Residential Care Assessment ToolFax completed form and any attachments to:

360-902-9170 or 360-902-6030

Worker’s Name:      

Claim Number:       Date:      

Background Information:Name:     

Age:     

Primary Language:     

Current Height:     

Current Weight:     

Bariatric Concerns? Yes No

Known Allergies/Reactions:     Transferred From:     Assessment Location (Address):     City:     

State:     

Zip Code:     

Is there a substitute decision-maker? Yes NoIndicate Type:

Guardian DPOA Family Member POA Representative Payee

Name:     

Phone:     

Primary Physician:     

Attending Physician:     

Clinic Address:     

Clinic Address:     

City:     

State:     

Zip Code:     

City:     

State:     

Zip Code:     

Phone Number:     

Fax Number:     

Phone Number:     

Fax Number:     

Facility Information:RN/LPN Coverage:

Yes NoDirect Caregivers per Shift:#      /day #     /night

RN Delegation: Yes No

Number of Residents at Facility:     

L&I Provider Number:     

Type of Service Assisted Living Boarding House Adult Family Home Other:      

Reason for Services (worker):     

F245-377-000 Residential Care Assessment Tool 06-2017 Page 1 of 13

Name: Claim Number:

Current Medical Diagnosis

Only include diagnoses made by a licensed medical professional. Also include if appropriate:

History of mental illness. Diagnosis of a developmental disability. Recent surgeries and hospitalization.

Date of most recent exam:     

By whom:     

     

Current Medications

Include prescribed, over-the-counter, and herbal medications. Attach additional pages if needed. You may attach a current medication list.

Medication name: What medication is used for: Dosage, route, and frequency:                 

                 

                 

                 

                 

                 

                 

                 

                 

                 

                 

                 

                 

F245-377-000 Residential Care Assessment Tool 06-2017 Page 2 of 13

Name: Claim Number:

Recent Medical History/Significant Symptoms Assessment

VisionDate of last exam:      

Normal without correctionNormal with correctionSignificant impaired vision, difficulty identifying objectsSeverely impaired, sees only light/colors; can’t track objectsBlind

Left eye Right eyeHearingDate of last exam:      

No problem identifiedNormal with hearing aidesHears only in special situations; must adjust tonal quality and volume.Highly impaired – no useful hearing

Loss: Left RightAids: Left RightOther:      Lung/Breathing

No problem identifiedDifficulty breathing/shortness of breath at restDifficulty breathing/shortness of breath with activityWheezingChronic coughCough assistSleep apneaCPAPTracheostomy*Ventilator**Special circumstance, would not consider tracheostomy or ventilator to be a standard placement

Other:      Cardiovascular

No problem identifiedChest painHigh blood pressureLow blood pressureDizzinessEdema Location:      

Other:      Gastrointestinal

No problem identifiedDietary restrictionsAbdominal painGall bladder historyTube feedingIV fluidTPN

Other:      

F245-377-000 Residential Care Assessment Tool 06-2017 Page 3 of 13

Name: Claim Number:

Kidney/Urinary TractNo problem identifiedChronic infectionsStonesNephrostomy tube

Other:      Muscular-Skeletal

No problem identifiedLimited range of motionContracturesFoot problemsBone/joint painMissing limbOrtho devices (prosthetic)

Other:      Skin

No problem identifiedDry skinFragile/tearsBruises easilyRashes/itchy skinSkin allergiesLotions/soaps/linens/sensitivitiesOpen wounds

Other:      Neurology

No problem identifiedTremorsSeizuresParalysis/paresthesia

Other:      Pain Management

No problem identifiedHas pain

Severity 1 – 10:      Describe location, duration, cause:     

**Please attach a copy of the current signed treatment plan from the facility.

F245-377-000 Residential Care Assessment Tool 06-2017 Page 4 of 13

Name: Claim Number:

Instructions

(1) Medical Complexity & Medical Care Needs

Nurse assessor ― Place an “X” in the box next to the corresponding descriptor or medical care need required by the worker.

ONC ― For this section, select: Basic, Intermediate, or Advanced/Special and mark in the scoring section.

(2 ― 4) Activities of Daily Living ― Part A, B, C

Nurse assessor ― Place an “X” in the box next to the description that best describes the worker’s ability to perform ADLs (in Parts A, B, and C).

ONC ― For this section, select the highest level (1, 2, or 3) and mark in the scoring section.

(5) Cognitive Assessment

Nurse assessor ― Place an “X” in the box next to the description that best describes the worker’s ability to perform each task.

ONC ― For this section, select the highest level (1, 2, or 3) and mark in the scoring section.

(6) Behavior

Nurse assessor ― Place an “X” in the box next to the corresponding behavior descriptor manifested by the worker. Below the box, mark the descriptor that best describes the impact of the worker’s behavioral symptoms on the need for care.(Example: No problems identified or Demonstrates behavior)

F245-377-000 Residential Care Assessment Tool 06-2017 Page 5 of 13

Name: Claim Number:

Medical Complexity

Medical Status DescriptorMedically stable, wellness careMedically stable, chronic medical conditionsMedically unstable, post-acute surgery, infection(s), recent injuryEnd of life, hospice, vegetative stateSpecialty care (i.e. tracheostomy)

(1) Medical Care Needs

Basic CareGlucose monitoringOral medications, non-prescription, one time per day, or prnSkin monitoring/stage one

Other:      Intermediate Care (Includes Nurse Delegation)

Insulin injections (1 ― 2x/day)Stage 2, non-infected woundsOther non-infected woundsEye medicationsOral prescription medications (can self-administer, need assistance with set-up/reminders)Dietary restrictions Explain:      Intermittent catheterizations

Other:      Advanced Care

Infected woundsOral prescription medication (2+ times per day, administered by staff)Ostomy changes/irrigationsCatheter irrigationIV medications, fluid supplementation, TPN*Tube feedings/medicationsMini-enemas, other non-oral bowel medicationsO2 with pulse oximetryMeasuring intake/output (keeping records of I&O)Choking issues requiring suction standbyUnstable blood pressure (requires daily BP monitoring)

Other:      Specialty Care

TracheostomyVentilator

Other:      Medical Conditions (May Require Advanced Care)

Dialysis dependentEnd stage liver disease (ESLD)Frequent seizuresAcute or chronic pain management, opioids >120 MED/day

Other:      

F245-377-000 Residential Care Assessment Tool 06-2017 Page 6 of 13

Name: Claim Number:

(2) Activities of Daily Living Assessment ― Part A

Personal Hygiene/BathingIncludes shaving, washing hands, face, and perineum, oral care, bathing (shower).

Independent with personal hygiene/bathing (shower) 1

Requires monitoring, encouragement, and/or cueingRequires hand-on assistance and/or needs assistance to guide through task completion with personal hygiene or grooming 2Bathes self and/or needs assistance, needs help getting in/out of tub/showerUnable to assist or mostly dependent personal hygiene

3Other:      

DressingIncludes dressing, hearing aids, glasses

Dresses independently and appropriately 1Requires monitoring, encouragement, and/or cueing with hearing aids and/or glasses or

dressingRequires hands-on assistance with shoe/sock/TED hose/prosthetics

2Requires hands-on assistance with buttoning and upper extremity tasksUnable to assist, dependent on all aspects of dressing

3Other:      

Eating/DrinkingAbility to eat/drink food/liquids including equipment or preferences

Independent, no help or oversight needed 1Requires monitoring, encouragement, and/or cueing, normal swallow

Requires set up (includes cutting up meat and opening containers)Able to feed self some foods but always needs to be fed a meal or part of a meal

2Able to feed self, chewing/swallowing problems (choking, coughing, pocketing food, drooling)Must be fed, dependent for all foods/fluids

3Must be fed TPN*, enteral or enteral feeding

F245-377-000 Residential Care Assessment Tool 06-2017 Page 7 of 13

Name: Claim Number:

(3) Activities of Daily Living Assessment ― Part B

Toilet UseIncludes commode, bedpan, urinal, transfer on/off toilet, manage clothing, cleanse, change pads, manage ostomy/catheter.

Independent with toileting tasks

1Setup supplies only, including self-catheterizationRequires monitoring, remindersOccasional bladder and bowel incontinenceRequires assistance with toileting routinely, includes emptying of ostomy/Foley

2Bladder and bowel incontinence (1 ― 3 time per week)Urinates in inappropriate places (see Behavior Section)

3Total bladder and bowel incontinence (greater than 3 times per week)Staff performs intermittent catheterization

Bladder/Bowel Program (Informational, not rated)Bladder

Training programDribblingUrgencyStress incontinence when exercising, sneezing, coughingUses:Incontinent pads or undergarmentsIndwelling catheterSuper Pubic or Foley:Intermittent catheterization

BowelScheduled bowel programEnemasOstomy Type:

     

F245-377-000 Residential Care Assessment Tool 06-2017 Page 8 of 13

Name: Claim Number:

(4) Activities of Daily Living Assessment ― Part C

Mobility/TransfersIncludes walking, wheelchair mobility and transfers

Independent in wheelchair or walking on level ground, may use assistive devices

1Independent in walking with or without assistive devices ― needs standby assistance for safety and cueing ― may need assistance walking on uneven ground.Independently goes up and down stairsTransfers independentlySupports own weight when walking with or without assistive devices, needs contact guard assistance (1 person)

2Walks with weight-bearing support from 1 personUnable to go up or down stairs without assistanceNeeds assistance to maneuver manual wheelchair or close supervisionNeeds assistance with all transfer (1 person, includes mechanical lifts)Walks with weight-bearing support from 2 people (includes mechanical lifts)

3Does not walk or use wheelchair (bedbound)Unable to assess

PositioningIncludes pressure releases and bed/chair positioning.

Moves independently without assistance (may require a timer) 1Requires 1 person assistance for turning or repositioning 2Requires 2+ person assistance for turning or repositioning 3

InformationalReposition every       hours daytime nighttime

Assistive DevicesEquipment Used: (Informational, not rated)

CaneWalkerCrutchesQuad CaneGait BeltRequires ProsthesisWheelchair

Regular Electric Self-Propels Needs AssistanceOther:      

F245-377-000 Residential Care Assessment Tool 06-2017 Page 9 of 13

Name: Claim Number:

(5) Cognitive Assessment

Orientation (Informational)Oriented to person? Yes No Sometimes (explain):      Oriented to place? Yes No Sometimes (explain):      Oriented to time? Yes No Sometimes (explain):      

Communication/Speech (Informational)Follows simple verbal instructions?

Yes No Sometimes (explain):      

Follows simple written instructions?

Yes No Sometimes (explain):      

Able to follow a verbal discussion

Yes No Sometimes (explain):      

Can communication basic needs

Yes No Sometimes (explain):      

Speech is normal Yes No Impaired (explain):      

Cognitive Skills for Daily Decision Making/JudgementIncludes how the individual makes decisions about everyday tasks or activities of daily living. It’s also important to consult with caregivers, family and other persons who knows this individuals in order to understand how this individual is presently functioning. May need to consider lifestyles, cultures, and values.

Decisions are consistent, reasonable, and organized. Safe to be alone in the facility and community. 1

Decision are generally appropriate in familiar situation but may reflect confusion in new environment. 2

Decisions are limited to immediate needs, are disorganized, or lack follow through in daily routines. 3Decision making is not testable (non-verbal, comatose)

(6) Behavior

Metal IllnessMood swings Withdrawn or lethargicManic DelusionsDepressed HallucinationsCries frequently or constantly Paranoid/unrealistic fears or suspicions

No problems identified Good control with medication Limited control with medications

F245-377-000 Residential Care Assessment Tool 06-2017 Page 10 of 13

Name: Claim Number:

Suicide PotentialNo historyOccasional thoughts of SI. Not dangerous to self or othersHas history and potential for danger to self or othersDanger to self and others

No problems identified Expresses suicidal thoughts

Agitation LevelEasily worried or anxious Seeks/demands attention/reassuranceRepetitive anxious complaints/questions Inability to control own behaviorObsessive about health or body function Yelling/screamingEasily irritable/agitated DisrobesRepetitive physical movement (pacing, hand wringing, fidgeting)

No problems identified Good control with medication Limited control with medications

Social InteractionsPredatory sexual behavior (seeks vulnerable or unwilling partners)

Sexual aggression

Sexual acting out Undresses in public in order to expose self No problems identified Demonstrates behaviors

Assault PotentialBreaking, throwing items ManipulativeInjuries staff/others CombativeUses foul languages/verbal abusive SpittingResistive to care (biting, hitting) AssaultiveAggressive/intimidating

No problems identified Demonstrates behaviors

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Name: Claim Number:

Other Behavior ProblemsHoarding/squirreling WanderingHiding items Exit seekingAccuses other of stealing Accidental firesEats non-edible objects History of arsonNot sleeping at night Other ― be specific:      

No problems identified Demonstrates behaviors

Signatures

Print Name/Title Signature/Title

Date Phone Number

F245-377-000 Residential Care Assessment Tool 06-2017 Page 12 of 13

Name: Claim Number:

This section is be completed by the Department of Labor & Industries Occupational Nurse Consultant.

Occupation Nurse Consultant will review nurse assessment and enter the residential facility code into the Authorization Screen. Fee schedule is based on level of care.

Use the billing codes listed below based on the level of care.

(1) Medical Complexity Basic Intermediate Advanced/Special(2) ADL Part A 1 2 3(3) ADL Part B 1 2 3(4) ADL Part C 1 2 3(5) Cognitive Skills 1 2 3(6) Behavioral Needs 1 2 3

Billing Code Level of Care8893H Basic8894H Intermediate8895H Advanced/Special

Signature of the Occupational Nurse Consultant (ONC) completing Residential Care Assessment Tool.

Print Name/Title Signature/Title

Date Phone Number

F245-377-000 Residential Care Assessment Tool 06-2017 Page 13 of 13