Free 48115.fh8 - Indiana

450B ATTACHMENT FOR THE AGED & DISABLED WAIVER, THE MEDICALLY FRAGILE CHILDREN WAIVER, THE TBI WAIVER, AND THE AL AND AFC WAIVER
State Form 48115 (R2 / 9-01) / HCBS 0011

The information contained on this form is CONFIDENTIAL according to IC 4-8-1, IC 12-15-2, IC 12-10-10 and IC 12-21.
Name RID:

SECTION 1. A & D WAIVER, MEDICALLY FRAGILE CHILDREN WAIVER, THE TBI WAIVER, AND THE AL AND AFC WAIVER MENTAL ILLNESS AND DEVELOPMENTAL DISABILITY SCREEN 1. Does the individual have a documentable diagnosis of senile or presenile dementia (including Alzheimers Disease or related disorder) based on criteria in DSM-III-R, without a concurrent primary diagnosis of a major mental illness or a diagnosis of mental retardation or developmental disability? Yes No

2. Does the individual have a documentable diagnosis of a major mental illness [limited to the following disorders: schizophrenic, schizoaffective, mood (bipolar and major depressive type), paranoid or delusional, panic or other severe anxiety disorder; somatoform or paranoid disorder, personality disorder; atypical psychosis or other psychotic disorder (not otherwise specified; or another mental disorder that may lead to a chronic disability]? Yes No 3. Does the person have a diagnosis of mental illness not listed above? List diagnosis: 4. A Has the person had any recent (within the last two years) history of outpatient care or supportive services for a condition of mental illness? Yes If "Yes", explain: No Yes No

B. Has the individual been prescribed (within the past year) a major tranquilizer or psychoactive drug on a regular basis for a mental health condition listed in number 2 or 3 above? (If given for another purpose, explain by listing the name of the drug and the purpose of the prescription; for example, Mellaril for dementia. When explained and documented in the individual's medical record, check "No".) Yes No 5. Is there any presenting evidence of mental illness including possible disturbances in orientation, affect of mood? (If the problem is attributed to Yes a condition of dementia, explain and check "No".)

No

6. Does the individual have a diagnosis of mental retardation, developmental disability (MR/DD) or other related condition? (If "Yes" complete section 2) Yes No 7. Is there any history of a MR/DD or related condition in the individual's past? (If "Yes" complete section 2) Yes No

8. Is there any presenting evidence (cognitive or behavior characteristics) that may indicate that the person has - MR/DD or related condition? (If "Yes" complete section 2) Yes No If "Yes", explain:

Signature of assessor

Title / Position

Date signed

Should the applicant be approved for the Aged & Disabled Waiver, the Medically Fragile Children Waiver, the TBI Waiver or the AL and AFC Waiver, and choose nursing facility placement at any time while on the Waiver, the PASRR Level I assessment and Level II (if required) must be completed prior to admission. The applicant must sign that he / she has read and understands this policy.

I understand that if level of care is approved for the Aged & Disabled Waiver, the Medically Fragile Children Waiver, the TBI Waiver, or the AL and AFC Waiver, and if, for whatever reason, I need nursing facility placement, it will be necessary to complete the PASRR Level I assessment and the Level II (if required) prior to nursing facility admission.
Signature of applicant Date signed

SECTION 2: AGED & DISABLED WAIVER, MEDICALLY FRAGILE CHILDREN WAIVER, TBI WAIVER, AND THE AL AND AFC WAIVER DEVELOPMENTAL DISABILITY WORKSHEET
Name RID:

Depending on the medical needs and / or geriatric needs, an individual with a developmental disability may meet the level of care criteria for the Aged & Disabled Waiver, the Medically Fragile Children Waiver, or the TBI Waiver. However, if the individual has specialized services needs, he / she MAY be appropriate for the ICF / MR Waiver. THE A & D WAIVER, THE MEDICALLY FRAGILE CHILDREN WAIVER, THE TBI WAIVER, AND THE AL AND AFC WAIVER ARE NOT APPROPRIATE AS AN INTERIM MEASURE FOR AN INDIVIDUAL WHO IS AWAITING AN ICF / MR WAIVER SLOT AS THE ALTERNATIVE PLACEMENT IS A NURSING FACILITY RATHER THAN AN ICF / MR FACILITY. While the PASRR Level II process is not required for determination of eligibility for the A & D Waiver, the Medically Fragile Children Waiver, the TBI Waiver, or the AL and AFC Waiver, the individual MUST have medical needs to meet Indiana's nursing facility level of care criteria. To determine that the individual meets the nursing facility criteria rather than the ICF / MR level of care criteria, additional information may be necessary. The following information will aid in identifying whether an individual's needs are appropriate for the A & D Waiver / Medically Fragile Children Waiver / TBI Waiver / AL and AFC Waiver or whether further evaluation is necessary to determine if the individual's needs are appropriate for the ICF / MR Waiver. CHECK ALL THAT APPLY: Person is over 60 years of age (see IDDARS Comments Sheet, this is NOT an exemption). Person is under 60 years of age, but conditions of aging may adversely affect participation in specialized services (explain in comments). Person does not desire to participate in specialized services (comments must explain how this was determined). History of Service Participation (list in comments). Person is school-aged or preschool aged, receiving services through the school system (list services in comments). Health / Medical issues (must be explained in comments). COMMENTS (may use attachments to this form)

Completed by

Title / Position

Date

NOTE: If none of the above apply, a D & E will be needed for level of care determination. Regardless of how many of the above apply, OMPP may request a D & E to clarify level of care.

SEE ATTACHED COMMENTS FROM IDDARS REGARDING INDICATORS THAT SPECIALIZED SERVICES MIGHT NOT BE REQUIRED FOR AN INDIVIDUAL.

INDICATORS OF PERSONS WHO DO NOT REQUIRE SPECIALIZED SERVICES Service coordinators and nursing facility staff are challenged to ascertain those activities which have meaning and value to individuals who routinely decline to participate in any or all offered activities. It must be determined that these apparent choices are not based on fear, lack of experience, low self-esteem, or behavioral manipulation, as opposed to duly considered and informed choice. Documentation of activities to appropriately present service options to these individuals is required. The following indicators are considerations for determining that an individual does not require specialized services. In and of themselves, their presence does not constitute an exemption or release from participation. It is suggested that the indicators be used as considerations in guiding the decision making process. It is recommended that staff approach this determination as a question of quality, not quantity (i.e. presence of 3 of 4 indicators). AGE - It does not seem appropriate to "push" older persons into participation in specialized services. Although the age factor varies from person to person, it is appropriate to consider relaxing expectations on persons who are 60 years old or older. There may be individuals in their 70s or 80s who willingly or even avidly embrace specialized services, as well as individuals in their late 40s or 50s who decline participation. Therefore, each person must be considered relative to his or her own circumstances. DESIRE - Some individuals are motivated and desire to participate in the opportunities and experiences afforded by specialized services. A few individuals may not. Before accepting this apparent lack of desire as a rationale that the individual does not require specialized services, it is essential that the service coordinator work with nursing facility staff and families to ascertain what activities have value and meaning to individuals. A person may decline to participate out of fear, lack of experience, habit, or other unstated reasons. The process of assuring that an individual does not desire to participate must be creatively explored and thoroughly documented. HISTORICAL LACK OF PARTICIPATION IN / ACCESS TO SERVICES - It is not uncommon to find individuals, especially older persons, who due to geographical isolation, family preference, or lack of service availability have never been in educational, vocational, or other day services. It is not appropriate to require a person over sixty, who has no experience with receiving services, to suddenly "need" specialized services. HEALTH / MEDICAL / NEUROLOGICAL - Health and medical concerns are the most common consideration in determining that persons do not require specialized services. The following factors can be used to analyze the impact of medical concerns: * Diagnosis; * Medical history; * Physician's orders; * Frequency of orders; * Evidence of deterioration while participating in specialized services; * Stamina. Again, the presence of a particular diagnoses, set of physician's orders, or even history of deterioration during participation does not automatically constitute rationale that the person does not need specialized services. Services may need to accommodate medical treatment issues or be modified to permit participation. Some neurological impairments make it difficult, if not impossible, for an individual to benefit from specialized services. Additional assessment may clarify the expectation of benefit.