Free Care Level Determination Worksheet-F-62288 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62288 (Rev. 07/08)

STATE OF WISCONSIN
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CARE LEVEL DETERMINATION WORKSHEET
FOR NURSING FACILITIES
Completion of this form is voluntary. Personally identifiable information will be used to determine the level of care for Medicaid reimbursement and will be used for no other purpose. Refer to the Long Term Care Resident Assessment Instrument User's Manual, for assistance when completing this form. Complete and submit this form to your Division of Quality Assurance Regional Office. AA.1. Resident Name a. First b. MI AA.5a. Social Security Number c. Last d. Jr/Sr AA.5b. Medicare Number

SECTION AB 10. CONDITIONS RELATED TO MR/DD STATUS No MR/DD ­ Not Applicable MR/DD with Organic Condition Down's Syndrome Autism Epilepsy Other organic condition related to MR/DD MR/DD with No Organic Condition SECTION E. MOOD AND BEHAVIOR PATTERNS Indicators of Depression, Anxiety, Sad Mood Code for indicators observed in last 30 days, irrespective of assumed cause 0 = Indicator not exhibited in last 30 days 1 = Indicator of this type exhibited up to five days a week 2 = Indicator of this type exhibited daily or almost daily (6, 7 days a week) Resident made negative statements (e.g., "Nothing matters." "Would rather be dead." "What's the use?" Regrets having lived so long; "Let me die.") Persistent anger with self or others (e.g., easily annoyed, anger at placement in nursing home, anger at care received) Repetitive health complaints e.g., persistently seeks medical attention, obsessive concern with body functions) Repetitive anxious complaints/concerns (non health related) (e.g., persistently seeks attention/ reassurance regarding schedules, meals, laundry, clothing, relationship issues) Repetitive physical movements (e.g., pacing, hand wringing, restlessness, fidgeting, picking) G.B. ADL Support Provided Code for most support provided over all shifts during last 7 days; code regardless of resident's self-performance classification.) See (A) Self Performance codes See (B) Support Provided codes Bed Mobility Transfer Locomotion ­ on unit Locomotion ­ off unit Dressing Eating Toilet Use Personal Hygiene (A) Self Perf. a. b. e. f. g. h. l. j. (B) Support a. b. e. f. g. h. l. j. b. c. d. e. f. a. Diarrhea

SECTION H.2. BOWEL ELIMINATION PATTERN Constipation Fecal Impaction SECTION I. DISEASE DIAGNOSES Check only those diseases that have a relationship to current ADL status, cognitive status, mood and behavior status, medical treatments, nursing monitoring, or risk of death. Do not list inactive diagnoses. 1. DISEASES Endocrine / Metabolic / Nutritional Diabetes mellitus Hyperthyroidism Hypothyroidism Heart / Circulation
Arteriosclerotic heart disease (ASHD)

b. c. d.

Hemiplegia / Hemiparesis Multiple Sclerosis Paraplegia Parkinson's disease Quadriplegia

v. w. x. y. z.
aa. bb. cc.

a. b. c.

d. e. f. g. h. I. j. k. l. m. n. o. p. q. r. s. t. u.

Seizure disorder
Transient ischemic attack (TIA)

a.

Cardiac dysrhythmias Congestive heart failure Deep vein thrombosis

Traumatic brain injury Psychiatric / Mood Anxiety disorder Depression Manic depression (bipolar disease) Schizophrenia Pulmonary Asthma Emphysema / COPD Sensory Cataracts Diabetic retinopathy Glaucoma Macular degeneration Other Allergies Anemia Cancer Renal Failure

d.

Hypertension Hypotension

dd. ee. ff. gg.

h.

Peripheral vascular disease Other cardiovascular disease Musculoskeletal

l. n.

Arthritis Hip fracture Missing limb (e.g., amputation) Osteoporosis Pathological bone fracture Neurological Alzheimer's disease Aphasia Cerebral Palsy
Cerebrovascular accident (stroke)

hh. ii.

jj. kk. ll. mm.

nn. oo. pp. qq.

Dementia other than Alzheimer's disease

Care Level Determination Worksheet F-62288 (Rev. 07/08) SECTION I.3. OTHER CURRENT DIAGNOSES a. b. c. d. e. SECTION J.1. PROBLEM CONDITIONS Check all problems present in last 7 days unless another time frame is indicated. Recurrent lung aspiration in Dizziness / vertigo f. the last 90 days Edema g. Shortness of breath Fever h. Syncope (fainting) Hallucinations Internal bleeding I. j. Vomiting
. . . . .

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SECTION M. SKIN CONDITION 1. Ulcers (Due to any Cause) k. l. m. o.
Record the number of ulcers at each ulcer stage, regardless of cause. If none present at a stage, record "0" (zero). Code all that apply during last 7 days. (Code 9 = 9 or more.)

Requires full body exam. Stage 1 A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved. A partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater.

Number at Stage

a.

SECTION J. - PAIN SYMPTOMS 2. Pain Daily SECTION J.3. PAIN SITE Joint pain (other than hip) SECTION K.5. NUTRITIONAL APPROACHES Feeding tube SECTION P. 1a. SPECIAL CARE Chemotherapy Dialysis IV Medications Oxygen therapy Radiation a.. b. c. g. h. SECTION P. 1b THERAPIES Record the number of days and total minutes each of the following therapies was administered (for at least 15 min/day) in the last 7 calendar days. Enter "0" if none or less than 15 minutes daily. NOTE: Count only post admission therapies. (A) No. of Days Administered for 15 Min. or More (B) Total No. of Minutes Provided in Last 7 Days a. Speech (language pathology and audiology services) b. Occupational therapy c. Physical therapy d. Respiratory therapy e. Psychological therapy (by any licensed mental health professional) COMMENTS Days (A) Minutes (B) Suctioning Tracheostomy care Transfusions I. j. k. Stage 4 b. g. Stage 3 Stage 2

b.

A full thickness of skin is lost, exposing the subcutaneous tissues; presents as a deep crater with or without undermining adjacent tissue. A full thickness of skin and subcutaneous tissue is lost exposing muscle or bone. 4. Other Skin Problems or Lesions Present Check all that apply during last 7 days.

c.

d.

Abrasions, bruises Burns (second or third degree) Rashes (e.g., intertrigo, eczema, drug rash, heat rash, herpes zoster) Skin desensitized to pain or pressure Skin tears or cuts (other than surgery) Surgical wounds NONE OF THE ABOVE

a. b.

Open lesions other than ulcers, rashes, cuts (e.g., cancer lesions) c. d. e. f. g. h.

PERSON COMPLETING THIS FORM SIGNATURE ­ Person Completing this Form Title Date Signed