Download Aging and People with Disabilities PASRR II Final Review Date of r

PASRR II Final Review
Aging and People with Disabilities
Date of review:
I. Candidate information:
Name:
Address:
Date of birth:
Hospital:
Social Security number:
DMR client:
Nursing facility:
Yes
No
II. Reason for referral:
Change in health status (resident review)
Non-categorical
Exempted hospital discharge
Emergency
Respite
III. Family/guardian/contact person:
Name:
Address:
Phone:
IV. Sources of information:
County DD/ATD Program
Individual
Family
H & P reviewed on:
Guardian/POA
Previous Tx records
Hospital
Nursing facility
Other:
by:
V. Preadmission living situation:
ALF
Foster home:
Independent Living
Family/spouse
Provider:
Group home
Other:
VI. Developmental history:
Developmental milestones:
WNL
IQ testing results prior to age 22:
Disabling condition prior to age 22:
Other pertinent information:
MR/DD diagnosis documentation reviewed on:
Diagnosis onset date:
Patient:
Delayed
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Unknown
by:
SDS 0487 (07/13)
VII. Developmental disability functional profile areas:
Learning/self-direction/independent living:
Special education
Completed grade school
Completed high school
College courses
Completed high school with modified degree
Is or has been married
Has held jobs in the past
Has drivers license
Has had apartment/home
Initiates phone calls
Knows value of money
Has bank account
Knows current date, time and location
Makes medical/dental appointments on own
Did own food and clothing shopping
Self care:
Dresses self completely
Dresses in anticipation of weather changes
Uses spoon, fork and knife
Bathes or showers
Cares for all toileting needs
Brushes teeth
Makes own bed
Sets table
Independent
Understanding language/communication:
Reads newspapers
Writes letters or notes
Tells story, TV plots, jokes
Asks ”what”, “why”, “when” questions
Can listen to a story for at least 5 minutes
Uses gestures to communicate
Uses sign language to communicate
Uses adaptive device to communicate
Uses eye movement only to communicate
Mobility:
Walks unassisted
Can walk only on level ground
Uses walker/cane
Uses wheelchair
Confined to bed most of time
Other pertinent information:
Patient:
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
No
No
No
No
No
No
Needs
assist
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Totally
dependent
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
No
No
No
No
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Unknown
Yes
Yes
Yes
Yes
Yes
No
No
No
No
No
Unknown
Unknown
Unknown
Unknown
Unknown
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SDS 0487 (07/13)
Health information review:
Medical information including current diagnoses and medications can be found on the health
screen/interagency referral document and/or other medical information that is included in
the OBRA Preadmission referral packet received from DSS.
Advanced directives (if known):
Yes
No
Medical diagnosis and onset dates:
Allergies and onset dates:
Behavioral needs:
Wandering
Abusive/assaultive (verbal/physical)
Impaired judgment with threats to
health and safety
Unsafe/unhealthy hygiene habits
Unknown
Other:
Nursing needs:
Assess and monitor medical status
Monitor medication effectiveness
and possible side effects
Monitor prescribed diet
Other:
Therapy services:
Occupational
Physical
Respiratory
Other:
Vocational needs:
Present vocational placement or day program:
Patient:
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SDS 0487 (07/13)
Guardianship:
Does the individual have a legal guardian? If not, is he/she capable of making important
informed consent decisions (such as, medical or financial) for him/herself?
Yes, has a legal guardian (if over 18 years old, must be court appointed guardian).
Guardian’s name:
Address:
No legal guardian and is believed to be capable of making decisions for him/herself.
No guardian and is NOT believed to be capable of making important informed consent
decisions for him/herself.
Other:
Family involvement:
Does the individual have family members involved in decision making concerning him/her?
Yes, very involved
Somewhat, not very involved
No, not involved, no family, family too far away
Critical incident:
Has this individual had any critical incidents in the past year? If so, please indicate the type of
incident below. (Check all that apply.)
No critical incident in last year
Suicide attempt
Unauthorized absence (left supervised
Hospitalization for any reason
setting without letting anyone know)
Drug abuse/alcohol related incident
Medication (wrong amount, missed)
Other:
Adaptive equipment:
Does this individual need any adaptive equipment, such as glasses, hearing aids, wheelchairs,
braces/splints, ramps? If so, does he/she have them and know how to use them?
Yes, complete access and knows how to use
Yes, limited access, needs more devices or needs to better understand use or needs
assistance and does not always have someone available to assist
No access, some important adaptive equipment is not available
Other:
None needed
If yes, list type of adaptive equipment used:
Basic medical self-help:
(First aid and use of non-prescription medication. Examples: applies band-aids,
takes aspirin, uses cough drops.)
Does not display any medical self–help skills
Seeks aid from others for treatment of minor injuries
Performs simple first aid tasks, but needs some prompting
Performs simple first aid tasks and takes nonprescription medications appropriately
and without prompting
Receptive communication skills:
(Degree to which individual understands spoken language or American Sign Language.)
Does not understand any verbal or signed language
Patient:
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SDS 0487 (07/13)
Receptive communication skills:
Understand and responds only to names
Understands and responds to single words
Understands and responds to simple sentences or instructions
Understands and responds to complex sentences or instructions
Expressive communication skills:
(Degree to which individual uses spoken language or
American Sign Language to communicate.)
Does not use any verbal language or American Sign Language (ASL) in a meaningful way
Understands and uses only spoken or signed names
Understands and uses simple spoken or signed sentences
Understands and uses simple spoken or signed phrases
Understands and uses complex spoken or signed sentences
One-to-one interaction with familiar individuals:
(Degree to which person communicates, shares with and interacts on a one-to-one basis
appropriately with other individuals with whom he/she is familiar, such as friends, co-workers,
roommates, staff, family. Tactile or eye contact may be considered interaction.)
Does not enter into interaction
Does not typically initiate interaction, but does respond when others initiate
Initiates interaction in familiar or previously successful situations or settings, such as,
living area, classroom or work area, but not in unfamiliar settings or situations such as
office parties or stores
Initiates interaction in both familiar and unfamiliar situations or settings; comfortable
seeking out social interaction with others in most situations
Initiates all the types of interactions described above and offers to help or assist others
One-to-one interaction with unfamiliar individuals:
(Degree to which person communicates, shares with and interacts appropriately on a
one-to-one basis with individuals with whom he/she is unfamiliar, such as store clerks,
new staff, new co-workers or roommates and other unknown persons.)
Does not interact
Does not typically initiate interactions, but does respond when others initiate
Initiates interaction in familiar or previously successful situations or settings, such as
living area, classroom or work area, but not in unfamiliar settings such as office
parties or stores
Initiates interaction in both familiar and unfamiliar situations or settings; comfortable
seeking out social interactions with unknown individuals in most situations
In addition, offers to help or assist others
Group interaction in social and/or work environments:
(Active or passive involvement in social activities, recreational activities, group projects, work
projects or other activities which include more than one individual, such as bowling, dances,
picnics, baseball, clubs, doing chores, office projects.)
Does not participate in activities involving interaction with groups
Participates in activities which involve interaction with groups only with considerable
encouragement; participation may be counter-productive, resistive or not goal-directed
Participates with minor encouragement in activities which involve interaction with groups;
example: “let’s all go to the ball game”
Patient:
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SDS 0487 (07/13)
Group interaction in social and/or work environments:
Does not need encouragement to participate in activities which involve interaction with
groups; participates without prompting; gets along well, cooperates; efforts are beneficial
and appropriate to task
Even with groups with whom he/she is unfamiliar, does not need encouragement to
participate in activities which involve interaction with groups; participates without
prompting; gets along well, cooperates; efforts are beneficial and appropriate to task
Movement in settings familiar to consumer: (Example: in home, school, work setting)
Does not find way from room to room within familiar settings without physical assistance
Finds way from room to room within familiar settings with prompting; does not
need physical assistance
Finds way in part of, but not all of, familiar setting without prompting or
physical assistance (example: to bathroom, to bedroom or to cafeteria)
Finds way in all areas but needs physical assistance
No problem in this area; independently finds way in all areas of familiar setting
Community mobility:
(Movement around the neighborhood or community, including buildings, stores and
restaurants, using any mode of transportation. Examples: walking, wheelchair,
cars, buses, taxis, bicycles.)
Only able to move about the neighborhood or community with accompaniment
Moves about the neighborhood or community with some physical assistance or
occasional accompaniment
Moves about the neighborhood or community independently for a simple direct trip or to
familiar locations with instructions or directions
Moves about the neighborhood or community independently for a complex trip (example:
several stops, unfamiliar places, etc.) with instructions or directions
Moves about the neighborhood or community independently
Time skills — associating time with events and actions:
(Indicate person’s sense of time. Note: Does NOT have to tell time.)
Does not associate events and actions with time
Associates regular events with morning, noon or night, does not understand time but
knows the sequence of daily or weekly events (Example: We go to school in the morning,
I go to bed at night, we go bowling every week.)
Associates regular events with specific hour (Example: Dinner is at six, work starts at
eight, bedtime is at ten, etc.)
Associates events with specific time in past, present and future (Example: The ball game
is at six tomorrow.)
Communication:
Does the individual need communication devices, interpreters or other assistance in order to
communicate? If so, does he/she have them whenever needed? Does he/she know how to
use them? (Assessor – try to find out whether such devises are available, accessible at most
locations. For example not just at home, but also at work/day sites.)
Yes, complete access and knows how to use
Yes, but limited access, needs more devices or needs to better understand use or needs
assistance and does not always have someone available to assist
Patient:
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SDS 0487 (07/13)
Communication:
Yes, but no access
None needed
If yes, list type of device used or needed:
Writing skills: (Including Braille and typing.)
Does not copy or trace
Copies or traces from model
Prints, writes or types only single letters or name without a model
Prints, writes or types single words
Prints, writes or types a short note or other communication using simple phrases
Prints, writes or types a more complex composition with multiple
sentences such as a letter
Reading skills: (Including Braille.)
Does not read
Reads simple word, but does
not comprehend
Reads and comprehends complex
sentences and stories
Recognizes single letters
Reads and comprehends simple words
Reads and comprehends
simple sentences
Nutrition:
(Self-monitoring of nutritional status, such as weight gain/loss, appetite, maintaining
therapeutic diets, eating a well balanced diet [meats, vegetables, dairy, fruit].)
Does not monitor nutritional status
Monitors nutritional status with supervision or assistance on a daily basis
Monitors nutritional status with minimal (weekly) supervision or assistance
Independently self-monitors nutritional status
Food and meal preparation:
(Preparation of meals such as sandwiches, cold cereal, frozen dinners, eggs. Ratings should
be independent of whether items require heating or what method is used for heating [example:
microwave, regular oven, stovetop].)
Does not perform task, even with assistance
Able to prepare simple foods with assistance (Example: microwave frozen dinner,
pour cereal into a bowl and pour milk over it)
Prepares simple foods independently, prepares more complex meals with assistance
(Example: sandwich with two or more foods in the middle, salad and main course)
Prepares complex meals independently
Plans for meals, makes grocery shopping lists, prepares complex meals independently
Housekeeping:
(Such as vacuuming, dusting, sweeping, taking the trash out [No food prep].)
Does not perform tasks, even with assistance
Requires hands on assistance with these tasks
Able to complete tasks with verbal prompts, cue by touch or other modifications
such as verbal reminders or cleaning equipment laid out
Completes tasks independently (knows what to do and what times of day or days of week)
Managing prescription medications:
Patient:
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SDS 0487 (07/13)
Managing prescription medications:
Not applicable, does not require any routine prescription medication or is in a service
setting in which the individual is prevented from self-medication, such as an ICF/MR,
Regional Center or nursing home
Does not perform task, even when assisted; must be done for the individual
Requires hands-on assistance to initiate/complete the task
Able to complete the task with verbal prompts, cue by touch or other
modifications such as verbal reminders or medication laid out
Completes the task independently and knows what to take and takes at correct times
List types and doses of medications:
Attention span:
(Attention to specific activities which require person to focus his/her efforts, such as
cleaning up, performing work/school activities, reading, playing games. Does NOT
include responses to simple, direct, commands or non-purposeful activities such as
vacant staring at the TV or stereotypic behaviors.)
Does not keep attention focused on a single purposeful task or
activity regardless of supervision level
Keeps attention on a task or activity if frequent physical prompts are given
Keeps attention on task or activity if frequent verbal or
occasional physical prompts are given
Keeps attention on a task or activity if occasional prompts are given
Keeps attention on a task or activity for long periods of time without prompts
(example: most of workday)
Remembering instructions and demonstrations:
(Can recall examples of how to complete a task when shown or told how to do it.)
Displays no or extremely limited (rare or very incomplete) memory
of instructions or demonstrations
Displays memory of instructions or demonstrations if they are
repeated three or more times and if prompted to recall
Displays memory of instructions or demonstrations if they
are given once and if prompted to recall
Displays memory of instructions/demonstrations without prompting if they are given once
Math skills:
(Knowledge of numbers, counting, relative values, adding, subtracting, etc.
Handling money could be one example.)
Has no math skills, may say numbers at random
Understands more complex math concepts such as multi-digit subtraction,
multi-digit additions, multiplication, division; may use calculator
Money skills:
(Knowledge of concept, use of money for payment,
worth of coins and bills, planning and budgeting.)
Does not use money or understand the concept of money
Uses money and understands the concept of payment for purchases, but not the
value of coins or bills (Example: gives one dollar to purchase any item)
Patient:
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SDS 0487 (07/13)
Friendship formation:
(Establishes close social attachments characterized by companionship, sharing and affection.
Shows clear preference for the company of certain individuals.)
Does not form friendships
Potential friends must initiate friendships
Initiates and establishes friendships with difficulty
Initiates and establishes friendships easily
Friendship maintenance: (Maintains friendships for at least three months.)
Does not maintain friendships
Maintains friendships only in stable or familiar settings (classrooms, residence, etc.)
Maintains friendships in many different settings
Work related questions
Work:
Is this individual working? (Work may be integrated in the community, in a sheltered
environment or volunteer.)
Yes, continue to the next question
No, no current work involvement
Type of work:
(Check all that apply. For instance, someone could be in both paid work and volunteer work or
you could check both volunteer work and no paid work.)
Work is paid by hour or salaried
Work is paid by the piece
Work is volunteer
Pre-employment or work activities
No paid work (explain below)
Type of paid work:
If the individual has a paying job, please select the choice below which best matches the
individual’s work setting and support. (Choose the one setting where the individual spends
most of their working hours.)
Sheltered setting or workshop
Enclave in the community
Mobile crew
Community job, supported one-on-one on a community job, support is fairly frequent
Community job, most support on job is provided by employees at job location
(not specialized staff)
Other: (Clarify below.)
Initiative:
(Degree to which individual undertakes home or work-related tasks without having
to be reminded or encouraged.)
Shows no initiative in task performance, requires close supervision
Shows some initiative in task performance with some additional supervision
Shows some initiative in task performance with routine supervision
Patient:
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SDS 0487 (07/13)
Initiates new tasks independently without supervision
Making judgments:
(Degree to which individual assesses situations and makes good decisions or
draws sound conclusions.)
Never makes judgments
Makes some judgments with extensive outside assistance
Makes judgments with occasional prompts and assistance
Makes simple judgments independently
Makes more complex judgments independently
Expressing emotions:
(Level of clarity and complexity with which individual expresses feelings.)
Only expresses emotions nonverbally (for instance — smiling when happy, tears when sad)
Expresses emotions by name (for instance — “I am happy”, “I am angry”)
Expresses emotions and some understanding of their relationship to external
events and thoughts (for instance — why they are angry)
Expresses emotions and a good understanding of their relationships with
external events and thoughts
Psychiatric diagnoses:
Has this individual been diagnosed with one or more psychiatric conditions?
(These diagnoses must be based on assessment by a qualified psychiatrist,
other physician or psychologist.)
Note: The diagnosis must be documented in the person’s records.
Do not include any strictly medical diagnoses.
Do not include any diagnoses of developmental disabilities.
No, no psychiatric diagnoses
Yes, has at least one psychiatric diagnosis (list diagnoses below)
Psychoactive medication:
In the last calendar year, has this individual has a psychoactive medication prescribed by a
qualified physician or psychiatrist/psychologist?
No, no psychoactive medications
Yes, has received one or more psychoactive medications
Thoughts of suicidal or homicidal ideation:
Yes
No
Homicidal
Yes
No
Suicidal
Anxiety related behaviors:
(Customary pattern of intense apprehension, worry, fearfulness and anxiousness sometimes
accompanied with shortness of breath, palpatations, pain and discomfort, obsessions and
compulsions that disrupt participation in activities of daily living and increase isolation or
Patient:
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SDS 0487 (07/13)
severe dependency.)
Serious problem; totally inhibits daily functions and requires constant assistance
with total needs.
Moderate problem; substantially affects daily functioning and requires frequent
attention/intervention to assist with participation in daily activities.
Minor problem; impacts some daily functions but does not have a substantial impact and
requires minimal attention/intervention to assist with participation in daily activities.
No evidence of anxiety related behavior.
Depressive-related behaviors:
(Customary pattern of withdrawal, apathy or lack of energy that is not attributable to physical
illness or injuries. Includes listlessness, lethargy, excessive crying or other depressive-like
behaviors. May result in neglect of self-care, loss of self-help skills, loss of appetite, refusal to
participate in activities or disruption of normal sleeping patterns.)
Serious problem; totally inhibits daily functions and requires constant
assistance with total needs
Moderate problem; substantially affects daily functioning; requires frequent
attention/intervention to assist with participation in daily activities
Minor problem; impacts some daily functions but does not have a substantial impact;
requires minimal attention/intervention to assist with participation in daily activities
No evidence of depressive-like behavior
Involvement with criminal justice system:
Has this individual had any involvement with the criminal legal system?
(For the following two questions, charges must have been filed.
Guilt need not have been determined for listing here as an involvement.)
No, no criminal/legal involvement
Yes, has had involvement with the criminal legal system
Verbal or physical threatening:
(Threatens to do harm to self, others or objects. Do not include actual acts of physical
violence or self-injury, only threats.)
Extremely urgent problem; has had serious incident(s) in the last year; incidents always
generate fear and/or are likely to result in aggression from others; requires close
supervision and interruption; may result in legal action
Serious problem; frequent threats; sometimes results in fear and/or aggression from
others; requires close supervision and/or frequent interruption
Minor problem; threats are not taken seriously and do not frighten others nor
result in aggression from others; requires some additional supervision and/or
occasional interruption
No problems in this area
Self-injurious behavior:
(Any self-inflicted injuries or attempts to injure self; including but not limited to biting;
scratching; putting inappropriate objects into ear, mouth or nose; repeatedly picking at skin;
head slapping or banging; anorexia; attempted suicide.)
Extremely urgent problem; has had episode(s) causing serious injury requiring immediate
medical attention in the last year; requires close supervision and physical interruption;
may result in legal action against agency
Patient:
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SDS 0487 (07/13)
Serious problem; frequent incidents; requires close supervision and/or frequent
interruption; has had episode(s) which caused injury but which did not require
immediate medical attention
Minor problem; occasional incidents which require some additional supervision in a few
situations and/or occasional
No problems in this area
Destruction of property:
(Attempts to or destroys property, including but not limited to, tears, dents, breakage. Do not
include accidental destruction of property unless it is atypical pattern. Examples of serious
property damage: breaking windows, slashing tires, repeatedly tearing clothing, destroying
furniture. Examples of minor property damage: throwing chairs, occasional tearing of clothing.)
Extremely urgent problem; has caused serious property damage within the past year;
requires close supervision and physical interruption; may result in legal action
Serious problem; has frequent incidents causing minor damage; requires close
supervision and frequent interruption
Minor problem; causes occasional minor damage; requires some additional supervision
and/or occasional interruption
No problems in this area
Running or wandering away:
(Attempts to or leaves situations or environments inappropriately without following expected
procedures for notifying or receiving permission. Running or wandering occur after the person
has had supervised opportunities for exploring his/her environment.)
Extremely urgent problem; occurs frequently or poses a very serious threat to the safety of
self or others; requires close supervision and intervention; may result in legal action
Serious problem; occurrences pose minor safety issues to self or others; requires close
supervision and intervention
Minor problem; occurrences may not pose a safety problem but, do require some
additional supervision and/or occasional intervention
No problems in this area
Safety/health awareness:
(Places self or others in dangerous situations due to lack of awareness of safety and health
issues. Example: pica behaviors; not following safety rules regarding electricity, fire, water,
tools, traffic, interacting with strangers or not avoiding hazardous situations like open trenches,
broken windows, DO NOT use aggressive behaviors here.)
Extremely urgent problem; has seriously endangered self or others in last year; requires
close supervision in all settings; requires interruption to prevent serious injury
Serious problem; actions would frequently result in endangerment of self or others without
close supervision and/or frequent intervention
Moderate problem; endangers self or others only in special settings and requires close
supervision and interruption of endangering actions in those settings only
Minor problem; requires occasional interruption of endangering action; routine guidance
by a supervisor makes it unlikely that problem will occur
Does not endanger self or others
Patient:
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SDS 0487 (07/13)
Aggression toward people:
(Any physical attacks or attempts to attack others, including throwing objects, punching, biting,
pushing, pinching, pulling hair, scratching. DO NOT INCLUDE self-injurious behaviors,
threatening or property destruction.)
Extremely urgent problem; has caused serious injury requiring immediate medical
attention in the last year; requires close supervision and physical interruption;
may result in legal action
Serious problem; frequent aggression that requires close supervision and/or frequent
interruption; has had episode(s) which caused injury, but which did not require
immediate medical attention
Minor problem; occasional aggression which requires some additional supervision and/or
causes occasional interruption in a few situations
No problem in this area.
Mental health evaluation
Pre-Admission Level II
Resident Review Level II
Post-Admission
Data collected and attached:
H and P (medical hx, body systems, Neuro systems, etc.) including items which
are basis for NF placement
Drug history
Psychosocial evaluation
Psychiatric eval
ADL’s
Functional assessment
Relevant history:
Mental health:
Describe briefly:
Medical/physical:
Describe briefly:
Yes
No
Yes
No
Psychiatric hospitalizations:
Describe briefly:
Past psychiatric hospitalizations:
Describe briefly:
Patient:
Yes
No
Yes
No
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SDS 0487 (07/13)
Substance abuse:
Describe briefly:
Yes
Cultural/ethnic considerations:
Describe briefly:
Family/environmental:
Describe briefly:
Yes
No
Yes
No
No
Presenting problem/assessment:
Diagnosis:
Axis I:
Axis II:
Axis III:
Axis IV:
Axix V:
Patient:
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SDS 0487 (07/13)
Brief mental status exam (MSE) form
1. Appearance:
Casual dress, normal grooming and hygiene
Other (describe):
2. Attitude:
Calm and cooperative
Other (describe):
3. Behavior:
No unusual movements or psychomotor changes
Other (describe):
4. Speech:
Normal rate/tone/volume without pressure
Other (describe):
5. Affect:
Reactive and mood congruent
Labile
Tearful
Blunted
Other (describe):
Normal range
Depressed
Constricted
Flat
6. Mood:
Euthymic
Irritable
Elevated
Other (describe):
Anxious
Depressed
7. Thought processes:
Goal-directed and logical
Other (describe):
Disorganized
8. Thought content:
Suicidal ideation:
Passive
If active:
Yes
Plan:
Intent:
Means:
Delusions
Other (describe):
9. Perception:
10. Orientation:
11. Memory/concentration:
Patient:
None
Active
No
Homicidal ideation:
Passive
If active:
Yes
Plan:
Intent:
Means:
Phobias
None
Active
No
Obsessions/compulsions
No hallucinations or delusions during interview
Other (describe):
Oriented:
Time
Other (describe):
Place
Person
Self
Short term intact
Long term intact
Distractable/inattentive
Other (describe):
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SDS 0487 (07/13)
12. Insight/judgement:
Good
Fair
Poor
Mental health recommendations (evaluator): Attach additional page(s) as needed.
Evaluation completed by (include credentials, print)
Date
Signature:
Psychiatric review:
Name
Title
Presenting problem:
Medical review/recommendations (including medication review/recommendations):
Impression:
Treatment recommendations:
PMHNP, MD, PA name (print)
Date
Signature:
Patient:
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SDS 0487 (07/13)
Determination of need for PASRR SLS services
Answer all of the questions and provide brief explanations or examples of behavior to
justify each no response. Use additional sheets if necessary.
1.
Does this individual have the ability to care for most of their personal needs?
No (If no, explain below.)
Yes
2.
Is this individual able to understand simple instruction?
No (If no, explain below.)
Yes
3.
Is this individual able to communicate basic needs and wants?
No (If no, explain below.)
Yes
4.
Is this individual able to be employed at a productive wage level without systematic
long-term supervision or support?
No (If no, explain below.)
Yes
5.
Is this individual able to learn new skills without aggressive and consistent training?
No (If no, explain below.)
Yes
6.
Is this individual able, without aggressive and consistent training, to apply skills
learned in a training situation to other environments or settings?
No (If no, explain below.)
Yes
7.
Is this individual able, without direct supervision, to demonstrate behavior appropriate
to the time, situation or place?
No (If no, explain below.)
Yes
8.
Is the individual able to make decisions requiring informed consent?
No (If no, explain below.)
Yes
9.
Does this individual demonstrate severe maladaptive behaviors that place self or
others in jeopardy with regard to health and safety?
Patient:
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SDS 0487 (07/13)
Yes (If yes, provide example below.)
10.
No
Does this individual have other specific skill deficits or other specialized training
needs that necessitate the availability of staff trained in developmental disabilities
24 hours/day, to teach functional skills?
Yes (If yes, provide example below.)
No
Does the individual want to be placed or remain on a list for movement from the
nursing facility?
Yes
No
(If Yes, describe the type of service or support needed and level of funding necessary.)
If the answer to #7 was No, is the individual receiving skilled nursing care at the facility that
cannot be provided in a less restrictive setting?
Yes
No
(If Yes, describe the skilled nursing care the person is receiving.)
If the answer to #7 and #8 were No, why does the individual want to
remain in the nursing facility?
Is the individual appropriate for specialized services (vocational)?
If No, list the reasons why:
Yes
No
List unique services the nursing facility must provide because the person has a developmental
disability. (Services may include health rehabilitation services; services of lesser intensity.) If
possible, incorporate person centered planning.
Does the nursing facility provide all needed services? (Include services listed above in
addition to services listed on the nursing facility Plan of Care.)
Yes
No
(If No, attach a plan to provide needed services within 30 days or
a plan to seek an alternative setting.)
Patient:
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SDS 0487 (07/13)
Determination of need for nursing facility
Is placement in the nursing facility appropriate?
Yes
No
(If No, do not answer the remaining questions on this form. Instead, please explain your
answer. Use the back or a separate sheet as needed. Then, sign the form and submit to DDD.
Include in your explanation whether your No answer means “no nursing facility is appropriate”
or whether it means “this particular facility is not appropriate but, another may be.”)
(If Yes, proceed to the remaining questions.)
If nursing facility placement is not appropriate are there Community Based Care options
available?
Yes
No
Is nursing facility placement authorized?
date of the authorized stay:
Yes
No If yes, what is the ending
Describe all the less restrictive community-based residential settings that have been explored
for this individual and explain why each setting is not appropriate. Include both existing settings
and those that could be created. Be specific. (Example: do not say, “the person’s medical
needs can’t be met.” say, “we do not have and cannot create any setting that administer IV
medication three times a day.”)
List all nursing facility services that are required.
(Example: therapies, health rehabilitation services.)
Authorized Signature
Patient:
Date
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SDS 0487 (07/13)