LTC FS Instructions Module 10 - Completion of the LTC FS and Notes

Adult Long-Term Care Functional Screen
Glossary of Acronyms (PDF)  |  LTC FS Paper Form (PDF)



By the end of this module you should be able to:

  • Record the Screen Completion Date.
  • Accurately record the time it took to complete a screen.
  • Record face to face and collateral contact time.
  • Record paperwork and contact time.
  • Utilize the Notes utility built into the LTC FS application.
  • Calculate functional eligibility (level of care).
  • When applicable, complete the COP Level 3 Section.
  • When applicable, complete the No Active Treatment Section.

10.1 Screen Completion Date

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.

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10.2 Face to Face Contact with Person

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:

  • Face-to-face contact with the person's guardian, authorized representative or any other collateral contacts.
  • Telephone contact, video conference, internet video, fax or email communication with the person being screened, their guardian, authorized representative or any other collateral contacts.

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
In rare instances, there may be a need to complete a screen for a person who is currently located or residing in a state other than Wisconsin. In these instances, the screening agency must obtain approval from the Department of Health Services (DHS) to conduct a screen without face-to-face contact.

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:

  • There is a compelling reason to conduct the screen, even though the person being screened is not physically located in Wisconsin. Program policies define when an agency must provide screening and assessment for state and federal programs. Agency protocols should indicate when and why a screen may be conducted prior to the physical presence of an individual in the agency's service area.
  • Traveling to conduct the screen is a hardship to the agency. Hardships might include the need for air travel, overnight stay, excessive loss of work time (more than one workday), etc. It is not considered a hardship when the individual requesting screening lives in a bordering state to which a screener could travel without excessive cost or loss of work time.
  • The screening agency has attempted to arrange for screening to be performed by screening agency located closer to the individual, or such an attempt is unreasonable. The screen is site neutral and screening instructions are uniform across all adult LTC programs.
  • The screening agency does not have other responsibilities for the person that require face-to-face contact. If the screening agency is the placing agency or county of responsibility for an annual Watts Review or has other court ordered responsibilities for an individual, screening should occur in conjunctional with these other requirements.

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:

  • The screening agency's LTC FS liaison will email the request to the DHS Functional Screen Operations Section, attention The submission must include the reasons for the request, based on the criteria listed above.
  • As needed, Functional Screen Operations Section will consult other state program staff to determine the appropriateness of waiving the face-to-face contact requirement.
  • Within 10 working days of the request, the Functional Screen Operations Section will notify the screening agency's liaison of approval or denial of the agency's request.

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10.3 Collateral Contacts

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):

  • Communication with the person being screened, by:
    • Telephone
    • Telephone voice mail
    • Video conference
    • Internet video
    • Written information
    • Fax
    • Email
  • One-way communication with someone other than the person being screened (e.g., guardian, healthcare providers), by:
    • Telephone voice mail
    • Written information
    • Fax
    • Email

Round all contact time to the nearest 15 minute increment.

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10.4 Other Screen-Related Activity (Paper Work)

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:

  • Communication with the person being screened, by:
    • Telephone
    • Telephone voice mail
    • Video conference
    • Internet video
    • Written information
    • Fax
    • Email
  • One-way communication with someone other than the person being screened (e.g., guardian, healthcare provider), by:
    • Telephone voice mail
    • Written information
    • Fax
    • Email
  • Review of previous Adult or Children's LTC FS, written documentation, test results, evaluation reports or other medical information.
  • Consultation with the agency screen liaison, co-workers or DHS staff regarding any aspect of an individual's screen.
  • Completing the online LTC FS.

Round screen-related activity time to the nearest 15 minute increment.

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10.5 Travel Time

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.

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10.6 Notes

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:

  • Notes should be dated with the month, day and year.
  • When new notes are added, the most current notes should be entered at the top of the notes section.
  • At a minimum, notes should be initialed by the screener. It is best practice to include the screener's full name, screening agency and professional designation at the end of any notes.
  • Notes should be concise and provide consumer-specific information, only. Notes should be written in a style that is factual, objective, unbiased, without jargon and concise. Notes should be easily read and understood by others, including the person being screened, should he or she request a copy of the screen.
  • Notes must indicate the source of referenced information. For example: "SSA verified disability code as 3180 (MR). Neuropsychiatric evaluation on 12/23/12 by John Smith, PhD, lists diagnoses of ID, ADHD and Depression. Full Scale IQ 68" or "1/13/13 phone call with Dr. Smith's nurse verified the Parkinson's disease with dementia diagnosis."
  • Notes that are no longer accurate or relevant should be deleted. These notes are saved in screen history.
  • Notes should not include personal information about people other than the individual who is being screened.
  • Example of an appropriate note: "January 12, 2003: Ms. Washington has many throw rugs on her wooden floors. We spoke briefly about falling, but this should be pursued further. She is able to prepare meals, but is inclined to get by on sweets because it is too much trouble to cook for one. --Susan Smith, RN, Wisconsin MCO"

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10.7 Calculating Eligibility

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.

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10.8 COP Level 3 (For Home and Community Based Waiver Counties Only)

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:
1. The person has a physician's written and dated statement that the person has Alzheimer's and/or another qualifying irreversible dementia.

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:

  • Alzheimer's Disease
  • Creutzfeld-Jacob Disease
  • Friedrich's Ataxia
  • Frontotemporal Dementia
  • Huntington's Disease or Huntington's Chorea with Dementia
  • Lewy Body Dementia
  • Multi-Infarct Dementia
  • Mixed Dementia
  • Normal Pressure Hydrocephalus
  • Parkinson's Disease with Dementia
  • Pick's Disease
  • Progressive Supranuclear Palsy
  • Vascular Dementia
  • Wernicke-Korsakoff Syndrome
  • Wilson's Disease

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:
1. The person resided in a nursing home or received CIP II/COP-W services and was referred through Interdivisional Agreement 1.67 in accordance with s. 46.27(6r)(b)(3).

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).

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10.9 No Active Treatment (for Family Care MCO, IRIS, PACE and Partnership Counties, Only)

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:

  1. The person has a terminal illness.
  2. The person has a documented IQ greater than 75.
  3. The person is ventilator-dependent.

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:

  1. The person has physical or mental incapacitation due to advanced age such that his or her needs are similar to those of geriatric nursing home residents.
  2. The person is elderly (generally over age 65) and would no longer benefit from active treatment.
  3. The person has severe chronic medical needs that require skilled nursing level of care.

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.

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Last Revised: November 30, 2015