LTCFS Instructions Module 5: Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs)

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Contents

Objectives

By the end of this module, the screener should be able to:

  • Define the six activities that make up the Activities of Daily Living (ADL) section.
  • Define the six activities that make up the Instrumental Activities of Daily Living (IADL) section.
  • Describe how to apply the coding for level of help needed, and properly code “who will help in the next 8 weeks” for each ADL/IADL.
  • Identify the adaptive equipment items that are included in the ADL section of the Long Term Care Functional Screen (LTCFS).
  • Define significant, negative health outcomes and provide examples of simple, reasonable adaptations.
  • Identify and correctly enter primary and secondary diagnoses that cause any need identified in this module.

Definitions

Cognitive impairment: A cognitive impairment in the LTCFS is defined as a permanent impairment of thought due to a severe and persistent mental illness, dementia, brain injury, intellectual/developmental disability, or other organic brain disorder.

  • A cognitive impairment does not include temporary impairment due to medications and/or substance use intoxication.
  • A cognitive impairment does not include temporary impairment due to a temporary medical condition such as infection, electrolyte imbalance, or dehydration.

Declining the task: A person declines a task when that person decides not to complete one or more health-related services or tasks included on the HRS table or in the IADL Medication Management and Medication Administration. Refer to the General Guidance section in this module for specific details to consider when a task has been declined.

Need for assistance: A need for assistance in the LTCFS is the NEED for “help from another person,” which is defined as supervision, cueing, and/or hands-on assistance (partial or complete). Refer to the General Guidance section in this module for specific details about need for assistance.

Memory loss: An unverified diagnosis of Memory Loss can only be selected on the Diagnoses Table and, therefore, as a primary or secondary diagnosis, if the Animal Naming Tool is administered and the score is less than 14 and the Mini-cog is administered with results of 0, 1, or 2. While these results are not verification of diagnosis of memory loss, they are acceptable evidence of memory loss and the screener may select Memory Loss based on these results. Refer to Module 4.3 Completing the Diagnoses Table.

Safely: Means without significant risk of harm to oneself or others. Wis. Admin. Code § DHS 10.33(1)(d).

Significant, negative health outcome: A significant, negative health outcome has occurred when a person experiences any of the following symptoms: shortness of breath, dizziness, chest pain, exhaustion, falls, incontinence, or debilitating pain to the point where the individual is unsafe and another person should be present to help with some or all of the components of a task. Requiring additional time to complete a task is not a significant, negative health outcome in and of itself.

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5.1 General Guidance for ADLs/IADLs

A determination that an individual is limited in his or her capacity to perform an ADL or IADL task should always equate with a physical, cognitive, or memory loss impairment.

  • The screener should select the level of assistance needed based on the level of help needed from another person.
  • The screener should indicate the amount of help the person currently needs from another person, no matter who is providing the help. When a person is in the process of changing their residence, the screener should estimate what assistance the person might need in his/her new residence.
  • Screeners should select the level of assistance needed based on need and not solely on a diagnosis.
  • When a screener identifies a level of help needed in an ADL or IADL, the screener will select the diagnosis that correlates to the deficit.
  • If an individual has never performed or is not performing an activity or a task, a screener should not assume that the individual is physically or cognitively capable or incapable of doing so.
  • A lack of experience is not the same as the inability to perform a task due to a physical, cognitive, or memory loss impairment.
  • Although an individual may be currently receiving assistance with a task, they may be able to perform the activity independently or with limited assistance if given the opportunity and training.
  • For a person living in a residential facility, screeners should assess the person’s actual need for assistance. Screeners should not select the level of help needed based on the services or equipment available as part of the residential facility package.

NEED for Assistance
To reflect a person’s NEED for assistance, the screener should select the most accurate answer that most closely describes the person's NEED for “help from another person,” whether the person is actually receiving that assistance or not. Help from another person is defined as supervision, cueing, and/or hands-on assistance (partial or complete).

  • If a person has an identified need but is not receiving assistance (this includes declining the assistance and a significant, negative outcome occurs), the screener should still capture the need for the assistance from another person to complete the task.
  • If a person has an identified need but they have declined assistance and there is no significant negative health outcome, the screener is to select Independent.
  • If a person has a legal guardian, an activated power of attorney for health care, or is currently involved with adult protective services, that person may be considered not able to perceive and recognize potential risks or negative health outcomes and the selection of a need might be appropriate.

Declining a Task
For the IADL Medication Administration and Medication Management, if the individual has declined the task of taking medications itself, and is able to perceive and recognize the potential risk or negative health outcome that could result from declining the task, the screener should select “NA – Has no medications” for the IADL Medication Administration and Medication Management. In this situation, the person has no need for Medication Administration or Medication Management because it is not occurring. For example, if an individual able to perceive potential risk or negative outcome chooses not to take any prescribed medications, the person has no need for medication administration and medication management assistance because no medications are being taken (the task itself is not being done).

  • If the person is not able to perceive and recognize the potential risk or negative health outcome that could result from declining the task, the screener should select the frequency of need.
  • If a person has a legal guardian, an activated power of attorney for health care, or is currently involved with adult protective services, that person may be considered not able to perceive and recognize potential risks or negative health outcomes, and the selection of a need might be appropriate.

If a person can complete a task independently, but it takes him/her a very long time, a screener should consider if the person needs any help with that task to complete it safely.

  • If it takes so much time for the person to complete a task independently and that results in a significant, negative health outcome, then it would be justified to indicate the person has a need for help completing the task.
  • If an identified need is due to a significant, negative health outcome, the screener should write a note describing the significant, negative health outcome.

When an individual’s conditions and abilities fluctuate over time, reference Module 1.11 Screening Limitations and Strategies to Mitigate Limitations, Abilities Fluctuate, for assistance on how to complete the LTCFS.

An individual’s need for assistance with personal hygiene, such as grooming and mouth care, is not captured on the LTCFS. This information, as well as hygienic conditions of the home, can be captured in the notes section.

It is not uncommon for an individual to underrate his or her need for help or overstate his or her independence. Screeners should use the following steps when assessing an individual’s level of help needed:

  • Select the level of assistance required based on need and not solely on the report of the individual.
  • Seek more details and consider asking for a demonstration on how a task is completed.
  • Seek collateral informants, other people you could ask for additional information.
  • Use your professional judgment and assessment skills to select the best answer. Follow the definitions and instructions for the screen.

Example: Bert tells you he does not need any help with bathing. He lives alone. He is unkempt and has body odor. He walks very unsteadily with a cane and is bent over. It is quite clear to you that he is not able to safely get in and out of his bathtub and that he, in fact, has not bathed for many weeks.

  • Step 1: Seek more details: You ask him if you can see his bathroom, where you notice he has a claw-foot bathtub with sides about two feet high off the floor (with no grab bars, bench, or non-slip mats). You observe his ambulation and ask him to lift his foot high for you. He lifts it about four inches. You ask him for details on how he gets in and out of the bathtub.
  • Step 2: Seek collateral informants: Bert’s daughter referred him to the aging and disability resource center (ADRC) and is present during the screen interview. With Bert’s approval, you speak to her privately on the way out to get her perspective on her dad’s functioning. She says he is lying now because he is afraid, but he has admitted to her that he is unable to get into the bathtub.
  • Step 3: Use your professional judgment to select the best answer: You can see from Bert’s general body movement that he would need help with all aspects of bathing and would require his helper to be present throughout the entire task. For Bathing, select box 2, “Helper needs to be present throughout the task.”

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5.2 Communal Living Situations

A screener may encounter a person living in a communal living situation or congregate living arrangement, like a dormitory, convent, or monastery. This person may lack experience performing certain tasks. Socioeconomic barriers, religious beliefs, or cultural norms may be factors that result in this person having fewer opportunities to perform select IADLs (e.g., making phone calls, managing a checkbook, driving, or food preparation). In a communal living situation, activities are often centralized and tasks assigned to certain individuals for the convenience of the community or setting.

When a person resides in a communal living situation, do not presume ADL and IADL tasks cannot be performed by the person unless a physical, cognitive, or memory loss impairment is evident. Assume the person can be independent when the opportunity and training are provided to learn new tasks. When a person is receiving assistance with an ADL/IADL task, or has no experience performing the task, the screener must:

  • Ascertain whether a communal living situation, socioeconomic barriers, religious beliefs, or cultural norm factors result in the individual receiving assistance or lacking experience with a task.
  • Determine (if such factors are evident) whether there is a physical, cognitive, or memory loss impairment limiting the person's capacity to perform the task.

Examples:

  • A college student living in a dormitory who has relied on his parents to manage his financial matters. Do not assume this student is unable to manage money and pay bills unless he has a physical, cognitive, or memory loss impairment limiting his ability to do so.
  • A nun has taken a vow of poverty and has spent her adult life in a convent. Financial resources have always been pooled and bills paid centrally. Money available to her has been limited to a small stipend. Do not assume this nun is unable to manage money and pay bills unless she has a physical, cognitive, or memory loss impairment limiting her ability to do so.
  • A large farm cooperative is managed by a religious order of monks living at the farm in a monastery. The monks have experience with farming tasks but not driving, shopping, or food preparation. When determining a monk's ability to perform these IADL tasks, assess for any functional or cognitive limitations that may diminish his capacity to perform these IADL tasks, not the inexperience or lack of training opportunities.

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5.3 Coding for Who Will Help in the Next Eight Weeks

The LTCFS requires screeners to indicate who will help in the next eight weeks for each ADL and most of the IADLs. The codes for this section are below. Screeners should check all that apply.

  • U – Current UNPAID caregiver will continue
  • PF – Current PUBLICLY FUNDED paid caregiver will continue
  • PP – Current PRIVATELY PAID caregiver will continue
  • N – Need to find new or additional caregiver(s)

If the level of assistance needed for a particular ADL/IADL task is selected as “0 – Independent” or “NA – Has no medications,” the boxes for "Who Will Help in the Next 8 Weeks?" should be left blank.

If it is determined that the person needs assistance with a task, it is mandatory to complete the "Who Will Help in the Next 8 Weeks?" category. In other words, if the “Level of Help Needed” is indicated for an ADL or IADL task as “1” or greater, the screener must select at least one of the “Who Will Help in the Next 8 Weeks?” boxes.

“PP – Current PRIVATELY PAID caregiver will continue” means non-public funding, including the person's own money, that of a family member or friend, etc., private insurance (including long-term care insurance benefits), or a trust fund.

“PF – Currently Publicly Funded paid caregiver will continue” means funded with public program assistance including but not limited to services funded by Medicare, Medicaid, waiver programs, Veterans Affairs, and any other federal, state, or county funding sources.

Nursing Home or Hospital Resident
If a person resides in a nursing home or hospital and discharge is not expected in the next eight weeks, indicate how the nursing home is being paid (Privately Paid or Publicly Funded). If the person is expected to be discharged within the next eight weeks, try to be as accurate as possible with the "Who Will Help in the Next 8 Weeks?" boxes. Record the help the person will need once at home. Many individuals are discharged to their own homes with a mixture of public, private, and unpaid care giving services.

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5.4 Identifying Primary and Secondary Diagnoses

To be selected as a primary or secondary diagnosis that causes a need for assistance or support from another person, the need must be due to a physical, cognitive, or memory loss impairment, with one exception as outlined in the section titled “Exception to Physical, Cognitive, or Memory Loss Impairment Requirement.”

For each need or additional support, including some selections of adaptive equipment, identified in the LTCFS, the diagnoses that cause the need or necessary support must be selected from options prepopulated in a drop-down menu. Only diagnoses that were previously identified on the Diagnoses Table will be prepopulated in the drop-down menus. FSIA will use these diagnoses to assign the correct target group(s) for each individual who is being screened.

Primary and secondary diagnoses carry equal weight in regard to assignment of target group by FSIA. One diagnosis must be selected from the drop-down menu under primary diagnosis for each need or support identified on the screen. Under secondary diagnosis, a selection must be made from the drop-down menu. If there is no secondary diagnosis contributing to the need for assistance, the screener must select “None.”

When determining which diagnosis to select from the primary or secondary diagnosis drop-down menu, the screener is to be thoughtful and consistent. The diagnosis selected should justify and explain the need for assistance from another person. If there is only one diagnosis that affects the need for assistance, the screener would select “None” from the drop-down menu under secondary diagnosis. If a person has more than one diagnosis that corresponds to the person’s need, the screener could choose one of the other diagnoses as the secondary diagnosis. However, if both diagnoses are clearly related to a single target group it is not necessary to list both of them on the functional screen. For example, a 74-year-old man needs assistance with getting into the shower due to right-sided weakness after a cerebral vascular accident (CVA). The diagnosis that corresponds to why he needs assistance is a CVA. If he also has a diagnosis of right hemiparesis (right-sided weakness) due to the CVA, while the diagnosis of right hemiparesis could be selected as secondary, it is not required because it is actually caused by the identified primary diagnosis and it clearly relates to the same target group.

If the need for assistance is due to multiple diagnoses that are related to different target groups, the screener should select diagnoses from different categories on the Diagnoses Table. This is important for accurate assignment of target group(s). For example, a 43-year-old woman needs hands-on assistance with bathing due to obesity (B8) and cueing with bathing due to intellectual disability (A1). In this example, both the obesity and intellectual disability diagnoses should be selected; one from the drop-down menu under primary diagnosis and one from the drop-down menu under secondary diagnosis. The diagnosis of obesity is relevant to the Physical Disability target group and the diagnosis of intellectual disability is relevant to the Intellectual/Developmental Disability target group. A review of Module 2 Target Groups can provide some guidance as to what factors into each target group.

Mental Health Diagnoses: For a mental illness to be selected as a primary or secondary diagnosis that causes a need for assistance or support from another person, the person must have a permanent impairment of thought due to a severe and persistent mental illness.
 
A screener should always consider if the diagnosis creates a permanent cognitive impairment that cannot be controlled by medications or therapy, is not situational, or varying to the degree that the person can complete the task another time. In the notes, the screener should clearly state what it is about the diagnosis that makes it permanent and not able to be overcome to complete the task.

A cognitive impairment in the LTCFS is defined as a permanent impairment of thought due to a severe and persistent mental illness, dementia, brain injury, intellectual/developmental disability, or other organic brain disorder.

  • A cognitive impairment does not include temporary impairment due to medications and/or substance use intoxication.
  • A cognitive impairment does not include temporary impairment due to a temporary medical condition such as infection, electrolyte imbalance, or dehydration.

Exception to Physical, Cognitive, or Memory Loss Impairment requirement
There are occasions when the need for assistance is not due to a physical, cognitive, or memory loss impairment. This is relevant only to certain skilled tasks captured on the HRS Table (Module 7) and IADL Medication Administration and Medication Management (Module 5.14). These skilled tasks may include Medication Administration, Medication Management, Ostomy-related Skilled Services, Oxygen and/or Respiratory Treatments, Dialysis, Transfusions, Tracheostomy care, Ulcer care, Urinary Catheter-related skilled tasks, Other Wound Cares, Ventilator-related interventions, RNAI, and Skilled Therapies.

In these cases, the screener should determine why a primary or secondary diagnosis is selected even though it may not be the cause of a physical, cognitive, or memory loss impairment requiring assistance from another person. The screener must document this in the Notes section.

Examples include (this is not an all-inclusive list):

  • A person who is paralyzed from the waist down has a stage 4 ulcer on their coccyx region requiring dressing changes every three days. He has no physical, cognitive, or memory loss impairment preventing him from performing the wound care, but due to the location of the ulcer, he is unable to complete the needed care. In addition, due to the depth of the wound, the physician has ordered a wound care nurse to complete the wound care. The screener would select K4: Wound/Burn/Bedsore/Pressure Ulcer as the primary diagnosis for Ulcer – Stage 3 or 4 on the HRS Table and explain in the Notes section why this selection was made.
  • A person has a verified diagnosis of chronic pain treated with a Fentanyl patch. The patch is placed on her back, near the scapula, and the site is changed every three days. She does not have a physical, cognitive, or memory loss impairment, but cannot reach the site, and she requests assistance to place and remove the patch. The screener needs to confirm with the person or her medical professional if the patch must be placed in a location that she cannot reach, or if an alternate, accessible, location is possible. If the location of the patch does indeed need to be in an inaccessible spot, the screener would select D12: Other Chronic Pain or Fatigue as the primary diagnosis for Medication Administration and explain in the Notes section why this selection was made.
  • A person has a verified diagnosis of end-stage kidney disease and receives hemodialysis three times a week at a dialysis center. His need for assistance at a dialysis center is not due to a physical, cognitive, or memory loss impairment. The screener would select G1: Renal Failure, other Kidney Disease as the primary diagnosis for Dialysis on the HRS Table and explain in the Notes section why this selection was made.

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5.5 Activities of Daily Living (ADLs)

The six ADLs include:

  • Bathing
  • Dressing
  • Eating
  • Mobility in home
  • Toileting
  • Transferring

ADL Coding for Level of Help Needed
All of the ADLs have the same rating system for “Coding for Level of Help Needed to Complete the Task Safely.” When recording the level of help an individual needs to safely complete an ADL, a screener should select only one rating of “Level of Help Needed” with each ADL. The rating system used for ADLs in the LTCFS is below.

  • 0 – Person is independent in completing the activity safely.
  • 1 – Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task. “Help” can be supervision, cueing, or hands-on assistance.
  • 2 – Help is needed to complete the task safely and helper DOES need to be physically present throughout the task. “Help” can be supervision, cueing, or hands-on assistance.

ADL Adaptive Equipment Guidance
Adaptive equipment is defined as specific types of equipment captured on the LTCFS that an individual may use to safely complete an ADL.

Four of the ADLs (Bathing, Mobility in Home, Toileting, and Transferring) have some adaptive equipment options. Screeners should select only equipment the person currently needs, has, and is using. The only exception to “need, have, and use” is prosthesis in 5.9 Mobility in Home. Prosthesis should be selected if the person has a prosthesis; regular use or use only in the home are not requirements.

Do not select one of the equipment options if a person uses an improvised or homemade item as a substitute for the equipment on the list. For example, a person may use a sturdy object to sit on during bathing instead of a tub bench. In this instance, you would not select “Uses tub bench” in the Bathing equipment box, because the object is a substitute for a tub bench.

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5.6 Bathing

LTCFS ITEM DEFINITION:

Bathing: The ability to safely shower, bathe, or take a sponge bath for the purpose of maintaining adequate hygiene. The task of Bathing consists of the following components:

  • Getting in and out of the bathtub or shower.
  • Physically turning on and off the faucets and adjusting the water temperature as desired.
  • Determining the proper water temperature. (This component pertains only to people with a cognitive impairment.)
  • Washing and drying self.
  • Shampooing hair.

The need for assistance with transferring to bathe is included in this task.

If a person needs assistance with only accessing the bathroom, this need is captured in Module 5.9 Mobility in Home, not the Bathing task.

CODING FOR LEVEL OF HELP NEEDED

  • 0 – Person is independent in completing the activity safely.
  • 1 – Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task. “Help” can be supervision, cueing, and/or hands-on assistance.
  • 2 – Help is needed to complete the task safely and helper DOES need to be present throughout the task. “Help” can be supervision, cueing, and/or partial or complete hands-on assistance.

ADAPTIVE EQUIPMENT

Adaptive equipment is defined as specific types of equipment captured on the LTCFS that an individual may use to safely complete an ADL. Screeners should only select the adaptive equipment the person currently needs, has, and is using.

Adaptive equipment options for Bathing include:

  • Uses Grab Bar(s)
  • Uses Shower Chair
  • Uses Bathtub Bench
  • Uses Mechanical Lift

Do not select one of the equipment options if a person uses an improvised or homemade item as a substitute for the equipment on the list. For example, a person may use an object to sit on during bathing instead of a bathtub bench. In this instance, you would not select “Uses Bathtub Bench” in the Bathing equipment box, because the object is a substitute for a bathtub bench.

BATHING-SPECIFIC RESPONSE GUIDANCE:

The “Check 0, 1, 2” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “0” (“Person is independent in completing the activity safely”) for a person who:

  • Has no physical, cognitive, or memory loss impairments affecting his or her ability to complete the task of Bathing independently.
  • Bathes independently with the use of adaptive equipment.
  • Bathes independently with the use of simple, reasonable adaptations such as a hand-held washing aid, hand-held shower attachment, or a shampoo dispenser.
  • Is able to maintain adequate hygiene by bathing on good days.
  • Bathes independently but it takes additional time to do so and there are NO significant, negative health outcomes.
  • Uses an improvised or homemade item and without it, he or she would NOT need assistance from another person to complete the task. Do not check the use of any adaptive equipment if an improvised or homemade item is being used, since this is not considered adaptive equipment.
  • Requires assistance with grooming only (such as shaving, brushing hair, mouth care, nail care). Grooming is not considered an ADL on the LTCFS.
  • Prefers a sponge bath and can do so independently and maintains adequate hygiene.
  • Bathes independently but is unable to wash his or her back.
  • Bathes independently but chooses not to do so unless a family member or staff is present somewhere in the home, "just in case."
  • Bathes independently but needs toiletries (such as shampoo, soap, towels) retrieved and/or laid out for him or her. These needs are captured in Module 5.16 Laundry and/or Chores.
  • Has a seizure disorder with no seizures in the last three months and there is no intervention needed; however, family or staff is present "just in case."

Check “1” (“Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with at least one but not all of the components of Bathing.
  • Bathes independently but doing so results in a significant, negative health outcome and another person should be present to help with SOME of the components of the task.
  • Uses an improvised or homemade item and without it, he or she would need assistance from another person to complete at least one but not all of the components of Bathing. Do not check the use of any adaptive equipment if an improvised or homemade item is being used, since this is not considered adaptive equipment.
  • Bathes independently but, due to a cognitive impairment, regularly requires cueing or else he or she would not initiate the task of bathing.
  • Prefers to sponge bathe but does not maintain adequate hygiene due to a physical, cognitive, or memory loss impairment.

Check “2” (“Help is needed to complete the task safely and helper DOES need to be present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or partial or complete hands-on assistance with ALL of the above components of Bathing.
  • Bathes independently but doing so results in a significant, negative health outcome and another person should be present to help with ALL of the components of the task.
  • Uses an improvised or homemade item and without it, he or she would need assistance from another person to complete ALL of the components of Bathing. Do not check the use of any adaptive equipment if an improvised or homemade item is being used, since this is not considered adaptive equipment.
  • Requires assistance with ALL of the components of Bathing but he or she can be left alone to soak in the bathtub (without negative health and/or safety concerns). Soaking in the bathtub is not a component of the Bathing ADL.
  • Requires supervision due to having an uncontrolled seizure disorder, evidenced by one or more seizures in the last three months AND requires standby assistance* during the entire task of Bathing.

*Standby assistance for seizure is defined as the need for a person to be next to the individual (within arm’s length) in order to be readily available to help the individual in the event he or she experiences a seizure.

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5.7 Dressing

LTCFS ITEM DEFINITION:

Dressing: The ability to safely dress and undress as necessary. The task of Dressing consists of the following components:

  • Dressing/undressing the top half of body (includes putting on undergarments)
  • Dressing/undressing the bottom half of body (includes putting on undergarments)
  • Getting shoes and socks on and off
  • Putting on or removing prostheses, orthotic devices, anti-embolism hose (TED hose), compression products or devices (stockings, bandages, pumps), and/or pressure relieving devices, if applicable.
  • Choosing the appropriate clothing to maintain health and safety for the environment and setting. (This component pertains only to people with a cognitive impairment.)

CODING FOR LEVEL OF HELP NEEDED

  • 0 – Person is independent in completing the activity safely.
  • 1 – Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task. “Help” can be supervision, cueing, and/or hands-on assistance.
  • 2 – Help is needed to complete the task safely and helper DOES need to be present throughout the task. “Help” can be supervision, cueing, and/or partial or complete hands-on assistance.

ADAPTIVE EQUIPMENT

This is not applicable for this ADL. There are no adaptive equipment options listed under “Dressing.”

DRESSING-SPECIFIC RESPONSE GUIDANCE:

The “Check 0, 1, 2” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “0” (“Person is independent in completing the activity safely”) for a person who:

  • Has no physical, cognitive, or memory loss impairments affecting his or her ability to complete the task of dressing independently.
  • Dresses independently with the use of simple, reasonable adaptations such as wearing pullover sweaters, elastic-waist pants, front-clasp bra, slip-on shoes, or use of a sock aid.
  • Dresses independently but it takes additional time to do so and there are NO significant, negative health outcomes.
  • Requires assistance only with a zipper and/or button(s).
  • Dresses independently, has no cognitive impairment and chooses not to wear appropriate clothing for the environment or setting.
  • Dresses independently and has no cognitive impairment, but refuses to change his or her clothes, even when clothes are stained or carry an odor.
  • Dresses independently but may mismatch clothes.
  • Dresses independently but needs clothes retrieved and/or laid out for him or her. These needs are captured in Module 5.16 Laundry and/or Chores.
  • Has a seizure disorder with no seizures in the last three months and there is no intervention needed; however, family or staff is present “just in case.”

Check “1” (“Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with at least one but not all of the components of Dressing.
  • Dresses independently but doing so results in a significant, negative health outcome and another person should be present to help with SOME of the components of the task.
  • Dresses independently but, due to a cognitive impairment, regularly requires cueing or else he or she would not dress.
  • Dresses independently but, due to a cognitive impairment, does not wear appropriate clothing for the environment or setting.
  • Dresses independently but, due to a cognitive impairment, refuses to change his or her clothes when clothes are stained or carry an odor.
  • Needs assistance from another person to either get dressed OR undressed, but not both.

Check “2” (“Help is needed to complete the task safely and helper DOES need to be present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or partial or complete hands-on assistance with ALL of the above components of Dressing.
  • Dresses independently but doing so results in a significant, negative health outcome and another person should be present to help with ALL of the components of the task.
  • Requires supervision due to having an uncontrolled seizure disorder, evidenced by one or more seizures in the last three months AND requires standby assistance* during the entire task of Dressing.*
  • Needs assistance from another person to get dressed AND undressed.

*Standby assistance for seizure is defined as the need for a person to be next to the individual (within arm’s length) in order to be readily available to help the individual in the event he or she experiences a seizure.

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5.8 Eating

LTCFS ITEM DEFINITION:

Eating: The act of getting food or drink from a plate/bowl or cup to the mouth (chewing if necessary and swallowing) using routine or adaptive utensils.

Examples of adaptive utensils include weighted and/or built up eating utensils, scooper plates/bowls, food bumpers, special cups.

CODING FOR LEVEL OF HELP NEEDED

  • 0 – Person is independent in completing the activity safely.
  • 1 – Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task. “Help” can be supervision, cueing, and/or hands-on assistance.
  • 2 – Help is needed to complete the task safely and helper DOES need to be present throughout the task. “Help” can be supervision, cueing, and/or partial or complete hands-on assistance.

ADAPTIVE EQUIPMENT

This is not applicable for this ADL. There are no adaptive equipment options listed under “Eating.”

EATING-SPECIFIC RESPONSE GUIDANCE:

The “Check 0, 1, 2” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “0” (“Person is independent in completing the activity safely”) for a person who:

  • Has no physical, cognitive, or memory loss impairments affecting his or her ability to complete the task of Eating independently.
  • Eats independently with the use of simple, reasonable adaptations.
  • Has no cognitive impairment and chooses not to eat.
  • Has a history of choking or has a risk of choking and there is no intervention in place but is monitored “just in case.”
  • Needs portion control for weight reduction.
  • Is on a special diet (such as diabetic, low-calorie, low-sugar, or low fat).
  • Eats independently but must have food pureed or minced, or follows a mechanical soft diet. This need is captured in Module 5.13 Meal Preparation.
  • Eats independently but requires assistance with the placement of food on the plate or table (serving) or with carrying a plate/cup to the table. This need is captured in Module 5.13 Meal Preparation.
  • Needs to have a plate “set up” with food due to his or her visual impairment. This need is captured in Module 5.13 Meal Preparation.
  • Is a messy eater.
  • Takes other people’s food.
  • Needs the refrigerator, pantry, or other storage area to be locked to deter snacking or stealing (except for a person with Prader-Willi syndrome).
  • Eats independently but requires assistance from another person to cut food. This need is captured in Module 5.13 Meal Preparation.
  • Eats independently but requires assistance to locate the dining area. This need is captured in Module 8.4 Cognition.
  • Has pica or polydipsia. These needs are captured in Module 9 Behavioral Health, as self-injurious behaviors.
  • Is fed via tube feedings or total parenteral nutrition (TPN) and can independently complete the task.
  • Has a seizure disorder with no seizures in the last three months and there is no intervention needed; however, family or staff is present “just in case.”

Check “1” (“Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with the task of Eating SOME of the time.
  • Eats independently but doing so results in a significant, negative health outcome and another person should be present to help with the task of Eating SOME of the time.
  • Eats independently but, due to a cognitive impairment, requires cueing to initiate eating.
  • Eats independently but requires assistance to put on or remove a splint (or other device such as a universal cuff) with which the person can then hold a utensil and independently feed him or herself.
  • Is fed via tube feedings or total parenteral nutrition (TPN) and requires assistance from another person to complete the task of Eating SOME of the time. Also, see Module 7.23 Tube Feedings and Module 7.20 TPN.

Check “2” (“Help is needed to complete the task safely and helper DOES need to be present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or partial or complete hands-on assistance with the task of Eating ALL of the time.
  • Eats independently but doing so results in a significant, negative health outcome and another person should be present to help with the task of Eating ALL of the time.
  • Eats independently but, due to a cognitive impairment, requires cueing to eat throughout the task of Eating.
  • Is fed via tube feedings or total parenteral nutrition (TPN) and he or she requires assistance from another person to complete the task ALL of the time. Also, see Module 7.23 Tube Feedings and Module 7.20 TPN.
  • Has Prader-Willi syndrome.
  • Requires supervision due to having an active risk of choking and requires standby assistance* during the entire task of Eating.
  • Requires supervision due to having an uncontrolled seizure disorder, evidenced by one or more seizures in the last three months AND requires standby assistance** during the entire task of Eating.

*Standby assistance for choking is defined as the need for a person to be next to the individual (within arm’s length) in order to be readily available to help the individual in the event he or she were to begin choking.

**Standby assistance for seizure is defined as the need for a person to be next to the individual (within arm’s length) in order to be readily available to help the individual in the event he or she experiences a seizure.

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5.9 Mobility in Home

LTCFS ITEM DEFINITION:

Mobility in Home: The ability to move between locations (including stairs) in the individual's living space. Living space is defined as kitchen/dining room, living room, bathroom, and sleeping area.

A person’s living space does not include the basement, attic, garage, yard, and places outside of the home, including any stairs to enter the home.

Excluded from Mobility in Home is the task of transferring, which includes the ability to move from a bed, usual sleeping place, or chair to a wheelchair, or up to a standing position. The need for assistance to transfer to bathe or use a toilet is captured in Module 5.6 Bathing or Module 5.10 Toileting.

CODING FOR LEVEL OF HELP NEEDED

  • 0 – Person is independent in completing the activity safely.
  • 1 – Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task. “Help” can be supervision, cueing, and/or hands-on assistance.
  • 2 – Help is needed to complete the task safely and helper DOES need to be present throughout the task. “Help” can be supervision, cueing, and/or partial or complete hands-on assistance

ADAPTIVE EQUIPMENT

Adaptive equipment is defined as specific types of equipment captured on the LTCFS that an individual may use to safely complete an ADL. Screeners should only select the adaptive equipment the person currently needs, has, and is using. The only exception to “need, have, and use” is prosthesis in 5.9 Mobility in Home. Prosthesis should be selected if the person has a prosthesis; regular use or use only in the home are not requirements.

Adaptive equipment options for Mobility in Home include:

  • Uses Cane in Home*
  • Uses Wheelchair or Scooter in Home
  • Has Prosthesis
  • Uses Quad-Cane in Home*
  • Uses Crutches in Home
  • Uses Walker in Home

*A cane or quad-cane intended solely as a probe to identify obstacles or as an indicator of visual impairment does not count as an aid for Mobility in Home.

Do not select one of the equipment options if a person uses an improvised or homemade item as a substitute for the equipment on the list. For example, a person may use a chair with wheels instead of a wheeled walker. In this instance, you would not select “Uses Walker in Home” in the Mobility equipment box because the object is a substitute for a walker.

Do not include the following types of equipment or medical supplies used by an individual as a type of adaptive equipment counted under Mobility in Home:

  • Ace bandage
  • Orthotic devices such as splints or braces
  • Anti-embolism hose
  • Neoprene wrap
  • Orthotic shoes
  • Walker, cane, crutches, wheelchair, scooter only used when ambulating outside of their home

Mobility is the only ADL that requires a primary and/or secondary diagnosis when the coding selection is independent and Uses Wheelchair or Scooter in Home or Has Prosthesis has been selected.

MOBILITY IN HOME-SPECIFIC RESPONSE GUIDANCE:

The “Check 0, 1, 2” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “0” (“Person is independent in completing the activity safely”) for a person who:

  • Has no physical, cognitive, or memory loss impairments affecting his or her ability to complete the task of Mobility in Home independently.
  • Walks (or wheels) him or herself independently with the use of adaptive equipment.
  • Walks (or wheels) him or herself but it takes additional time to do so and there are no significant, negative health outcomes.
  • Uses an improvised or homemade item and without it, he or she would not need assistance from another person to complete the task. Do not check the use of any adaptive equipment if an improvised or homemade item is being used since this is not considered adaptive equipment.
  • Has a risk of falling only due to environmental conditions such as clutter, rugs, or uneven flooring.
  • Walks (or wheels) him or herself independently but needs direction on where to go due to a cognitive impairment. This need is captured in Module 8.4 Cognition.
  • Walks (or wheels) him or herself independently but has a vision impairment.
  • Walks (or wheels) him or herself independently but has a fear of falling.
  • Walks (or wheels) him or herself independently but does so slowly and safely.
  • Walks (or wheels) him or herself independently but has a shuffling gait and walks safely.
  • Walks (or wheels) him or herself independently but needs assistance outside of the living space including using steps or ramp to get into the home.
  • Walks (or wheels) him or herself independently but does not get up and walk in the home unless a family member/staff is present somewhere in the home, “just in case.”
  • Walks (or wheels) him or herself independently but needs assistance putting on or taking off orthotic devices (such as braces, shoe inserts, ankle foot orthosis (AFOs), anti-embolism hose, or orthotic shoes). These needs are captured in Module 5.7 Dressing.
  • Prefers to crawl and can do so independently and there are no significant, negative health outcomes.
  • Is unable to access the laundry because it is located outside of the living space. This need is captured in Module 5.16 Laundry and/or Chores.
  • Uses walls, furniture, or railings for guidance or reassurance only.
  • Has a seizure disorder with no seizures in the last three months and there is no intervention needed; however, family or staff is present “just in case.”

Check “1” (“Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with the task of Mobility in Home SOME of the time.
  • Walks (or wheels) him or herself independently but doing so results in a significant, negative health outcome and another person should be present to help with the task.
  • Uses an improvised or homemade item and without it, he or she would need assistance from another person to complete the task of Mobility in Home some of the time. Do not check the use of any adaptive equipment if an improvised or homemade item is being used since this is not considered adaptive equipment.
  • Walks independently but, due to a cognitive impairment, requires a cue to use adaptive equipment.
  • Walks independently throughout his or her living space but must lean on walls, furniture, or railings or would otherwise require the assistance of equipment or another person.
  • Needs assistance only to use steps in his or her living space or if the person needs and uses a stair lift.
  • Needs assistance only to access the bathroom.
  • Requires standby* or hands-on assistance with mobility SOME of the time.

Check “2” (“Help is needed to complete the task safely and helper DOES need to be present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or partial or complete hands-on assistance with the task of Mobility in Home ALL of the time.
  • Walks (wheels) him or herself independently but doing so results in a significant, negative health outcome and another person should be present to help with the task of Mobility in Home ALL of the time.
  • Uses an improvised or homemade item and without it, he or she would need assistance from another person to complete the task of Mobility in Home all of the time. Do not check the use of any adaptive equipment if an improvised or homemade item is being used since this is not considered adaptive equipment.
  • Requires standby* or hands-on assistance with mobility ALL of the time.
  • Requires supervision due to having an uncontrolled seizure disorder, evidenced by one or more seizures in the last three months and requires standby assistance** during the entire task of Mobility in Home.

*Standby assistance for mobility is defined as the need for a person to walk next to the individual (within arm’s length) in order to be readily available to help the individual in the event he or she falls or loses balance.

**Standby assistance for seizure is defined as the need for a person to be next to the individual (within arm’s length) in order to be readily available to help the individual in the event he or she experiences a seizure.

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5.10 Toileting

LTCFS ITEM DEFINITION:

Toileting: The ability to use the toilet, commode, bedpan, or urinal for bowel and/or bladder management in the home. The activity of Toileting consists of the following components, if applicable:

  • Locating the bathroom facility. (This component pertains only to people with a cognitive impairment.)
  • Transferring on or off the toilet, commode, bedpan, or placing a urinal
  • Maintaining regular bowel program*
  • Cleansing of perineal (peri) area
  • Changing of menstrual products and/or incontinence products
  • Managing a condom catheter or the ostomy or urinary catheter collection bag (including emptying and/or rinsing the collection bag)
  • Redressing the bottom half of the body
  • Emptying the commode, bedpan, or urinal container
  • Flushing the toilet

The cleaning of the bathroom after incidental soiling during toileting is captured in Module 5.16 Laundry and/or Chores.

Hand washing after toileting is not a component of Toileting.

*A regular bowel program includes using suppositories, enemas, and digital/manual stimulation with the goal of having regular bowel movements at a predictable time and frequency. This does not include the use of oral laxatives such as Metamucil, Ex-lax, stool softeners, or fiber used by a person not on a formal bowel program.

If the individual has an ostomy or indwelling or straight urinary catheter, screeners should review Health-Related Services Module 7.16 and Module 7.26 to ensure the individual’s needs have been accurately identified.

CODING FOR LEVEL OF HELP NEEDED

  • 0 – Person is independent in completing the activity safely.
  • 1 – Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task. “Help” can be supervision, cueing, and/or hands-on assistance.
  • 2 – Help is needed to complete the task safely and helper DOES need to be present throughout the task. “Help” can be supervision, cueing, and/or partial or complete hands-on assistance.

ADAPTIVE EQUIPMENT

Adaptive equipment is defined as specific types of equipment captured on the LTCFS that an individual may use to safely complete an ADL. Screeners should only select the adaptive equipment the person currently needs, has, and is using.

Adaptive equipment options for Toileting include:

  • Uses Toilet Grab Bars/Rails
  • Uses Commode or Other Adaptive Equipment, including:
    • High rise/accessible toilet
    • Elevated or adaptive toilet seat
    • Bed pan
    • Urinal
    • Transfer board or other transfer aids that assist the person to get on or off the toilet
  • Uses Urinary Catheter
  • Has Ostomy
  • Receives Regular Bowel Program

Do not select one of the equipment options if a person uses an improvised or homemade item as a substitute for the equipment on the list. For example, a person may use a container as a urinal. In this instance, you would not select “Uses Commode or Other Adaptive Equipment” in the Toileting equipment box because the object is a substitute.

TOILETING-SPECIFIC RESPONSE GUIDANCE:

The “Check 0, 1, 2” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “0” (“Person is independent in completing the activity safely”) for a person who:

  • Has no physical, cognitive, or memory loss impairments affecting his or her ability to complete the task of Toileting independently.
  • Toilets independently with the use of adaptive equipment.
  • Toilets independently with the use of simple, reasonable adaptations such as a self-wipe toilet aid.
  • Uses an improvised or homemade item and without it, he or she would not need assistance from another person to complete the task some of the time. Do not check the use of any adaptive equipment if an improvised or homemade item is being used, since this is not considered adaptive equipment.
  • Is incontinent and is independent with managing incontinence products; however, select the appropriate frequency related to the person’s incontinence in the sub-section addressing incontinence.
  • Only requires assistance with skilled tasks associated with ostomy or urinary catheter care. These needs are captured in Module 7.16 Ostomy-Related Skills Services and Module 7.26 Urinary Catheter-Related Skilled Tasks.
  • Utilizes oral laxatives, fiber, or other bowel medications.
  • Needs assistance or reminders about the amount of toilet paper to use or not to flush inappropriate objects.
  • Uses the sink or countertop to get to a standing position from the toilet with no significant, negative health outcomes.
  • Requires supervision only for offensive or violent behaviors related to toileting such as urinating or defecating in inappropriate places (for example a living room or front porch), or on another person, or the act of spreading urine or feces. These needs are captured in Module 7.11 Behaviors Requiring Interventions and Module 9.4 Offensive or Violent Behavior to Others.
  • Toilets independently but chooses not to do so unless a family member/staff is present somewhere in the home, “just in case.”
  • Has a seizure disorder with no seizures in the last there months and there is no intervention needed; however, family or staff is present “just in case.”

Check “1” (“Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with at least one but not all of the components of Toileting.
  • Toilets independently but doing so results in a significant, negative health outcome and another person should be present to help with SOME of the components of the task.
  • Uses an improvised or homemade item and without it, he or she would need assistance from another person to complete at least one but not all of the components of Toileting. Do not check the use of any adaptive equipment if an improvised or homemade item is being used since this is not considered adaptive equipment.
  • Toilets independently but, due to a cognitive impairment, requires cueing or he or she would be incontinent.

Check “2” (“Help is needed to complete the task safely and helper DOES need to be present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or partial or complete hands-on assistance with ALL of the above components of Toileting.
  • Is able to toilet independently but doing so results in a significant, negative health outcome and another person should be present to help with ALL of the components of the task.
  • Requires supervision due to having an uncontrolled seizure disorder, evidenced by one or more seizures in the last three months and requires standby assistance* during the entire task of Toileting.

*Standby assistance for seizure is defined as the need for a person to be next to the individual (within arm’s length) in order to be readily available to help the individual in the event he or she experiences a seizure.

INCONTINENCE

Select the applicable level of bowel and/or bladder incontinence in this section. Urge incontinence is the sudden uncontrollable urge to frequently urinate. Do not count stress incontinence, which is leakage of urine during sneezing, coughing, or other exertion. Incontinence options include:

  • Does not have incontinence
  • Has incontinence less than daily but at least once per week
  • Has incontinence daily

If there are interventions to prevent the incontinence, such as cueing or scheduled toileting, indicate the frequency of the intervention being provided under Toileting. Do not select incontinence.

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5.11 Transferring

LTCFS ITEM DEFINITION:

Transferring: The ability to move between surfaces. The task of Transferring includes the ability to get up to a standing position and down to a sitting position from a bed, usual sleeping place, chair, or wheelchair. Excluded from the task of Transferring is the need for assistance with a transfer to bathe or use a toilet. These needs are captured in Module 5.6 Bathing and 5.10 Toileting.

CODING FOR LEVEL OF HELP NEEDED

  • 0 – Person is independent in completing the activity safely.
  • 1 – Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task. “Help” can be supervision, cueing, and/or hands-on assistance
  • 2 – Help is needed to complete the task safely and helper DOES need to be present throughout the task. “Help” can be supervision, cueing, and/or partial or complete hands-on assistance.

ADAPTIVE EQUIPMENT

Adaptive equipment is defined as specific types of equipment captured on the LTCFS that an individual may use to safely complete an ADL. Screeners should only select the adaptive equipment the person currently needs, has, and is using.

Adaptive equipment options for Transferring include:

  • Uses Mechanical Lift or Power Stander
  • Uses Transfer Board or Pole
  • Uses Grab Bars, Bed Bar, or Bed Railing (if used for transferring)
  • Uses Trapeze

Do not select one of the equipment options if a person uses an improvised or homemade item as a substitute for the equipment on the list. For example, a person may use an object to assist them in transferring out of bed instead of a bed rail. In this instance, do not select “Grab Bars, Bed Bar, or Bed Railing” in the Transferring equipment box because the object is a substitute for a grab bar.

Do not select one of the equipment options if a person safely uses furniture, such as a nightstand or coffee table, for transfers.

Under Transferring, do not count a lift chair or an electric hospital bed as a mechanical lift. However, a screener may select a need for transfer assistance for a person who uses a lift chair or electric hospital bed, if the person is unable to transfer from the chair or bed without them.

TRANSFERRING-SPECIFIC RESPONSE GUIDANCE:

The “Check 0, 1, 2” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “0” (“Person is independent in completing the activity safely”) for a person who:

  • Has no physical, cognitive, or memory loss impairments affecting his or her ability to complete the task of Transferring independently.
  • Transfers independently with the use of adaptive equipment.
  • Transfers independently but it takes additional time to do so and there are no significant, negative health outcomes.
  • Uses an improvised or homemade item and without it, he or she would not need assistance from another person to complete the task. Do not check the use of any adaptive equipment if an improvised or homemade item is being used since this is not considered adaptive equipment.
  • Has a lift chair or other mechanical device (such as an electric hospital bed), but can independently transfer without it.
  • Is independent with transfers by pushing on chair arms, other furniture, wheelchair, walker, or cane with no significant, negative health outcome.
  • Is independent with transfers after rocking back and forth to gain momentum to get up from a seated position with no significant, negative health outcome.
  • Requires transfer assistance getting in or out of a vehicle.
  • Transfers independently but has a fear of falling.
  • Transfers independently but does so slowly and safely.
  • Transfers independently but does not unless a family member/staff member is present somewhere in the home, “just in case.”
  • Transfers independently but needs assistance putting on or taking off orthotic devices (such as braces, shoe inserts, ankle foot orthosis (AFOs), anti-embolism hose, or orthotic shoes). These needs are captured in Module 5.7 Dressing.
  • Has a seizure disorder with no seizure in the last three months and there is no intervention needed; however, family or staff is present “just in case.”

Check “1” (“Help is needed to complete the task safely but helper DOES NOT have to be physically present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with the task of Transferring SOME of the time.
  • Transfers independently but doing so results in a significant, negative health outcome and another person should be present to help with the task SOME of the time.
  • Uses an improvised or homemade item and without it, he or she would need assistance from another person to complete the task of Transferring SOME of the time. Do not check the use of any adaptive equipment if an improvised or homemade item is being used since this is not considered adaptive equipment.
  • Transfers independently but, due to a cognitive impairment, requires a cue to initiate the transfer.
  • Transfers independently but, due to a cognitive impairment, requires a cue to use adaptive equipment to transfer.
  • Has a lift chair or other mechanical device (such as an electric hospital bed), and cannot independently transfer without it.
  • Transfers independently for some of the day, but needs assistance from another person for other parts of the day. For example, this includes a person who is able to transfer independently in the morning but in the evening if, for example, is fatigued, needs assistance with the task of Transferring some or all of the time.

Check “2” (“Help is needed to complete the task safely and helper DOES need to be present throughout the task”) for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or partial or complete hands-on assistance with the task of Transferring ALL of the time.
  • Transfers independently but doing so results in a significant, negative health outcome and another person should be present to help with the task ALL of the time.
  • Uses an improvised or homemade item and without it, he or she would need assistance from another person to complete the task of Transferring all of the time. Do not check the use of any adaptive equipment if an improvised or homemade item is being used since this is not considered adaptive equipment.
  • Needs step-by-step directions to transfer.
  • Needs hands-on or standby assistance* to complete safe transfers.
  • Needs to wear a gait belt that is used during transfers.
  • Requires supervision due to having an uncontrolled seizure disorder, evidenced by one or more seizures in the last three months AND requires standby assistance** during the task of Transferring.

*Standby assistance for transferring is defined as the need for a person to stand next to the individual (within arm’s length) in order to be readily available to help the individual in the event he or she falls or loses balance.

**Standby assistance for seizure is defined as the need for a person to be next to the individual (within arm’s length) in order to be readily available to help the individual in the event he or she experiences a seizure.

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5.12 Instrumental Activities of Daily Living (IADLs)

The six IADLs include:

  • Meal preparation
  • Medication administration and medication management
  • Money management
  • Laundry and/or chores
  • Telephone
  • Transportation

IADL Coding for Level of Help Needed
Each of the IADLs has a separate rating system to capture the level of help needed specific to each IADL. When recording the level of help an individual needs to safely complete an IADL, a screener should select only one rating of “Level of Help Needed” with each IADL.

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5.13 Meal Preparation

LTCFS ITEM DEFINITION:

Meal Preparation: The ability to obtain and prepare basic routine meals, including the task of grocery shopping. What constitutes a meal is an individual choice. Meal Preparation includes the ability to make a simple meal, which is defined by and includes, but is not limited to, cereal, sandwich, reheating food, such as frozen, leftovers, and food prepared by others.

Ability includes physical, cognitive, and memory.

The task of Meal Preparation consists of the following components:

  • Opening food containers
  • Opening the refrigerator and freezer
  • Safely using kitchen appliances
  • Safely preparing a simple meal, such as cereal, sandwich, reheating food including frozen, leftovers, and food prepared by others
  • Safely placing food on a plate or in a cup, and carrying it to a table
  • Cutting food
  • Proper food preparation
  • Obtaining groceries. The activity of obtaining groceries consists of the following components:
    • Retrieving the food at the store
    • Moving items between a basket or cart to the checkout counter
    • Getting the bags to a vehicle
    • Getting the bags into the home
    • Putting the groceries away

Meal Preparation does not include needed transportation to and from a grocery store or assistance with the money transaction to pay for the groceries. These needs are captured in Module 5.18 Transportation and Module 5.15 Money Management.

Meal Preparation does not include when a person makes food choices consistent with his or her lifestyle and values, even if those food choices are not in agreement with a professional’s advice or nutritional goals for the person. Examples include when a person chooses to eat more than three meals per day, eats fewer than three meals per day, or chooses to not follow the federal dietary guidelines, such as not eating recommended amount of fruits and vegetables or exceeding recommended consumption of added sugar or saturated fats. Such food choices may be considered when evaluating for Risk 1. Refer to Module 10.3 Part B – Risk Evident During Screening Process.

CODING FOR LEVEL OF HELP NEEDED

  • 0: Independent
  • 1: Needs help from another person weekly or less often
  • 2: Needs help 2 to 7 times a week
  • 3: Needs help with every meal

MEAL PREPARATION-SPECIFIC RESPONSE GUIDANCE:

The “Check 0, 1, 2, 3” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “0” (“Independent”) for a person who:

  • Has no physical, cognitive, or memory loss impairment limiting his or her ability to complete the task of Meal Preparation independently.
  • Is independent with Meal Preparation with the use of simple, reasonable adaptations, such as an electric can opener, easy jar opener, or food preparation board.
  • Is independent with Meal Preparation, but it takes additional time to do so and there are NO significant negative health outcomes.
  • Can independently prepare a meal if he or she takes breaks to sit down during the task.
  • Has no physical, cognitive, or memory loss impairment affecting his or her ability to complete the task of Meal Preparation independently, but:
    • Prefers assistance with Meal Preparation due only to a gender, age, or cultural norm.
    • Needs assistance with Meal Preparation due only to a language barrier.
    • Needs assistance with Meal Preparation due only to illiteracy.
    • Hasn’t had experience or learned the task of Meal Preparation and his or her ability to complete this task has yet to be reviewed to determine the person’s ability to complete the task.
  • Receives home-delivered meals (HDM), but is physically or cognitively able to prepare meals. There is a variety of reasons why a person may receive HDMs that do not relate to a physical, cognitive, or memory loss impairment to prepare meals independently.
  • Can make a simple meal such as cereal, sandwich, reheating food including frozen, leftovers, and food prepared by others.
  • Is independent with Meal Preparation and chooses to only eat cold foods.
  • Is independent with Meal Preparation and is only able to cook or heat up food in a microwave oven.
  • Is independent with Meal Preparation but needs assistance planning a menu or making a grocery shopping list.
  • Is independent with Meal Preparation but requires transportation to the grocery store. This need is captured in Module 5.18 Transportation.
  • Wants to grocery shop more than once a week.
  • Is independent with Meal Preparation but needs to use the grocery store’s scooter or wheelchair to shop.
  • Is independent with Meal Preparation but needs assistance from a grocery store employee or fellow shopper to retrieve items from high or low shelves because he or she cannot reach the items without assistance.
  • Can shop independently when groceries are bagged in smaller and lighter bags so he or she can manage them.
  • Has fluctuating abilities and grocery shops on his or her good days. For additional information on screening a person with fluctuating abilities, review Module 1.11 Screening Limitations and Strategies to Mitigate Limitations, Abilities Fluctuate.
  • Is able to independently prepare meals but lives in a residential facility and does not prepare his or her meals solely because meals are provided as part of the service in the facility where the person resides.
  • Only needs assistance getting food out of a refrigerator or freezer located in his or her garage or basement.
  • Is independent with Meal Preparation but needs assistance cleaning up after a meal. This need is captured in Module 5.16 Laundry and/or Chores.
  • Needs to have a special diet, such as diabetic, low-calorie, low sugar, or low sodium, but is independent with Meal Preparation.
  • Needs to have liquids thickened or food pureed, minced, or cut, but is independent with Meal Preparation.
  • Receives nutrition by tube or intravenous feedings and can independently prepare his or her liquid nutrition.
  • Is independent with Meal Preparation but has a vision impairment.
  • Is independent with Meal Preparation but needs assistance cleaning the inside of his or her refrigerator. This need is captured in Module 5.16 Laundry and/or Chores.
  • Could prepare meals safely and independently using a toaster oven, toaster, stove top, stove, oven, microwave oven, or electric frying pan, whether or not he or she currently has any of these appliances.
  • Is independent with Meal Preparation but needs assistance with the money transaction to pay for the groceries with cash, credit card, debit card, gift card, personal check, or by store charge account. This need is captured in Module 5.15 Money Management.
  • Independently orders his or her groceries online, calls-in, or emails his or her grocery order for convenience.
  • Has pica or polydipsia. These needs are captured in Module 9 Behavioral Health, as self-injurious behaviors.

“Check 1, 2, 3” using guidance provided under CODING FOR LEVEL OF HELP NEEDED, at the appropriate frequency for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, or hands-on assistance with the task of Meal Preparation.
  • Is independent with Meal Preparation but doing so results in a significant, negative health outcome.
  • Needs assistance preparing meals due to his or her inability to stand long enough to cook food, even when taking breaks to sit down during the task of making a meal.
  • Needs assistance to have liquids thickened or food pureed or minced to prepare a mechanical soft diet.
  • Needs assistance to cut prepared food on a plate.
  • Needs assistance preparing his or her liquid nutrition for his or her tube or intravenous feedings.
  • Needs assistance placing food on plate or table (serving) or with carrying a plate and/or cup to the table.
  • Needs assistance to open food containers.
  • Needs assistance opening his or her refrigerator or freezer.
  • Is unable to safely use any appliance to heat food.
  • Needs to have a plate “set up” with food due to his or her visual impairment.

Exceptions to determining appropriate frequencies:

Check “1”: (Needs help from another person weekly or less often) for a person who:

  • Due to a cognitive impairment, is unable to determine when properly stored food is spoiled.
  • Needs assistance only with grocery shopping.
  • Due to a cognitive impairment, needs assistance with grocery shopping because only selects food with no nutritional value, for example, only selects soda and candy.

Check “2”; (Needs help 2 to 7 times a week) for a person who:

  • There are no exceptions to Check “2”; refer to CODING FOR LEVEL OF HELP NEEDED

Check “3”: (Needs help with every meal) for a person who:

  • Has Prader-Willi syndrome.
     

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5.14 Medication Administration and Medication Management

LTCFS ITEM DEFINITION:

Medication: A medication is a drug used to treat disease, symptoms, or injury that enters the body in the prescribed manner. The type of medications prescribed for the person can be brand name, generic, or over-the-counter (OTC). A medication on the LTCFS must meet these three criteria:

  1. Approved by the U.S. Food and Drug Administration.
  2. Prescribed by a Medicaid-recognized prescriber, such as physician, psychiatrist, nurse practitioner, physician assistant, optometrist, or dentist.
  3. Regularly scheduled and used.

PRN Medication: A PRN medication is a medication taken only when needed based on symptoms, and typically PRN medications are not captured on the LTCFS.

In order for a PRN medication to be captured on the LTCFS, it must meet the definition of a medication and be used as stated here:

  • Regularly scheduled and used at minimum once a month every month. Examples include:
    • Pain medicine that is ordered PRN but taken every four to six hours, every day.
    • Skin cream that is ordered PRN but applied every week.
    • A medication to relieve menstrual symptoms, such as Midol, that is ordered PRN but used once every month.
  • Sliding scale insulin (where the exact dosage is adjusted according to the blood glucose level) can be treated as a regularly scheduled medication, because it is regularly given, with the dose merely adjusted to blood glucose level.

The following are not considered medications on the LTCFS:

  • PRN medications that do not meet the definition of a medication.
  • Vitamin (unless injected, such as vitamin B-12 injections), mineral, supplement, and alternative or complementary medicines, even if prescribed by a Medicaid-recognized prescriber.
  • Non-vitamin, non-mineral natural substances such as omega 3 or fish oil, glucosamine, ginkgo, anti-oxidants, ginseng, echinacea, chondroitin, coenzyme Q10, flaxseed, cranberry, garlic, soy, melatonin, green tea, saw palmetto, grape seed, milk thistle, lutein, barkwater, or shark cartilage, even if prescribed by a Medicaid-recognized prescriber.
  • Other complementary or alternative medicines such as a homeopathic, naturopathic, or herbal therapy; or other treatment such as aromatherapy, flower remedies, crystal or magnet therapy, chelation, bowel cleansing, detoxifier, acupuncture, or acupressure.
  • Other dietary supplements with calories, minerals, vitamins, and/or other additives.

In the IADLs, Medication Administration and Medication Management are coded together. This differs from the HRS table where Medication Administration and Medication Management are coded separately.

The LTCFS application will check to ensure that the level of help indicated in the IADL Medication Administration and Medication Management correlates with the Medication Administration and Medication Management tasks on the HRS Table. If the level of help does not correlate between that IADL task and the Medication Administration and Medication Management tasks on the HRS Table, the screener will receive an error message to prompt review.

LTCFS ITEM DEFINITION:

Medication Administration: A person’s need for assistance from another person to take or be given a medication by any route except intravenously (IV). This could be by mouth, under the tongue, injection, onto or into the body, rectally, vaginally, by feeding tube, or by inhaler. Common forms of medication include but are not limited to tablet, capsule, liquid, drops, and skin preparations. The person’s need for assistance from another person in order to use a prescribed medication that is regularly scheduled and used should be captured here.

The preparation of medications, such as crushing a tablet to be diluted or measuring to fill a syringe or dosage cup, may be considered Medication Administration when it is prepared within one hour of when the dose is to be taken.

Excluded are:

  • IV medications. This need is captured in Module 7.13 IV Medications, Fluids, or Line Flushes
  • Topical medications used for ulcer, wound care. This need is captured in Modules 7.24 Ulcer–Stage 2, 7.25 Ulcer–Stage 3 or 4, or 7.27 Other Wound Cares
  • Medications used for nebulizer treatments. This need is captured in Module 7.18 Oxygen and/or Respiratory Treatments

LTCFS ITEM DEFINITION:

Medication Management: A person’s need for assistance from another person to set up or monitor his or her prescribed and regularly scheduled and used medications. The two components of Medication Management include:

1.) Medication Set-Up: To separate out the proper dosage and set it aside for later use by the individual. Medication set-up is completed for several reasons. One reason is to ensure the proper medication, at the proper dosage is selected when the individual is unable to select it due to a physical, cognitive, or memory loss impairment. Another reason is to arrange the medications to help the person remember to take them at proper times and to make it easier to tell that medications were or were not taken.

Examples of medication set-ups:

  • Medication boxes with compartments labeled for different times and each day of the week, into which pills are placed.
  • Any other “set-up” system in which medications and dosages are preselected by another person, such as a bubble pack.
  • Automated medication dispensers, such as a CompuMed, that can be programmed (often weekly) to dispense pills.
  • Prefilling of syringes, such as insulin syringes.

Medication set-ups are commonly used for convenience in organizing and remembering one’s medications, even by people with no physical, cognitive, or memory loss impairments. When a person uses a medication set-up, the screener needs to determine whether due to a physical, cognitive, or memory loss impairment the person needs to use the medication set-up, and/or needs the assistance of another person to fill it.

The preparation of medications, such as crushing a tablet to be diluted or measuring to fill a syringe or dosage cup, may be considered Medication Management when it is NOT prepared within one hour of when the dose is to be taken.

2.) Medication Monitoring

Medication monitoring includes the following components:

  • Due to a memory loss or cognitive impairment, oversight is required for monitoring of effects, side effects, or adjustments. This oversight is captured at a frequency of one to three times per month.
  • The need to collect medication-related data, as ordered by the prescriber, prior to administering a medication, such as blood glucose level, blood pressure, or heart rate, and that the data collection is occurring.
  • The need to collect medication-related data, as ordered by the prescriber, such as vital signs, weights, seizure activity or in-home assistance to draw blood for a lab test, and that the data collection is occurring and reported to a health care provider.

Common reasons for a need for assistance with Medication Monitoring (this is not an all-inclusive list of examples):

  • Uncontrolled Seizure Disorder. An individual’s need for assistance in his or her residence from another person when the individual has an uncontrolled seizure disorder, evidenced by one or more seizures in the last three months, and medication is frequently adjusted.
  • Pain Management. An individual’s need for assistance from another person to adjust his or her medications, in the individual’s residence, in order to manage pain. This does not include care at a pain clinic or any other setting outside the person’s residence. This also does not include prescription or OTC PRN medications that do not meet the definition of a Medication as described at the beginning of this module.
  • Blood Levels. A person’s need for assistance from another person to draw blood samples, in his or her residence, for laboratory tests. The majority of these tasks are related to medications such as Pro-Times to regulate Coumadin administration or potassium levels for a person on diuretics. Blood levels also include “finger-sticks” for capillary blood to test blood glucose levels.

If the person’s condition is unstable and medication is frequently adjusted, then the need for medication monitoring may be several times per week or even daily. The condition or treatment may stabilize over time and then the frequency of medication monitoring would decrease. A rescreen should be completed when a person’s condition stabilizes to reflect this and any other changes.

CODING FOR LEVEL OF HELP NEEDED

  • NA: Has no medications
  • 0: Independent (with or without assistive devices).
  • 1: Needs help 1 to 2 days a week or less often. Includes having someone set-up medications, pre-fill syringes, or the administration of medication.
  • 2a: Needs help at least once a day 3-7 days per week--CAN direct the task and can make decisions regarding each medication.
  • 2b: Needs help at least once a day 3-7 days per week--CANNOT direct the task; is cognitively unable to follow through without another person to administer each medication.

Considering “can direct the task” versus “cannot direct the task”
As listed on the LTCFS, the distinction between “can direct the task” and “cannot direct the task” applies only if the person needs help at the higher frequency of ”at least once a day 3-7 days per week.“ If the person needs help less often than 3-7 days per week, the screener does not need to make a determination about the person’s ability to direct the task of taking or withholding his or her medications.

A person cannot direct the task of managing his or her medication if, due to a cognitive or memory loss impairment, the person needs a cue to take his or her medication. To code cueing assistance for a medication, the cue must be done within an hour of when the dose is to be taken.

In addition, not every person with a cognitive impairment will be unable to direct the task of managing his or her medication. Some individuals with a cognitive limitation can independently take his or her medication as prescribed, without misuse or error, once the medication is set up. For such a person, the selection of “1: Needs some help 1-2 days per week or less often,” would be applicable.

MEDICATION ADMINISTRATION and MEDICATION MANAGEMENT-SPECIFIC RESPONSE GUIDANCE:

The “Check NA, 0, 1, 2a, 2b” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “NA” (Has no medications) for a person who:

  • Has no medications.
  • Does not take regularly scheduled medication but needs assistance from another person with an infrequently taken prescription PRN medication (taken less than once a month every month). Such a PRN medication does not meet the LTCFS definition of a medication. Refer to the PRN Medication definition.
  • Chooses not to take any medications (the person is declining the task of taking medications itself). If the individual has declined the task of taking medications itself, and is able to perceive and recognize the potential risk or negative health outcome that could result from declining the task, the screener should select “NA–Has no medications.” In this situation, the person has no need for Medication Administration or Medication Management because it is not occurring. For example, if an individual able to perceive potential risk or negative outcome chooses not to take any prescribed medications, the person has no need for medication administration and medication management assistance because no medications are being taken (the task itself is not being done).
    • If the person is not able to perceive and recognize the potential risk or negative health outcome that could result from declining the task, the screener should select the frequency of need.
    • If a person has a legal guardian, an activated power of attorney for health care, or is currently involved with adult protective services, that person may be considered not able to perceive and recognize potential risks or negative health outcomes, and the selection of a need might be appropriate.

Check “0” (Independent) for a person who:

  • Has no physical, cognitive, or memory loss impairment affecting his or her ability to complete the task of Medication Administration and Medication Management independently.
  • Is independent with Medication Administration and Medication Management with the use of simple, reasonable adaptations, such as large-print or Braille labels, “talking” glucometer, easy-open pill bottles.
  • Is independent with Medication Administration and Medication Management and uses an alarm on their watch, clock, or phone as a reminder to take medications.
  • Is independent with Medication Administration and Medication Management and uses an automated pill dispenser such as, CompuMed.
  • Requests assistance with Medication Administration and Medication Management due only to a gender, age, or cultural norm.
  • Requests assistance with Medication Administration and Medication Management due only to a language barrier.
  • Requests assistance with Medication Administration and Medication Management due only to illiteracy.
  • Requires Medication Administration and Medication Management assistance less often than monthly.
  • Is independent with Medication Administration and Medication Management as prescribed, and receives services outside his or her residence, such as:
    • Has medication monitoring, including blood draws, done outside the person’s residence, such as at the physician’s office, clinic, pharmacy, or health care facility.
    • Receives injections, such as vitamin B-12 or Depo-Provera, outside his or her residence, such as at a clinic.
    • Takes medication through an intrathecal drug pump, also known as a pain pump or internal morphine pump, that requires only intermittent refills and maintenance in the clinic setting, but does not require monitoring in their residence.
    • Has a drug delivery implant, such as the birth control implant, Implanon.
  • Is independent with Medication Administration and Medication Management, takes medication as prescribed, is able to contact the prescriber with concerns, and understands the prescriber’s recommendations.
  • Is independent with Medication Administration and Medication Management, takes medication as prescribed, and is able to independently collect medication-related data, such as blood glucose levels, blood pressure, weights, or pulse.
  • Is independent with Medication Administration and Medication Management and independently sets up and uses his or her medication box.
  • Is independent with Medication Administration Medication Management and uses a medication box as a convenience.
  • Is independent with Medication Administration and Medication Management and has an unorthodox system of organizing medications, but has no history of medication misuse or errors.
  • Is independent with Medication Administration and Medication Management; however, a lock box is used:
    • Due to the policy of their provider agency (such as a hospice agency or personal care provider agency).
    • To prevent another person or a pet from having access to the medication.
    • Solely due to suicidal ideations or substance use issues.
    • Due to taking their medication other than as prescribed.
  • Is independent with Medication Administration and Medication Management; however, needs assistance to prevent someone else, including a pet from having access to the medication.
  • Only needs assistance reordering or obtaining medication refills. This includes assistance to arrange for a medication refill, such as a request to the pharmacy or picking up the refilled medication at the pharmacy. These needs are captured in Module 5.16 Laundry and/or Chores.
  • Is independent with Medication Administration and Medication Management and lives in a residential facility but does not administer or manage their medications because medications are provided as part of the services in the facility where they reside.
  • Is independent with Medication Administration and Medication Management, lives in a residential facility, and on a regular basis receives routine monitoring for general health, behavior, etc., by the person’s agency’s staff because that monitoring is provided to all residents.
  • Is independent with Medication Administration and Medication Management but due to the policy of the person’s provider agency, such as hospice or a personal care provider, does not administer or manage their medications because this is a service provided by the agency.
  • Is independent with Medication Administration and Medication Management and is left a written reminder from another person as a cue to take his or her medications.
  • Is independent with Medication Administration and Medication Management and is contacted by another person to check if the person has or has not taken his or her medication but the cueing or call is not needed.
  • Does not have a cognitive or memory loss impairment and the person cannot name each of his or her medications but can tell you what health issues he or she takes medication for. Examples include but are not limited to when a person cannot name his or her hypertension medication, such as hydrochlorothiazide, but can tell you, “That little yellow pill is my water pill. I have high blood pressure.” Or, they can tell you, “I take a pill once a week for my osteoporosis” when they are prescribed alendronate.
  • Is independent with Medication Administration and Medication Management and takes a medication that only comes preselected from the manufacturer, such as birth control pills, some antibiotics, some steroids, or insulin in dispensing pens.
  • Is independent with Medication Administration and Medication Management and only needs assistance getting food or drink needed to take their medications but takes their medications at meal times.
  • Is given medication by IV only. This need is captured in Module 7.13 IV Medications, Fluids, or Line Flushes.

Check “1, 2a, 2b” using guidance provided under CODING FOR LEVEL OF HELP NEEDED, at the appropriate frequency for a person who:

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with the task of Medication Administration and Medication Management. To code cueing assistance for a medication, the cue must be done within an hour of when the dose is to be taken.
  • Needs assistance to crush his or her medication or assistance to put his or her medication in food, such as applesauce, in order for it to be taken.
  • Needs assistance to check his or her blood glucose level or to adjust his or her insulin dose given the current blood glucose level.
  • Needs assistance to prepare a medication for administration via a feeding tube. For example, crushing a tablet to be diluted and administered through a G-tube.
  • Has an unstable condition and medication is frequently adjusted and, due to a cognitive impairment, they need someone to monitor them for specific medication effects and side effects and report those to the prescriber.
  • Has cognitive impairment and has a court-ordered medication.
  • Requires assistance with a medication delivered subcutaneous with a pump, such as an insulin pump.
  • Needs someone to physically assist with the medication but is self-directing and has the cognitive ability to select the proper medication and dosage, and has the judgment to understand the medication’s purpose, side effects, and report problems. An example of this is a person with quadriplegia who instructs his or her helper, “Please put one of those three pills on my tongue and give me a drink.”
  • Due to a cognitive or memory loss impairment, needs someone to assist with the medication because the person is not self-directing, does not have the cognitive ability to select the proper medication and dosage, lacks the judgment to understand the medication’s purpose, side effects, and report problems.
  • Is independent with Medication Administration and only needs assistance getting food or drink, outside of meal preparation, needed to take their medication.

Exceptions to determining appropriate frequencies:

Check “1” (Needs help 1 to 2 days per week or less often) for a person who:

  • Only requires assistance with Medication Administration and Medication Management at the “1 to 3 times/month” or “Weekly” frequency as on the HRS Table.
  • Is independent with Medication Administration; however, only requires assistance with the filling of a medication box. Medication boxes are typically filled at the “1 to 3 times/month” frequency, since two or more medication boxes can be prefilled at one time. If this usual method does not work well for an individual due to their physical, cognitive, or memory loss impairment, more frequent medication set-up may be necessary.
  • Only requires assistance with prefilling insulin syringes as they can typically be completed weekly, since prefilled syringes can be stored in the refrigerator for a week. This task should be indicated at the “Weekly” frequency on the HRS Table.
  • Only requires assistance with measuring medication from a larger container to a smaller dosage cup as this can typically be completed weekly. This task should be indicated at the “Weekly” frequency on the HRS Table.
  • Has a cognitive or memory loss impairment but takes medication as prescribed, without misuse or error, once the medication is set up.
  • Only requires oversight due to a memory loss or cognitive impairment for monitoring of effects, side effects, or adjustments. This oversight is captured at a frequency of 1 to 3 times per month on the HRS Table.

Check 2a (Needs help at least once a day 3-7 days per week—CAN DIRECT the task) only for a person WITH A PHYSICAL IMPAIRMENT who:

  • There are no exceptions to Check “2a”; refer to CODING FOR LEVEL OF HELP NEEDED

Check 2b: (Needs help at least once a day 3-7 days per week—CANNOT direct the task) only for a person WITH A COGNITIVE OR MEMORY LOSS IMPAIRMENT who:

  • There are no exceptions to Check “2b”; refer to CODING FOR LEVEL OF HELP NEEDED

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5.15 Money Management

LTCFS ITEM DEFINITION:

Money Management: The ability to handle money, which includes allocating funds to pay bills and completing financial transactions needed for basic necessities (food, shelter, and clothing). These financial transactions include but are not limited to any of the following types of money transactions: cash, credit card, debit card, gift card, charge account, personal check, money order, automatic withdrawal, automatic deposit, the exchange of currency, online banking, or mobile banking.

The task of Money Management consists of the following components:

  • Having a basic understanding of a monetary transaction; for example, an individual knows they need money to complete a transaction at a store and they know they have enough money to complete the transaction (this component pertains only to people with a cognitive or memory loss impairment).
  • Having an understanding of how to allocate or budget money to pay bills needed for meeting the basic necessities of food, shelter, and clothing (this component pertains only to people with a cognitive or memory loss impairment).
  • Having the physical ability to complete a transaction and pay bills (this component pertains only to people with a physical impairment).

Money Management does not include when a person without a cognitive impairment makes money management choices consistent with his or her lifestyle, values, and goals, even if those choices do not align with the screener’s or other persons’ values or goals. Examples include a person who spends a majority of their money on gambling, drugs, alcohol, or cigarettes.

A screener must review a person’s ability to manage money even if a person has formal or informal supports who assist the individual with money management; for example, do not assume a person cannot manage their money even if they have a representative payee, durable power of attorney, power of attorney, authorized representative, activated power of attorney for health care decisions, designated power of attorney for health care decisions, conservatorship, guardian of the person, or guardian of estate.

CODING FOR LEVEL OF HELP NEEDED

  • 0: Independent
  • 1: Can only complete small transactions (Needs help from another person to complete some components of Money Management)
  • 2: Needs help from another person with all transactions

MONEY MANAGEMENT-SPECIFIC RESPONSE GUIDANCE:

The “Check 0, 1, 2” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “0” (“Independent”) for a person who:

  • Has no physical, cognitive, or memory loss impairment limiting his or her ability to complete the task of Money Management independently.
  • Is independent with Money Management with the use of simple, reasonable adaptations, such as using a debit card, online banking, or folding bills based on denomination for identification.
  • Has no physical, cognitive, or memory loss impairment affecting his or her ability to complete the task of Money Management independently, but:
    • Prefers assistance with Money Management due only to a gender, age, or cultural norm.
    • Needs assistance with Money Management due only to a language barrier.
    • Needs assistance with Money Management due only to illiteracy.
    • Hasn’t had experience or learned the task of Money Management and his or her ability to complete this task has yet to be reviewed to determine the person’s ability to handle at least some money transactions. Examples of a person with the cognitive ability to manage his or her money, but does not have the experience of doing so, could include a person with a severe and persistent mental illness or an intellectual/developmental disability, a young adult, a recent immigrant, or even a recent widow or widower whose partner handled all of the couple’s finances.
    • Has inadequate income to meet his or her basic needs and the only reason they need helps is due to the inadequate income.
    • Has a representative payee, money manager, or receives other assistance allocating his or her money due to a history of poor money management related to personal choices or issues with alcoholism, a drug addiction, or a gambling addiction.
  • Is independent with Money Management but has a vision impairment.
  • Is independent with Money Management but requires transportation to the bank. This need is captured in Module 5.18 Transportation.
  • Is independent with Money Management but needs assistance with mailing the bill. This need is captured in Module 5.16 Laundry and/or Chores.
  • Is independent with Money Management but needs assistance with setting up automatic payments.

Check “1” (Can only complete small transactions) (Needs help from another person to complete some components of Money Management) for a person who:

  • Due to a cognitive or memory loss impairment requires assistance with allocating or budgeting money, but is independent with transactions.
  • Due to a cognitive or memory loss impairment requires assistance with transactions, but is independent with allocating or budgeting money.
  • Due to a physical impairment requires assistance to complete transactions and pay bills beyond simple reasonable adaptations, but understands allocating and budgeting.

Check “2” (Needs help from another person with all transactions) for a person who:

  • Due to a cognitive or memory loss impairment requires assistance to complete a transaction and requires assistance to allocate or budget money to pay bills needed for basic necessities of food, shelter, and clothing.

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5.16 Laundry and/or Chores

LTCFS ITEM DEFINITION:

Laundry and/or Chores: The ability to complete one’s personal laundry, routine housekeeping, and basic home maintenance tasks.

The task of Laundry consists of, but is not limited, to the following components: 

  • Getting personal laundry to the washing machine and dryer. This includes accessing the laundry area associated with their residence such as in a kitchen, in a laundry room, in a basement, or another building in an apartment complex.
  • Loading the laundry in washing machine
  • Adding detergent
  • Setting dial(s)
  • Transferring the laundry from washer to dryer 
  • Removing the laundry from dryer
  • Putting the laundry away

Examples of Chores include but not limited to:

  • Routine Housekeeping
    • Vacuuming and floor washing
    • Dusting and surface cleaning
    • Cleaning up after meals including clearing and cleaning the eating area and food storage 
    • Washing and putting away dishes and utensils
    • Cleaning bathroom
    • Cleaning appliances
    • Taking out the garbage
  • Routine outdoor property maintenance
    • Snow and ice removal
    • Lawn mowing
  • Mailing bills
  • Reordering medications

Laundry and/or Chores does not include when a person makes laundry and/or chore choices consistent with his or her lifestyle choices, values, and goals, even if those choices do not align with the screener’s or other person’s values or goals. Examples include how often a person washes the dishes or their clothes, or how clean they keep their home.

Laundry and/or Chores only include one’s personal laundry, routine housekeeping, and basic home maintenance tasks. It does not include requests for housecleaning assistance due to having a pet(s) in his or her home, completing other household members’ laundry (such as spouse’s or children’s laundry), or the cleaning of living spaces not used by the individual (such as teenager’s bedroom or bathroom).

CODING FOR LEVEL OF HELP NEEDED

  • 0: Independent
  • 1: Needs help from another person weekly or less often
  • 2: Needs help more than once a week

LAUNDRY and/or CHORES-SPECIFIC RESPONSE GUIDANCE:

The “Check 0,1,2” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Check “0” (“Independent”) for a person who:

  • Has no physical, cognitive, or memory loss impairment limiting his or her ability to complete the task of Laundry and/or Chores independently.
  • Is independent with Laundry and/or Chores with the use of simple, reasonable adaptations, such as using a mop to wash the floor, using pre-measured laundry detergent, or sitting while washing dishes or folding laundry.
  • Is independent with the task of Laundry and/or Chores, but it takes additional time to do so and there are NO significant, negative health outcomes. 
  • Is independent with Laundry and/or Chores but needs assistance with tasks beyond routine housekeeping and routine outdoor property maintenance, such as: 
    • Heavy-duty cleaning done infrequently, such as carpet, drapery, and window cleaning, or wall washing. 
    • Infrequent seasonal outdoor maintenance, such as window washing, gardening, weatherization, cleaning gutters, and yard maintenance such as weeding, pruning hedges, raking leaves, and aerating or fertilizing the grass. 
    • Enhancing the dwelling’s appearance, such as painting. 
  • Is independent with Laundry and/or Chores but resides in a residential facility or institution and the provision of Laundry and/or Chore services is provided as part of the facility package.
  • Is independent with Laundry and/or Chores, but due to a cognitive impairment, requires assistance with determining when properly stored food is spoiled. This need is captured in Module 5.13 Meal Preparation.
  • Has no physical, cognitive, or memory loss impairment affecting his or her ability to complete the task of Laundry and/or Chores independently, but:
    • Prefers assistance with Laundry and/or Chores due only to a gender, age, or cultural norm.
    • Needs assistance with Laundry and/or Chores due only to a language barrier.
    • Needs assistance with Laundry and/or Chores due only to illiteracy.
    • Hasn’t had experience or learned the task of Laundry and/or Chores and his or her ability to complete this task has yet to be reviewed to determine the person’s ability to complete the tasks. 
  • Is independent with the task of Laundry but requires transportation to and from a laundromat. This need is captured in Module 5.18 Transportation. 
  • Would require assistance completing routine outdoor property maintenance but is not responsible for these tasks.

Check “1” (“Needs help from another person weekly or less often”) for a person who

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with Laundry and/or Chores tasks that typically occur weekly or less often. 
  • Is independent with Laundry and/or Chores tasks that typically occur weekly or less often but doing so results in a significant, negative health outcome. 
  • Needs assistance with the task of Laundry when the person is NOT in need of more frequent laundry assistance due to incontinence or other documented medical reason, such as a MRSA infection. 
  • Needs assistance with vacuuming and/or dusting when the person is NOT in need of more frequent vacuuming or dusting assistance due to a documented medical reason, such as severe allergies or respiratory condition.
  • Needs assistance with surface cleaning and/or floor washing when a person is NOT in need of more frequent assistance due to incontinence or other documented medical reason, such as a MRSA infection.
  • Needs assistance with cleaning the bathroom when a person is NOT in need of more frequent cleaning of the bathroom due to incontinence, incidental soiling during toileting, or other documented medical reason, such as a MRSA infection.
  • Needs assistance with cleaning the inside of his or her refrigerator. This does not include determining if properly stored food is spoiled; this need is captured in Module 5.13 Meal Preparation. 
  • Needs assistance with re-ordering or obtaining medication refills. This does not include needed transportation to and from the pharmacy or assistance with the money transaction to pay for the item(s). These needs are captured in Module 5.18 Transportation and Module 5.15 Money Management.
  • Needs assistance with shopping other than for groceries, such as trying on clothes when shopping for clothes. This does not include needed transportation to and from the store or assistance with the money transaction to pay for the item(s). These needs are captured in Module 5.18 Transportation and Module 5.15 Money Management.
  • Needs assistance with mailing bills. 
  • Needs assistance with retrieving and/or laying out toiletries (such as shampoo, soap, towels) for bathing.
  • Needs assistance cleaning appliances. 
  • Needs assistance completing routine outdoor property maintenance, only if responsible for these tasks. 

Check “2” (“Needs help more than once a week”) for a person who

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with Laundry and/or Chores tasks that typically occur more than once a week. 
  • Is independent with Laundry and/or Chores tasks that typically occur more than once a week but doing so results in a significant, negative health outcome.  
  • Needs assistance with laundry due to incontinence or other documented medical reason, such as a MRSA infection, and is in need of more frequent laundry assistance. 
  • Needs assistance with vacuuming and/or dusting due to a documented medical reason, such as severe allergies or a respiratory condition, and is in need of more frequent vacuuming and/or dusting.
  • Needs assistance with surface cleaning and/or floor washing due to incontinence or other documented medical reason, such as a MRSA infection, and is in need of more frequent floor washing.
  • Needs assistance with cleaning the bathroom due to incontinence, incidental soiling during toileting, or other documented medical reason, such as a MRSA infection, and is in need of more frequent cleaning.
  • Needs assistance with cleaning up after a meal. 
  • Needs assistance with washing and putting away dishes and utensils.
  • Needs assistance with retrieving and/or laying out clothes for dressing.

If a person requires more frequent laundry and/or chores assistance due to a documented medical reason that is time limited, once the person no longer requires more frequent assistance, their LTCFS should be updated to reflect the change in condition. 

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5.17 Telephone Use

LTCFS ITEM DEFINITION: 

Telephone Use: The ability of a person to use a phone to exchange information with others (two-way communication) with or without simple reasonable adaptations. This includes, but is not limited to, voice call and video calls such as FaceTime or Skype, texting or messaging, telecommunications relay service, large button phones, or other assistive devices. Telephone use captures routine phone calls. What constitutes routine phone use is very person-specific. They are the familiar and frequent exchanges of information a person makes and receives.

Types of phones include but are not limited to landlines, cell or mobile phones (basic or smart phones).

Telephone use does not include when a person inappropriately uses a phone. Inappropriate phone use may be captured under Module 8.4 Cognition for Daily Decision or Module 9.4 Offensive or Violent Behavior to Others. Examples include calling 911 when no emergency exists, or calling others and making sexual comments or direct threats.

CODING FOR LEVEL OF HELP NEEDED (both items require a selection)

Ability to Use Phone:

  • 1a: Independent. Has cognitive and physical abilities to use a phone. 
  • 1b: Lacks cognitive or physical abilities to use phone independently. 

Access to Phone:

  • 2a: Currently has working phone or access to one. 
  • 2b: Has no phone and no access to a phone. 

TELEPHONE-SPECIFIC RESPONSE GUIDANCE:

The “Check 1a, 1b” list contains common, illustrative examples. This list is not an all-inclusive list of examples.

Ability to Use Phone:

Check “1a” (Independent. Has cognitive and physical abilities to use a phone) for a person who: 

  • Has no physical, cognitive, or memory loss impairments affecting his or her ability to use a phone independently. 
  • Independently uses his or her phone but requires supervision to use appropriately.   
  • Independently uses his or her phone but needs assistance with a phone other than their personal phone.
  • Independently uses a phone with preprogrammed numbers or contacts.
  • Independently uses a phone with the use of simple, reasonable adaptations. 
  • Has no physical, cognitive, or memory loss impairments affecting his or her ability to use a phone independently, but:
    • Prefers assistance with using a phone due only to gender, age, or cultural norm. 
    • Needs assistance with using a phone due only to a language barrier.

Check “1b” (Lacks cognitive or physical abilities to use phone independently) for a person who: 

  • Due to a physical, cognitive, or memory loss impairment requires supervision, cueing, and/or hands-on assistance with using a phone.
  • Will answer a ringing phone but is not able to place a call. 
  • Is unable to participate fully in a two-way exchange of information due to significant communication impairment.

Access to Phone:

Check “2a” (Currently has working phone or access to one) for a person who: 

  • Has access to a phone in their residence. 

Check “2b” (Has no phone and no access to phone) for a person who: 

  • Does not have access to a phone in their residence. 

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5.18 Transportation

Definition: At the time of the screening, the person is physically and cognitively capable of driving a regular or adapted vehicle.

TRANSPORTATION RATING SYSTEM

  • 1a: Person drives regular vehicle
  • 1b: Person drives adapted vehicle
  • 1c: Person drives regular vehicle, but there are serious safety concerns
  • 1d Person drives adapted vehicle, but there are serious safety concerns
  • 2: Person cannot drive due to physical, psychiatric, or cognitive impairment
  • 3: Person does not drive due to other reasons

A regular vehicle is a standard model vehicle the person operates without needing specialized adaptations to drive.

A regular vehicle may be equipped with modifications that allow the person to enter/exit the vehicle or allow his/her mobility device to be transported with him/her. While these modifications may be needed in order for the person to RIDE in the vehicle, they are not necessary for the person to operate the vehicle.

Examples of vehicular modifications include, but are not limited to, a car top carrier for a wheelchair, trunk lift for carrying a wheelchair or scooter, grab bar, automatic door opener, van lift used to enter/exit the van when sitting in a wheelchair or scooter, etc.

For the purposes of the LTCFS, a vehicle with these and similar modifications is not an adapted vehicle.

Select 1a: Person drives regular vehicle if he or she is able to drive a vehicle with or without modifications described above.

An adapted vehicle is one the person operates that has after-market specialized equipment making the vehicle accessible for the person to DRIVE; without the specialized adaptations, the person would not be able to drive the vehicle.

These adaptations help the driver control the vehicle’s speed and direction and may include, but are not limited to, hand controls, adaptive pedal extensions, switch pad controls, extended gearshift handle, etc.

Select 1b: Person drives adapted vehicle if he or she is only able to drive a vehicle that has specialized and adaptive driving equipment described above.

Serious Safety Concerns
Serious safety concerns may be evident when a person with a physical, psychiatric, or cognitive impairment drives a motor vehicle. The screener will rely on professional judgment when reviewing how limitations may affect the person’s ability to safely drive a vehicle.

Some examples of a person driving with serious safety concerns can include but are not limited to a person who drives:

  • With a diagnosis of dementia
  • With impaired vision
  • With paresis without using specialized equipment
  • Under the influence of alcohol or a controlled substance

REMINDER: Do not select 1b: Person drives adapted vehicle, when the person could drive an adapted vehicle but does not currently have the needed specialized equipment in his or her vehicle.

Select 1c: Person drives a regular vehicle, but there are serious safety concerns if the person has a diagnosis, condition, or driving history described above and he or she drives a regular vehicle.

Select 1d: Person drives adapted vehicle, but there are serious safety concerns if the person has a diagnosis, condition, or driving history described above and he or she drives an adapted vehicle.

Serious safety concerns should not be selected for a person who has made a reasonable accommodation(s) that limits driving to:

  • Only during daylight hours
  • Non-rush hours (typically weekdays, 9:00 a.m. to 3:00 p.m.)
  • Neighborhood driving
  • Only short distances from his or her residence
  • Comply with the Division of Motor Vehicles (DMV) restrictions on his or her license
  • Comply with the limits associated with his or her occupational license

Select 2: Person cannot drive due to physical, psychiatric or cognitive impairment if at the time of the screening, the person does not drive or is not capable of driving due to a physical condition (e.g., blindness or hemiparesis), psychiatric condition (e.g., schizophrenia), or cognitive impairment (e.g., dementia).

Select 3: Person does not drive due to other reasons if at the time of the screening, the person does not have a physical, psychiatric, or cognitive impairment limiting his or her ability to drive, but the only reason he or she does not drive is because the person:

  • Never learned to drive
  • Lacks a valid driver license due to a reason other than a physical, psychiatric, or cognitive impairment
  • Does not own a vehicle or have access to one
  • Cannot afford to maintain a vehicle
  • Cannot afford vehicle insurance coverage
  • Only utilizes mass transit or taxi service
  • By choice, is only driven by family members or friends
  • Adheres to an age, gender, or cultural norm

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Last Revised: December 20, 2019