Free None - Wisconsin

DEPARTMENT OF HEALTH AND FAMILY SERVICES Office of Quality Assurance OQA-2256 (Rev. 10-06)

STATE OF WISCONSIN s.49.45(6m)(bg) Wis. Stats.

REQUEST FOR TITLE XIX CARE LEVEL DETERMINATION
Completion of this form is not mandatory, however, a resident's level of care, for Medicaid reimbursement, cannot be evaluated and determined without the information requested below. Collection of personal information will be used to determine the resident's level of care and for no other purpose. STATE AGENCY USE Effective Nursing Care ORGANIC Level Decision Date Date DD Care Level Yes Decision Reviewed Reviewer MI Care Level No Decision Client/Resident Name (last, first, MI) Age Provider License Number

Client's/Resident's MA Number

Client'/Resident's County of Responsibility

Birth Date (month/day/year)

Sex Male Female

Provider Name

Provider Address

Client's/Resident's Address (if different from provider address - include city, county and zip)

I. REASON FOR REQUEST (check one) New admission Date of admission: (month/day/year) MA Established while in facility Date eligibility established: (month/day/year) Care level change Current care level: Provide a list of medication(s) and treatment(s) administered including all PRN meds given in the last 30 days. You may attach a copy of the Medication Administration Record. OBRA exception for short-term stay Number of days (check one) DD or MI MA waiver application MA waiver annual recertification II. THIS SECTION IS NOT APPLICABLE TO WAIVER PROGRAMS 1. Admitted from (home, name of hospital, etc.) 2. Address Discharge date: 3. If admitted from hospital, admission date: 4. Date resident first admitted to facility: III. REQUESTED LEVEL OF CARE (check all that apply) ISN ISV SNF ICF-1 DD1a DD1b DD2 DD3 EFFECTIVE DATE ICF-2 NAT SBI MI

STATEMENTS THAT SUPPORT THE DETERMINATION OF THIS CARE LEVEL (NOTE: Nursing Facilities need to submit a copy of the Level II screen for a NAT determination.)

ATTACH PHYSICIAN'S ORDERS; LIST OTHER ATTACHMENTS, AS NECESSARY

OQA STAFF NOTES

OQA-2256 (Rev. 10-06)

ISN (Intense Skilled Nursing Care) For residents whose health care requires specific interventions and are complex. Complex procedures/services may be identified as complex because of the status of the resident's condition, type of procedure or multiplicity of procedures utilized. Direct observation, monitoring or performance of complex nursing procedures by professional nurses are required to be performed on a continuing basis. Continuing care implies repeated application of the procedures or services every 24 hours, frequent monitoring and documentation of resident's condition and response to therapeutic measures. ISV (Intense Skilled Care Ventilator Dependent) For residents who meet the requirements for an ISN care level and are also ventilator dependent. SNF (Skilled Nursing Care) For residents who require 24 hours/day licensed nursing services and/or skilled rehabilitation services at least 5 days/week pursuant to physician's orders which: (1) Require the skills of technical or professional personnel, e.g., registered nurse, licensed practical nurse, physical therapist, occupational therapist, speech pathologist, audiologist, and (2) Are provided either directly by or under the supervision of such personnel. ICF-1 (Intermediate Nursing Care) For residents who require basic nursing care, including physical, emotional, social and other restorative services under periodic medical supervision. The nursing care requires the skill of a registered nurse in nursing administration, including observation and recording the reactions and symptoms and supervision of nursing care. Most ICF-1 level residents have long-term illnesses or disabilities which have reached a stable plateau but may need medical and nursing services to maintain stability. ICF-2 (Limited/Intermediate Nursing Care) For residents with long-term illnesses or uncomplicated disabilities. The resident may require simple nursing procedures in order to maintain stability. Nursing care to be provided by or under the supervision of a person no less skilled than a licensed practical nurse who shall be under the direction of a registered nurse. No Care Level (Nursing Care) For residents who do not meet any of the above nursing levels of care. These residents do not qualify for Medical Assistance payments for nursing home care. MEDICAID WAIVER PROGRAMS When applying the nursing care levels to persons participating in a Medicaid Waiver program (CIP IA, CIP IB, CIP II, & COP-W), determine the care level based on the person's needs IF they were in a facility. Do not determine the care level based on who provides the services (e.g., parents may perform postural drainage; in a facility, this would be performed by licensed staff). DD1 The DD1 care level describes two types of individuals who require a higher level of care. The DD1a person has health care needs and the DD1b person has maladaptive behavior such that it interferes with their program participation. Persons under 18 years of age must be a DD1a or a DD1b care level. DD1a All developmentally disabled children under the age of 18 and adults of any age who require active treatment and whose health status is fragile, unstable, or relatively unstable. DD1b All developmentally disabled children under the age of 18 and adults of any age who require active treatment and who exhibit behaviors of sufficient frequency, severity, or duration to cause a threat to the health, safety, or welfare of themselves or others. These persons may manifest hyperactive behaviors; they may be security risks. DD2 The DD2 care level describes an adult who requires active treatment to learn basic ADL and social skills. These persons have the learning capacity to perform some of these skills with staff intervention. DD3 The DD3 care level describes an adult who requires active treatment to learn a variety of skills in many areas, including but not limited to social skills, leisure skills, domestic, and vocational skills. These persons have the learning capacity to perform some of these skills independently and some with staff intervention. NAT (No Active Treatment) determinations A NAT determination may be made for any resident of any care level who is developmentally disabled, but is not in need of a active treatment because a resident: 1. 2. 3. 4. 5. 6. Had a prior Level II screen which determined that the resident is NOT in need of active treatment. Is generally independent. He can function with little supervision. He does not need a continuous active treatment program consisting of aggressive, consistent implementation to maintain his level of functioning.; Is developmentally disabled, but not mentally retarded. He is competent and manages his own affairs.; Is terminally ill.; OR Has achieved his maximum potential and would not benefit from active treatment based on medical/ neurological problems that substantially affect his ability to participant in an active treatment program. He has achieved his maximum potential as evidenced by lack of growth/acquisition of skills in several areas of adaptive behavior functioning despite prolonged receipt of bonafide active treatment programs. Note: age is not a factor in making a NAT determination.