), and the member's needs for personal care worker (PCW) assistance with these activities. The screener may not include services provided to the applicant by informal, unpaid supports such as family or friends. Whether the provider is using the Web-based or paper PCST, the PCST must be completed based on a face-to-face evaluation of the individual in his or her home. Only an authorized Adult Long Term Care Functional Screen (LTC FS) screener or agency-designated registered nurse (RN) may complete the PCST. Clerical entry of information into the PCST may be done by users to whom the Division of Disability and Elder Services has granted access; however, the information should be based on the authorized LTC FS screener or agency-designated RN's face-to-face visit. Providers should take into account the time it takes an individual to complete a task. If it takes the individual a very long time to complete the task, consideration should be given to the need for PCW assistance to complete the task safely. However, if the extended time it takes an individual to complete a task does not interfere with his or her ability to complete that task safely, the provider should indicate that the individual is able to complete the task "independently." When completing the elements in the ADL section, only one response should be selected when indicating the level of help needed (Elements 25-31). The only exception is Element 30 (Toileting); providers should indicate all responses that apply. When completing an element in this section, providers should first determine if assistance is needed with a task on at least a weekly basis. If assistance is needed at least weekly, the provider should select the most appropriate level of help from the choices listed in the element for that ADL. If the level of help varies, select the level of help that represents the level most often needed. When completing the frequencies in Elements 25-34 and 38, the screener should enter frequencies that represent only the PCW services that the provider will provide. When one or more agencies will be sharing the case, the screener should enter frequencies that represent only the PCW services the case-sharing providers will provide.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 2 of 13

Age-Appropriate Responses for Activities of Daily Living Typically, children age five and younger require the assistance of an adult to complete many ADL. For those tasks that have an age range associated with them (i.e., bathing, dressing, grooming, eating, mobility, toileting, and transfers) and the child's age falls within the stated range, the "age appropriate" response should be selected. If it is determined that the task requires more assistance than an adult would typically provide to a child of that age, and the weekly number of units allocated do not meet the total needs, submit the following to ForwardHealth for nurse consultant review: · · An explanation in the comment section for the reason that more assistance is needed with that ADL. The Personal Care Addendum, F-11136 (including the plan of care [POC]).

WEB-BASED PERSONAL CARE SCREENING TOOL DISCLAIMER (WEB-BASED VERSION ONLY) Providers who wish to use the Web-based PCST are required to read the following Web-Based PCST Disclaimer: The Web-based Personal Care Screening Tool (PCST) contains language that is abbreviated from the paper PCST. Instructions for the paper PCST provide guidance to the authorized screener responding to questions in the paper and the Web-based PCST formats. The authorized screener should refer to the paper PCST and to the PCST instructions for complete details. The responses selected when completing the Web-based PCST should not be different from those that would be selected if the authorized screener were to complete the paper PCST. By completing the Web-based PCST, you are acknowledging that you have read the above, understand the limitations of the Webbased PCST, and agree to the use of the PCST subject to the above terms. SCREENING INFORMATION Element 1a -- Name -- Screening Agency Enter the name of the agency that will complete the PCST for the applicant. Element 1b -- Telephone Number Enter the telephone number when submitting the paper PCST. Element 2 -- Screen Completion Date Enter the date of the face-to-face evaluation of the applicant in MM/DD/CCYY format. Element 3a -- Name -- Screener Enter the name of the authorized adult LTC FS screener or agency-designated RN completing the PCST for the applicant. Element 3b -- Qualifications -- Screener Check the box identifying the screener's qualifications. APPLICANT INFORMATION Element 4 -- Name -- Applicant Enter the last name, first name, and middle initial of the applicant being screened for personal care services. Element 5 -- Gender -- Applicant Check the appropriate box to indicate the applicant's gender. Element 6 -- Social Security Number -- Applicant Enter the applicant's Social Security number. Element 7 -- Address -- Applicant Enter the applicant's address, including street, city, state, and ZIP code. Element 8 -- Date of Birth -- Applicant Enter the applicant's date of birth in MM/DD/CCYY format. Element 9 -- Telephone Number -- Applicant (Optional) Enter the applicant's telephone number, including area code. Element 10 -- County / Tribe of Residence -- Applicant Enter the name of the county or tribe's borders in which the applicant resides. Element 11 -- County / Tribe of Responsibility -- Applicant Enter the name of the county or tribe that is responsible for the applicant's benefits.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 3 of 13

Element 12 -- Directions (Optional) Enter driving directions to the applicant's home. Element 13 -- Medical Insurance Check all appropriate boxes to indicate the type(s) of insurance the applicant holds. The applicant's ForwardHealth member identification number is required when submitting a request for prior authorization. Element 14 -- Race (Optional) Check all appropriate boxes to indicate the applicant's race. Element 15 -- Ethnicity (Optional) Check the box if the applicant's ethnicity is Spanish, Hispanic, or Latino. Element 16 -- Interpreter Services (Optional) Check the appropriate box to indicate if the applicant requires the services of an interpreter. If "Yes" is checked, indicate the language for which the applicant requires interpretation services. Element 17 -- Responsible Party Contact Type (Optional) Check the box that describes the responsible party's relationship to the applicant. The responsible party is a contact person other than the applicant. Element 18 -- Name -- Responsible Party (Optional) Enter the responsible party's last name, first name, and middle initial. Element 19 -- Telephone Numbers -- Responsible Party (Optional) Enter the responsible party's telephone number(s) and best time(s) to call. Element 20 -- Address -- Responsible Party (Optional) Enter the responsible party's address including street, city, state, and ZIP+4 code. Element 21 -- Comments (Optional) Enter any comments about the responsible party. Element 22 -- Scheduled Activities Outside Residence Check the appropriate box to indicate if the applicant regularly attends scheduled activities outside of his or her residence. If "Yes" is checked, enter the number of days per week that regularly scheduled activities occur. The applicant's complete schedule of regularly attended activities must be included in the applicant's medical file. Element 23 -- Diagnosis Codes Enter 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. Element 24 -- Living Situation Check the box that best describes the applicant's living situation. ACTIVITIES OF DAILY LIVING Element 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. Examples of transfers include the following: · Applicant needs to be physically transferred to a shower chair.

Select the response, A-F, that best describes the level of function the applicant possesses when bathing. For children age five or younger, select response "F." If the child requires more assistance than an adult would typically provide to a child of that age, explain in the comment section why more assistance is needed. Indicate how many days per week PCW assistance is needed with bathing. Do not count days in which unpaid caregivers will be providing the care, or when care is provided outside of the home.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 4 of 13

Examples A. Applicant is able to bathe him- or herself in the shower or tub with or without an assistive device. · · B. Applicant requires use of a shower chair but is able to complete bathing safely without any assistance from another person. Applicant is able to bathe him- or herself without any assistance from another person.

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 needs intermittent cueing to shower, gather towel, wash, etc., and to turn on water so scalding does not occur. He or she is then safe alone in the shower so the person cueing can leave. · Applicant needs occasional reminders to stay on task. · Applicant requires supervision intermittently to ensure personal safety. Applicant is able to bathe him- or herself in the 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 requires continuous cues to complete bath but can bathe him- or herself. The caregiver is required to be continually present. If continuous cues were not provided, the caregiver would be required to physically assist with the bath. · Applicant requires continual presence of another person and cannot be left alone as the applicant is confused and attempts to climb out of the bathtub. If the caregiver was not continually present, the person would require physical assistance to complete the bath. Applicant is able to bathe in shower, tub, or bed with partial physical assistance from another person. · Applicant is able to complete upper body bathing, but needs physical assistance with lower body bathing and application of lotion. Applicant needs physical assistance in and out of the tub, but can bathe self. · · Applicant requires a bed bath. Applicant is able to bathe upper body but needs physical assistance from another person to complete bathing of the lower body and provide routine care of an indwelling catheter. Applicant is unable to effectively participate in bathing and is totally bathed by another person. · Applicant is unable to assist with any aspect of bathing. · Applicant is able to hold washcloth but is unable to effectively participate in washing body. Applicant's ability is age appropriate for a child age five or younger. · Child is five years old or younger.

C.

D.

E.

F.

Element 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. For both the Upper Body and Lower Body categories, complete the following: · Select the response, A-F, that best describes the level of function the applicant possesses when dressing. For children age five or younger, select response "F." If the child requires more assistance than an adult would typically provide to a child of that age, explain in the comment section why more assistance is needed. Indicate the time of day when PCW assistance with dressing is needed. Indicate how many days per week PCW assistance is needed with dressing. Do not count days in which unpaid caregivers will be providing the care, or when care is provided outside of the home.

· ·

Examples Upper Body A. Applicant is able to dress upper body without assistance or is able to dress him- or herself if clothing is laid out or handed to the person. · · · B. Applicant is independent in dressing upper body and does not need assistance. Applicant is able to dress upper body independently if clothing is placed in front of him or her. Applicant is able to dress upper body independently but needs someone to choose appropriate clothes.

Applicant is able to dress upper body by him- or herself, but requires the presence of another person intermittently for supervision or cueing. · · Applicant can dress upper body independently, but needs someone to remind him or her to button the blouse and adjust the collar. Applicant requires cueing/instructing to fasten buttons on front of shirt.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 5 of 13

C. Applicant is able to dress 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 requires constant cueing to complete each aspect of dressing the upper body, but can dress him- or herself. The applicant requires the full attention of the caregiver throughout the dressing activity. If continuous cues were not provided, the caregiver would be required to physically assist with dressing the upper body. D. Applicant needs partial physical assistance from another person to dress the upper body. · Applicant can put on shirt, but cannot physically button it. · Applicant needs assistance pulling the shirt over the head. E. F. Applicant depends entirely upon another person to dress the upper body. · Applicant needs total assistance with dressing the upper body and is unable to effectively assist. Applicant's ability is age appropriate for a child age five or younger. · Child is five years old or younger.

Lower Body A. Applicant is able to dress the lower body without assistance or is able to dress him- or herself if clothing and shoes are laid out or handed to the person. · Applicant is independent in dressing the lower body and does not need assistance. · Applicant is able to dress the lower body without assistance if clothing is placed in front of 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. · Applicant can dress the lower body independently but needs to be reminded intermittently by another person to button and/or zip pants. · Applicant only needs intermittent verbal instruction to complete lower body dressing. · Applicant requires supervision intermittently to ensure personal safety. Applicant has a history of falls. Applicant is able to dress the lower body by him- or herself, but requires presence of another person throughout the task for constant supervision to provide immediate intervention to ensure completion of the task. · Applicant requires constant cueing to complete each aspect of dressing the lower body, but can dress him- or herself. The applicant requires the full attention of the caregiver throughout the dressing activity. If continuous cues were not provided, the caregiver would be required to physically assist with dressing the lower body.

C.

D. Applicant needs partial physical assistance to dress the lower body. · Applicant can pull on pants, but cannot button and/or zip them. · Applicant needs assistance pulling up pants. E. F. Applicant depends entirely upon another person to dress the lower body. · Applicant needs total assistance with dressing the lower body and is not able to effectively assist. Applicant's ability is age appropriate for a child age five or younger. · Child is five years old or younger.

Prosthetics, Braces, Splints, and/or Anti-Embolism Hose · Select "yes" if applicant needs assistance with placement or removal of a prosthetic, brace, splint, and/or anti-embolism hose. If the applicant does not need assistance, select "no." Do not check "yes" if the applicant needs assistance with placement or removal of any of the following items: hearing aids, eyeglasses, or dentures. Indicate the number of days per week PCW assistance is needed with placement and/or removal of a prosthetic, brace, splint, and/or anti-embolism hose. Do not count days and times of day in which unpaid caregivers will be providing the care, or when care is provided outside of the home.

·

Element 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. For children age five or younger, select response "G." If the child requires more assistance than an adult would typically provide to a child of that age, explain in the comment section why more assistance is needed. Indicate the time of day when PCW assistance with grooming is needed. Indicate how many days per week PCW assistance is needed with grooming. Do not count days in which unpaid caregivers will be providing the care, or when care is provided outside the home.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 6 of 13

Examples A. Applicant is able to groom him- or herself, with or without the use of assistive devices or adapted methods. · Applicant needs a chair placed due to being unsteady when standing, but can groom self if able to sit during the task. · Applicant can groom him- or herself with specially adapted utensils. B. Applicant is able to groom him- or herself, but requires the presence of another person intermittently for supervision or cueing. · Applicant needs to be cued to place toothpaste and brush teeth, but can physically perform task by him- or herself. · Applicant needs to be supervised intermittently to ensure proper completion of tasks.

C. 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 constant cueing to complete all tasks related to grooming, but can groom him- or herself. The caregiver is required to be continually present. If continuous cues were not provided, the caregiver would be required to physically assist with grooming. D. Applicant needs physical assistance to set up grooming supplies, but can groom him- or herself. · Applicant needs assistance putting toothpaste on toothbrush, but is able to complete other grooming by him- or herself. E. Applicant needs partial physical assistance to groom him- or herself. · Applicant is able to brush teeth and apply deodorant, but needs assistance combing hair and shaving. · Applicant is able to partially complete the task, but requires assistance to fully complete grooming. · Applicant is able to initiate tooth brushing, but is not able to effectively complete the task without the assistance of another person. Applicant depends entirely upon another person for grooming. · Applicant needs total assistance with all aspects of grooming.

F.

G. Applicant's ability is age appropriate for a child age five or younger. · Child is five years old or younger. Element 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 the applicant is fed exclusively via tube feedings or intravenously, select response "0." If a member is fed orally and via tube feedings, select the most appropriate response A through G (also complete daily tube feedings under Element 34, as appropriate). For children age three or younger, select response "H." If the child requires more assistance than an adult would typically provide to a child of that age, explain in the comment section why more assistance is needed. Indicate the meals with which the PCW will assist. Indicate how many days per week PCW assistance is needed for each meal. Do not mark meals for which the PCW will not be providing assistance. Do not count days in which unpaid caregivers will be providing the cares or when care is provided outside of the home. For example, an applicant requires partial feeding at lunch and is in a day program for five days per week; because PC may not be provided outside of the home, only two days of PCW assistance with lunch should be marked. Examples 0. Applicant is fed exclusively via tube feedings or intravenously. · Check this box if the applicant receives nutrition only through tube feedings or intravenously and is not fed orally. A. Applicant is able to feed him- or herself, with or without use of an assistive device or adapted methods. · Applicant is able to feed him- or herself with the use of adapted utensils. · Applicant is able to feed him- or herself. Applicant is able to feed him- or herself, but requires the presence of another person intermittently for supervision or cueing. Applicant is able to feed him- or herself, but requires occasional cueing to keep on task. · · Applicant needs to be reminded to use portion control as well as what types of food are appropriate for a special diet. Applicant needs to be reminded to eat. ·

B.

C. Applicant needs physical assistance at meal time to cut meat, arrange food, butter bread, etc. · Applicant needs assistance to cut meat, arrange food, or set up adaptive utensils.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 7 of 13

D. 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 needs to be constantly supervised for inappropriate behaviors while eating, but can feed him- or herself. The applicant requires the full attention of the caregiver throughout the eating activity. If continuous supervision was not provided, the caregiver would be required to physically assist with eating. E. Applicant has a recent history of choking or the potential for choking, based on documentation. · Applicant needs to be constantly monitored during eating to prevent choking, aspiration, or other serious complications due to a documented history of these problems. Applicant needs partial physical feeding from another person. · Applicant is able to feed him- or herself for a short period of time before being no longer able to do so. Assistance is needed to complete eating. · Applicant is able to drink from an adapted cup by him- or herself, but requires someone to feed him or her solid foods.

F.

G. Applicant needs total feeding from another person. · Applicant depends entirely on someone else for feeding. H. Applicant's ability is age appropriate for a child age three or younger. · Child is three years old or younger. Element 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 of 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 help from an assistive device. Assistive devices include, but are not limited to, canes, crutches, walkers scooters, and wheelchairs. If the applicant remains bedfast, select response "0." For children age 18 months or younger, select response "E." If the child requires more assistance than an adult would typically provide to a child of that age, explain in the comment section why more assistance is needed. Indicate how many days per week PCW assistance is needed with mobility in the home. Do not count days in which unpaid caregivers will be providing the care, or when care is provided outside of the home. Examples 0. Applicant remains bedfast. · A. Check this box only if the applicant remains bedfast and does not get out of bed.

Applicant is able to ambulate by him- or herself. Applicant is able to ambulate independently with the use of a cane or walker. · · Applicant is able to move wheelchair independently. Applicant is able to ambulate by him- or herself, but requires presence of another person intermittently for supervision or cueing. · Applicant needs to be reminded to stand up straight when using a walker. · Applicant needs to be cued to move a wheelchair to a specific location.

B.

C. Applicant is able to ambulate by him- or herself, but requires the constant presence of a PCW to provide immediate physical intervention. · Applicant needs constant supervision, but does not need physical assistance with ambulation. The applicant requires the full attention of the caregiver throughout ambulatory activities. If continuous supervision were not provided, the caregiver would be required to provide physical assistance with mobility. D. Applicant needs physical help from another person. · Applicant needs physical assistance with moving a manual wheelchair within his or her home. · Applicant needs physical assistance from one person plus a gait belt to assist with ambulation. · Applicant needs hands-on physical assistance when ambulating. E. Applicant's ability is age appropriate for a child 18 months or younger. · Child is 18 months old or younger.

Element 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.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 8 of 13

Select the responses, A-G, that best describe the level of function the applicant possesses when toileting. Select all responses that apply. For children age four or younger, select response "G." If the child requires more assistance than an adult would typically provide to a child of that age, explain in the comment section why more assistance is needed. If responses "C," "D," "E," or "F" are selected, also include the frequency per day of the situation described in which the PCW will provide assistance. If the frequency varies, record the higher of the frequencies. For example, a member requires assistance with toileting and the PCW assists her six times a day on average. However, the member attends a day program five days per week and on those days, the PCW assists with toileting four times per day. The frequency entered in the PCST would be six times per day. When toileting assistance is needed only for the bowel program, the screener should indicate assistance needed with the bowel program in Element 34, and not in the toileting section. Indicate how many days per week PCW assistance with toileting is needed. Do not count days in which unpaid caregivers will be providing the care, or when care is provided outside of the home. Examples A. Applicant is able to toilet him- or herself or provide his or her own incontinence care, with or without an assistive device. · Applicant needs a raised toilet seat and with its use can toilet self. · Applicant is incontinent, but can change his or her own incontinence product. 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. · Applicant needs to be reminded to wipe him- or herself and wash his or her hands, but can toilet him- or herself. · Applicant requires cueing/instruction to pull his or her pants up after toileting. · Applicant needs to be intermittently supervised while in the bathroom to ensure proper completion of toileting.

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. · Applicant requires constant cueing to complete each aspect of toileting, but can toilet him- or herself. The applicant requires the full attention of the caregiver throughout the toileting activity. If continuous cues were not provided, the caregiver would be required to physically assist with toileting activities. When estimating frequency, if the applicant is both constantly supervised during toileting and provided incontinence care during the same episode, then the episode should be counted under the incontinence frequency total. Do not total both constant supervision with toileting and incontinence care during the same episode. For example, the applicant is constantly supervised during toileting, generally six times per day. On average, the applicant is found incontinent two out of the six toiletings. The frequency should be indicated as constant supervision four times per day and incontinent two times per day. D. Applicant needs physical help from another person to use toilet and/or change personal hygiene product. · Applicant needs assistance pulling up and buttoning his or her pants. Applicant needs assistance with pulling down his or her pants, wiping, and washing his or her hands. · · Applicant needs physical assistance to change a personal hygiene product (such as Depends or a feminine hygiene product.) Applicant has stress incontinence and needs physical help changing a personal hygiene product. · When estimating frequency, if the applicant is both toileted and provided incontinence care during the same episode, then the episode should be counted under the incontinence frequency total. Do not total both toileting and incontinence care during the same episode. For example, the applicant requests to be toileted but was also incontinent. This would be totaled as one episode of incontinence. In another example, the applicant is generally toileted six times a day, but may be discovered to be incontinent two out of the six toiletings. This would be totaled as four episodes of toileting and two episodes of incontinence. E. Applicant needs physical help from another person for incontinence care. (Does not include stress incontinence.) Applicant needs assistance changing incontinence product, providing peri-care, and assisting with an occasional change of · clothes. When estimating frequency, if the applicant is both toileted and provided incontinence care during the same episode, then the episode should be counted under the incontinence frequency total. Do not total both toileting and incontinence care during the same episode.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 9 of 13

For example, the applicant requests to be toileted but was also incontinent. This would be totaled as one episode of incontinence. In another example, the applicant is generally toileted six times a day, but may be discovered to be incontinent two out of the six toiletings. This would be totaled as four episodes of toileting and two episodes of incontinence. F. Applicant needs physical help from another person to empty an ostomy or catheter bag. · Applicant is unable to release clamp on ostomy bag and needs physical assistance to empty bag. When estimating frequency, determine how many times per day the PCW will be assisting with emptying an ostomy or catheter bag. Do not count episodes in which the PCW will not be needed to provide the care. G. Applicant's ability is age appropriate for a child age four or younger. · Child is four years old or younger. Element 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. For children age three or younger, select response "G." If the child requires more assistance than an adult would typically provide to a child of that age, explain in the comment section why more assistance is needed. Indicate how many days per week PCW assistance with transferring is needed. Do not count days in which unpaid caregivers will be providing the care or when care is provided outside the home. Examples A. Applicant is able to transfer him- or herself, with or without an assistive device. Applicant is able to transfer him- or herself to a wheelchair with the use of an assistive device. · · Applicant is able to transfer him- or herself with the use of crutches. B. 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 needs to be reminded not to bear weight on a fractured foot. 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 requires constant supervision when transferring, but is able to transfer him- or herself. The applicant requires the full attention of the caregiver throughout the transfer activities. If continuous supervision was not provided, the caregiver would be required to physically assist with transfers.

C.

D. Applicant needs the physical help of another person but is able to participate (e.g., applicant can stand and bear weight). · Applicant is able to bear weight and assist with a pivot transfer with the physical assistance of another person. E. Applicant needs the 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 requires the assistance of another person with the use of a gait belt and the person is unable to effectively participate. Applicant needs help from another person with the use of a mechanical lift (e.g., Hoyer) when transferring. · Applicant needs a Hoyer lift to be transferred.

F.

G. Applicant's ability is age appropriate for a child age three or younger. · Child is three years old or younger. MEDICALLY ORIENTED TASKS (MOTs) Element 32 -- (Part I) Medication Assistance Select the option that best describes the applicant's need for assistance with his or her medication(s). Medication assistance includes assistance with oral medications, topical patches, eye drops, ear drops, nasal spray, inhalers, medications administered via a gastrostomy tube, and suppositories not related to a bowel program. When assistance is needed with the application of legend skin care, indicate the need in Element 33. When assistance is needed with nebulizer treatments, indicate the need in Element 34. Indicate how many days per week PCW assistance is needed with medication assistance. Do not count days in which unpaid caregivers will be providing the care, or when care is provided outside of the home.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 10 of 13

Examples 0. Not applicable. · Applicant has no medications. A. Independent with medications with or without the use of a device. · Applicant is able to self-administer medications. · Applicant is independent with medications with the use of a pill box. Needs reminders. · Applicant is able to self-administer medications, but requires another person or a device (e.g., electronic medication dispenser) to provide reminders. · Applicant requires instructions on how to take the medication (e.g., cueing him or her to place the medication in the mouth, take a drink, and swallow.)

B.

C. Needs the physical help of another person. · A family member or friend assists applicant with taking his or her medications. (The PCW does not perform this task.) D. Needs the physical help of a PCW. · Applicant requires assistance from a PCW to take medications. · Applicant requires PCW to place medication in his or her hand or mouth. If response "D" is selected, indicate the number of times per day a PCW needs to assist the applicant with his or her medications. Element 33 -- (Part II) Tasks to be Performed by a PCW Select the tasks to be completed by a PCW. If no PCW assistance is needed for a task, leave that task blank. Indicate the frequency per day and days per week each task will be performed by a PCW. If the frequency per day varies, indicate the higher frequency. Do not count days in which other unpaid caregivers will be providing the care or when care is provided outside of the home. Glucometer Readings. Allowed only when medical condition supports the need for ongoing, frequent monitoring, and the physician has established parameters on reporting readings. High blood sugars due to the noncompliance of a competent adult does not support the need for assistance of a PCW. Skin Care. Skin care is the application of legend solutions, lotions, or ointments that are ordered by the physician due to skin breakdown, rashes, etc. Pro re nata (PRN) or "as needed" or prophylactic skin care is an ADL task that is covered under bathing. If the PCW will be providing prescribed skin care, the name of the drug and frequency prescribed must be indicated. If the applicant has more than one prescription ointment, indicate the one that occurs most frequently. Document other prescription ointments on the comment line. Prescription ointments related to wound care should be indicated in Element 34 under wound care. Catheter Site Care. Cleaning a catheter site may be marked if the applicant requires PCW assistance with site care provided to a suprapubic catheter (drainage tube that extends from a small hole in the skin just above the pubic bone). "Site care" means that special care is given to the area where the catheter goes into the abdomen. Site care usually involves cleansing this area with soap and water and covering with dry gauze. Do not check this area for routine catheter care for an indwelling catheter. Routine catheter care usually involves soap and water as a normal part of bathing. Do not confuse site care for a suprapubic catheter with catheter care for an indwelling catheter. Check "Other" under Other Program in Element 34 if the PCW will be providing irrigation of the catheter, changing and/or replacing the catheter, or "in & out" catheterization. Gastrointestinal Tube Site Care. Cleaning a gastrostomy site may be marked if the applicant requires PCW assistance with site care provided to a gastrostomy or jejunostomy site (tube that extends from a small hole in the skin from the abdomen). "Site care" means that special care is given to the area where the tube goes into the abdomen. Site care is usually cleansing this area with soap and water and covering with dry gauze. Complex Positioning. This is specialized positioning, including positioning required to change body positions while at a specific location for the purpose of maintaining skin integrity, pulmonary function, and circulation. When determining frequency, the positioning related to the tasks of bathing, dressing, and toileting are accounted in the times allotted for each specified task and are not to be counted separately.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 11 of 13

Element 34 -- (Part III) Tasks to Be Performed by a PCW -- ForwardHealth Review and Manual Approval May Be Required Complete this section for tasks the RN is delegating to a PCW. Tasks in this element will not be assigned time if they are not delegated by an RN. If no PCW assistance is needed for a task, leave that task blank. Indicate the frequency per day and days per week each task will be performed by a PCW. Do not count days in which unpaid caregivers will be providing the care, or when care is provided outside of the home. For tasks indicated in this element, manual review of the PA request will be required only when the total amount of time computed by the PCST is insufficient for a PCW to provide the delegated tasks identified in this element and additional time is being requested for those delegated tasks. Include the Personal Care Addendum, F-11136, the POC, and other documentation as directed when submitting the PA request. Daily Tube Feedings. Administration of tube feedings is the process of giving nutrition via a tube inserted into a person's body. This may include a gastrostomy tube (g-tube), jejunostomy tube (j-tube), or a nasogastric tube (NG tube). Select this option when the applicant requires a PCW to administer a tube feeding. Do not select this option if the PCW is only monitoring the feeding while it is in progress. Administering includes starting and stopping the tube feeding and all tasks involved with starting or stopping a feeding, such as preparing the feeding, flushing the tube, hanging the bag, etc. Continuous Feeding. Select continuous feeding if the applicant is receiving a continuous feeding and requires a PCW to administer it. A continuous feeding is a feeding that is not given intermittently throughout the day or given by bolus. For example, an applicant receives continuous feeding; the PCW sets up the formula, flushes the tube, hangs the feeding bag and starts the feeding. The PCW does this once per day, three days per week. On the other days of the week, a family member administers the feeding. PCW frequency per day = 1, PCW days per week = 3. Intermittent (Bolus) Feeding. Select intermittent (bolus) feeding if the applicant receives feedings at various times during the day and requires a PCW to administer them. For example, an applicant receives bolus feedings (50cc each time) three times a day. The PCW will be administering the feeding two times per day, seven days per week. PCW frequency per day = 2, PCW days per week = 7. Respiratory Assistance. Assistance needed with suctioning, chest physiotherapy (CPT), nebulizer treatments, or tracheostomy related care. Check all that apply. Tracheostomy Care. Select tracheostomy care if the applicant requires cleaning of the tracheostomy site, changing of the tracheostomy tube, and/or changing of the tracheostomy straps or ties that hold the tube in place and assistance of the PCW is needed. Note: In the comments section at the end of this element, specify the care that the PCW will be providing. Suctioning. Select suctioning if the applicant requires suctioning of the oral cavity, the nasal cavity, the nasopharyngeal cavity, or of a tracheostomy and a PCW is performing the task. Note: In the comments section at the end of this element, specify the type of suctioning the PCW will be performing. Chest Physiotherapy. Select CPT if the applicant requires postural drainage or chest percussion and the PCW is performing the task. Nebulizer. Select nebulizer if the applicant requires a PCW to administer respiratory treatment via a nebulizer. Bowel Program. A bowel program is a regimen prescribed by a physician to develop proper bowel evacuation. A bowel program may include the use of suppositories, enemas, or digital stimulation. Assistance with a bowel program includes assistance with related hygiene needs. Indicate which task or tasks are being performed by the PCW as well as the frequency for each task. Each task indicated in this section must be performed by the PCW at least once per week. Note: In the comments section, specify the specific bowel program the PCW will be providing. Examples · The PCW inserts a suppository, waits 30 minutes, and then provides digital stimulation to promote proper evacuation of the colon. This is completed every three days. The PCW gives the applicant a warm water enema once a week and requires assistance with post task hygiene. · Wound or Decubiti Care (excludes basic skin care). A wound or decubitus requiring dressing and care. "Wound" is defined as a wound from a serious burn, traumatic injury, or a serious infection. Select this response if the applicant has documentation of a wound or a decubitus and requires a PCW to provide wound cleaning and/or dressing. This does not include ostomy care.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 12 of 13

For example, the applicant has a wound on the outer aspect of their ankle measuring 1 cm by 1 cm, red in color, and draining serosanguinous drainage. The wound is cleansed daily with normal saline and simple dry dressing (2x2) applied. The PCW will be providing wound care once per day, seven days per week. Frequency per day = 1, number of days per week = 7. Note: In the comments section, include a description of the wound or decubitus and explain the wound care the PCW will be performing. Therapy Program. Assistance with activities that are directly supportive of skilled therapy services. This includes activities that do not require the skills of a therapist to be safely and effectively performed. Activities may include routine maintenance exercises, e.g., range of motion (ROM) exercises and repetitive speech routines. In order to be medically necessary, the activities must be ordered in conjunction with a therapy program or as a result of a therapy evaluation and ordered by the physician. The therapist may screen the member as often as medically necessary to verify the continuing medical necessity of activities supportive of therapy, such as ROM, repetitive speech drills, and other routine exercise programs. A full therapy evaluation by a therapist is needed when there is a change in client condition or when the home exercise program is not accomplishing its goals. For example, the applicant has seen a physical therapist and the therapist has written a passive ROM program that the person needs physical assistance completing. Note: When submitting the PA request, a copy of the therapy program developed by a therapist must be submitted and the activities must be included in the physician orders. Range of Motion. Assistance with ROM that is not directly supportive of skilled therapy services. Do not select this if you have selected ROM under Therapy Program. A physician's order is required along with documentation supporting the medical necessity for ROM. The need for ROM must be directly supported by the member's diagnosis and medical condition (e.g., ROM to the left side due to left hemiparesis following a cerebrovascular accident). Typically, ROM that is not part of a prescribed therapy program should be able to be completed during routine ADL. If ROM is unable to be completed during routine ADL, the documentation must include information as to why it cannot be completed during these activities. Documentation must also include a description of the ROM the PCW will be assisting with (e.g., ROM to all four extremities once a day) and an explanation as to why the ROM activities cannot be completed without the physical assistance of a PCW. For example, the applicant has chronic contractures of the upper extremities and requires passive ROM to prevent further decline. In this situation, the ROM is ordered by a physician, but it is neither directly supportive of skilled therapy services nor is it part of an active therapy program that has been prescribed by a therapist. Note: When submitting a PA request for more time than the PCST has allocated and ROM has been selected, a Personal Care Addendum, F-11136, must be completed and submitted and include a description of the ROM with which the PCW will be assisting, the reason the member cannot complete ROM during routine ADL, and the reason the member cannot complete ROM without the physical assistance of a PCW. The POC with the physician's order for ROM by a PCW must also be submitted with the PA request. Vital Signs. Allowed only when medical condition support the need for ongoing, frequent monitoring, and the physician has established parameters at which point a change in treatment may be required. Vital signs include temperature, blood pressure, pulse, and respiratory rates. Other. List the medically oriented tasks prescribed by a physician that are not included among the other MOT listed in the PCST. The tasks listed in "Other" are RN-delegated tasks to be performed by a PCW. Examples could include catheter irrigations, catheter insertions, and ostomy appliance changes. Do not select "other" if applicant uses a mechanical lift for transfers. If a mechanical lift is needed for assistance with transfers, refer to Element 31 and select response "F." Note: When submitting a PA request for MOT listed in "Other", include a detailed description of the MOT to be provided by the PCW. INCIDENTAL SERVICES Element 35 Services incidental to the ADL and MOT include changing the applicant's bed, laundering the applicant's bed linens and personal clothing, care of eyeglasses (also contact lenses) and hearing aids, light cleaning in essential areas of the home used during PC 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.) Indicate if services incidental to the ADL and MOT will be performed by the PCW.

PERSONAL CARE SCREENING TOOL (PCST) COMPLETION INSTRUCTIONS F-11133A (10/08)

Page 13 of 13

BEHAVIORS AND MEDICAL CONDITIONS Element 36 -- Behaviors Indicate if the applicant exhibits more often than once per week behavior that makes ADL tasks more time consuming for the PCW to complete. If "Yes" is checked, list the behavior(s) and describe how the behavior(s) make the ADL and MOT tasks more time consuming for the PCW to complete. Examples · Applicant hits and kicks PCW while trying to complete the activities of bathing, dressing, and grooming. · Applicant is physically resistive to all care completed by the PCW. Element 37 -- Medical Conditions Indicate if the applicant has any medical conditions that make ADL and MOT tasks more time consuming for a PCW to complete and are expected to result in a long-term need for extra care. If "Yes" is checked, list the medical condition(s) and describe how it increases the amount of time for the PCW to complete the ADL and MOT tasks. Examples · Applicant has severe contractures and additional time is needed to safely complete personal care tasks without injuring him or her. · Applicant experiences severe shortness of breath due to chronic obstructed pulmonary disease and requires additional time for completion of tasks. Element 38 -- Seizures If the applicant has a diagnosis of seizures, indicate the time frame of the last seizure. Specify the seizure type, frequency, and the date of the last seizure. Specify if the PCW will provide seizure interventions and list the interventions he or she will perform. PRO RE NATA, INCLUDING MEDICAL APPOINTMENTS Element 39 -- Pro Re Nata Including Time to Accompany Applicant to Medical Appointments Time needed for PRN includes time to accompany the applicant to medical appointments and/or time for short duration episodes of acute need for PC services. Indicate if PRN is needed for a PCW to accompany the applicant to medical appointments and/or to provide PC services during short duration episodes of acute need for PC services. BILLING PROVIDER INFORMATION (PAPER PCST ONLY) Element 40 -- Name -- Billing Provider Enter the name of the Medicaid-certified provider billing services provided to the member. Providers sharing the case are required to indicate that the case is shared and to include on the PA/RF the names of the agencies sharing the case. Check the box to indicate that the applicant will be served by other providers under a case-sharing arrangement. Element 41 -- Billing Provider Number Enter the billing provider number. Element 42 -- Address -- Billing Provider Enter the billing provider's address, including street, city, state, and ZIP code. SIGNATURE (PAPER PCST ONLY) Element 43 -- SIGNATURE -- Authorized Screener The authorized screener completing this PCST is required to sign this form. Element 44 -- Date Signed -- Authorized Screener Enter the date the authorized screener completing this PCST signed the form. PCST SUMMARY SHEET INSTRUCTIONS (WEB-BASED PCST ONLY) The PCST Summary Sheet will be produced for Web-based users after all information is entered into the PCST. This summary will contain the allocation of units for the applicant and other important alerts and information for the provider about PA submission. At the bottom of the PCST Summary Sheet, enter the following information: · · · · Billing provider name. Billing provider address. Billing provider number. Case sharing arrangements. (Providers sharing the case are required to indicate that the case is shared and to include on the PA/RF the names of the agencies sharing the case.)