Adult Long-Term Care Functional Screen
Glossary of Acronyms (PDF) | LTC FS Paper Form (PDF)
LTC FS Instructions Module 10: Completion of the LTC FS and Notes
By the end of this module you should be able to:
Indicate the date on which all sections of the LTC FS were complete. It may take more than one day to complete all sections (ADL, IADL, HRS table, etc.), especially if a screener must wait for information from health care providers. Therefore, the Screen Completion Date is not always the date information is entered in the online LTC FS.
When correcting information on a screen, do not change the “Screen Completion Date.” Change this date when entering information that reflects a change in the functional abilities of the person being screened.
Do not change the Screen Completion Date when transferring a screen to another screening agency or to the Include, Respect, I Self-Direct (IRIS) program.
This is the amount of time the screener spent face-to-face meeting with the person being screened. The screening process requires face-to-face contact with the individual being screened. No screen may be completed without meeting with the individual, even if he or she is unable to communicate or has a guardian of his or her person or an activated power-of-attorney for healthcare.
The following types of contacts are not to be recorded as face-to-face contact:
When multiple screeners are present, record the combined amount of time they spent in face-to-face contact.
Round all contact time to the nearest 15 minute increment.
Waiving the Face-to-Face Contact Requirement for the Initial
Screen for an Applicant Out of State
Requests from a screening agency to waive this requirement will be considered for the initial Functional Screen, only, on a case-by-case basis, when the following criteria are met:
If the Department waives the face-to-face requirement, the functional screen must be completed based upon a review of records and must occur during a telephone or video conference call, or internet video that includes the individual, his or her parent (if a minor), guardian or legal representative and a credentialed professional knowledgeable about the individual and his or her daily care needs (e.g., nurse, teacher or caregiver). The notes section of the screen that is completed based on a waiver of this nature must indicate whether the screen was completed during a telephone call, video conference call or internet video and include the date of the DHS approval to waive the face-to-face contact requirement.
When a screening agency has received a waiver of face-to-face screening for any individual, a subsequent face-to-face screening must occur within 30 days of enrollment into a long-term care program.
When a screening agency has received a waiver of face-to-face screening for any individual, the agency must inform the individual that screening results are preliminary, as screen information was based on records and verbal responses, only. The individual must also be informed that long-term care programs have financial and residency requirements, and may have waiting lists. Eligibility based on the screen, alone, does not guarantee the provision of services.
Process for Requesting Waiver of Face-to-Face Contact for an Initial Screen:
Collateral contact is the amount of time the screener spent face-to-face or by telephone in a two-way exchange of information with collateral contacts to confirm information provided by the person being screened. Collateral contacts may include, but are not limited to, a person’s guardian, family members, friends, health care providers, authorized representative and service provider
Time spent conversing with others who are present while a person is being screened. If a person’s caregiver is present during the time a screener is conducting a screening, the time spent is recorded as face-to-face time with the person being screened. None of the time is recorded as collateral contact with the caregiver.
The following contacts are not collateral contacts and should be recorded under 10.4 Other Screen Related Activity (Paper Work):
Round all contact time to the nearest 15 minute increment.
Count as other screen related activity the amount of time spent completing paperwork, paper research, in-direct, non-face-to-face contact with the person being screened and in one-way communication with others to complete the LTC FS.
The time spent completing the following paperwork tasks and one-way communication of information must be recorded as screen related activity:
Round screen-related activity time to the nearest 15 minute increment.
This is the amount of time the screener spent traveling to and from appointments associated with the gathering of information necessary to complete the LTC FS.
When multiple screeners are present, record their combined travel time.
Round travel time to the nearest 15 minute increment.
Screeners are strongly encouraged to enter additional explanatory information in the notes sections of the online LTC FS. Notes clarify why a selection was made on the screen and substantiate the screener’s selections on the screen should the individual who was screened file an appeal of his or her level of care. Notations that explain how an individual being screened meets the selected target group and or how diagnosis was verified are particularly helpful.
Use the following guidelines when entering notes:
Calculating eligibility is the step that makes a functional screen ‘complete’. Both initial and rescreens must be calculated to be complete.
When a screener first enters information into Functional Screen Information Access (FSIA), the screen is incomplete until eligibility is calculated. The screen shows as incomplete when a blue arrow is found next to the Eligibility section in the Adult LTC Screen Status column, in the left-had margin of the screen. To direct FSIA to complete a screen and calculate eligibility, the screener selects the Calculate Eligibility button. Once eligibility is calculated, the blue arrow becomes a green checkmark.
Not all edits or changes made to an existing screen require recalculation of eligibility. However, eligibility must always be recalculated when a change is made that is related to an individual’s functional status, diagnosis, HRS, ADLs or IADLs.
Do not recalculate eligibility when transferring a screen to another screening agency.
Once eligibility has been calculated for a particular screen and individual, the screener cannot change the individual’s name, Social Security number or date of birth. When a correction is needed in regarding to these items, contact the DHS Help Desk at 608-266-9198 for assistance.
REMINDER: Whenever the screen status shows a blue arrow, eligibility must be calculated in order to complete the screen.
Note: COP Level 3 only applies to Home and Community-Based Waiver Counties and to Resource Center Counties without a Managed Care Organization.
The COP Level 3 page is optional and should be used after the person has been fully screened to test for waiver eligibility.
Part A - Alzheimer’s and related diseases:
2. The person needs personal assistance, supervision and protection, and periodic medical services and consultation with a registered nurse, or periodic observation and consultation for physical, emotional, social or restorative need, but not regular nursing care.
Alzheimer’s disease and other irreversible related dementia describes a degenerative disease of the central nervous system characterized especially by premature senile mental deterioration and also includes any other irreversible deterioration of intellectual faculties with concomitant emotional disturbance resulting from organic brain disorder.
Irreversible dementia diagnoses include, but are not limited to:
Consult with a healthcare professional to confirm the irreversible nature of a diagnosis that is not listed above before recording it as a dementia diagnosis during screening.
Diagnoses of Mild Cognitive Impairment or cognitive Impairment NOS are not irreversible dementia diagnoses and should be recorded as E6-Other Brain Disorders.
Part B – Interdivisional Agreement 1.67:
Applies to individuals for whom a DHS/Division of Quality Assurance nursing home surveyor has issued a 1.67 administrative order to refer the individual to the county for nursing home discharge and alternative living arrangement (or other needed services).
The Adult LTC FS NAT section must be completed for any individual who qualifies for a target group based on the Intellectual/Developmental Disability per Federal Definition.
Be aware that a NAT determination is not the same as a Pre-Admission Screening and Annual Resident Review (PASARR) determination. When an individual has received a determination of NAT, he or she is not necessarily exempt from a PASARR determination.
To augment your understanding of the text that follows, refer to the NAT page on the paper form and the NAT algorithm in the Appendices at the end of this instruction manual.
“No Active Treatment” (NAT) is a designation given to individuals with an intellectual/developmental disability who, for either health reasons or because of advanced age, no longer require treatment related to their intellectual/developmental disability. In addition, a person with an intellectual/developmental disability such as cerebral palsy but with a normal IQ could be appropriate for a NAT designation.
In order to use Medicaid funds for Family Care (FC) services, the U.S. Centers for Medicare and Medicaid Services (CMS), has granted Wisconsin two separate home and community-based waivers. One is for frail elders and people with physical disabilities, and one is for people with intellectual/developmental disabilities. CMS requires that individuals with an intellectual/developmental disability receive services through the intellectual/developmental disabilities waiver unless there is documented evidence that active treatment for the intellectual/developmental disability is not required. This decision would result in a NAT designation for such an individual.
There are limited circumstances in which a NAT designation would be beneficial to a FC consumer. The care planning process in FC is the same for all members, whether they have an intellectual/developmental disability or not, so any appropriate active treatment would be included no matter which waiver they are in. The only reason to process a NAT designation is related to a difference in the residential services allowable for people enrolled in the FC intellectual/developmental disabilities waiver, versus people enrolled in the FC elderly/physical disabilities waiver. Residential services for individuals in the FC intellectual/developmental disabilities waiver must be provided in a setting of 4 or fewer beds (MCOs can obtain a waiver for settings up to 8 beds). For individuals in the FC elderly/physical disabilities waiver, there is no limit on size or type of residential facility.
The county Economic Support (ES) unit must enter the appropriate waiver and level of care on the CARES system to complete the eligibility determination and FC enrollment process. In non-FC counties, assessment and care planning activities occur before eligibility determination, so the long-term care program has had an opportunity to determine if an individual with an intellectual/developmental disabilities should receive active treatment, or whether he/she should have a NAT designation. In Family Care counties, the MCO does the assessment and care plan after the individual enrolls.
In order for an appropriate waiver to be designated by an Aging and Disability Resource Center at enrollment, before a long-term care program has finished its comprehensive assessment and care plan, the initial Long Term Care Functional Screen (LTC FS) will automatically designate the intellectual/developmental disabilities waiver if the individual has been checked as being in the federal intellectual/developmental disabilities target group, (regardless of whether other target groups are checked). Similarly, if a diagnosis typically associated with an intellectual/developmental disability (i.e., cerebral palsy, muscular dystrophy) has been checked, the LTC FS will default to the FC intellectual/developmental disabilities waiver.
A NAT designation can be entered if the screening agency has sufficient information, or if a long-term care program’s comprehensive assessment supports a NAT designation.
The NAT Section contains two parts, A and B. When completing an Initial Screen, the Resource Center screener should complete Part A of the section, if he or she has sufficient information to respond to Part A statements. To avoid delaying an individual’s functional eligibility determination, Part A statements can be left unanswered until sufficient information is available. Part B statements should be completed by a screener at the program in which the applicant has chosen to enroll.
Part A statements:
For the purposes of the LTC FS, a terminal illness is defined as a condition in which death is expected to occur within one year from the date of screening.
Statement 2 should be left unanswered if the screener does not have documented information on the individual’s full-scale IQ score. Do not assume a person’s full-scale IQ is 75 or less based on a diagnosis such as Intellectual Disability or Down’s Syndrome. IQ score must be available and documented. Conversely, do not assume a person’s IQ score is above 75 when no diagnosis of Intellectual Disability has been made.
Not Applicable (NA) may be selected in response to Statement 2 when an individual’s IQ has not been determined due to difficulty in testing and, if testing had been completed, results would have confirmed a clinician’s diagnosis such as Profound Intellectual Disability.
“No” should be selected in response to Statement 2 when an individual’s full-scale IQ has been tested and found to be lower than 75.
After an individual enrolls in Family Care, PACE, Partnership or IRIS, the program’s screener should complete Part B of the NAT Section of the LTC FS. If all statements included in Part A are not completed, the program’s screener should also complete Part A.
Part B Statements:
Documentation (e.g., neuropsychiatric evaluation report, IQ testing result) that supports why a designation of NAT has been made must be retained in the individual’s record at the program agency. The individual and his or her guardian or authorized representative should be encouraged to keep a copy of this documentation.
April 29, 2014