DONR Training

1
DON-R Training

• April 2009

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Quality or Quantity?

• Quality is just as important as quantity.
• Poor quality reduces other peoples quantity,
  because someone is having to fix the mistakes!
• Quantity is still important!
• 3-5 GOOD screenings per screener per day is an
  achievable goal.

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What does a QUALITY call look like?

• Quality calls LISTEN and DOCUMENT what the caller
  requests they do not read into what is/is not
  said.
• Quality calls are fully documented with correct
  names and contact information (including mailing
  AND physical address)
• DON-R documentation matches the score so that
  another person would score the DON-R within 7
  points without additional information
• A quality HCBS only screen could be changed to a
  CCSP screen with only minimal additional
  information
• Quality screenings RARELY result in Removed from
  WL Client refused services when time for
  referral
• Quality screenings PAINT A PICTURE of the
  clients situation so that anyone reviewing the
  file would have a good understanding of what is
  going on with the client
• OR

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New Screen, Rescreen or Update?

• Only count as a new screen if client is not
  currently on WL for ANY services, or if you are
  adding CCSP element to HCBS only screening. You
  must complete a new DON-R
• Only count as rescreen when its been _at_ 120 days,
  and you are completing a new DON-R (be sure to
  add your own new comments as well!)
• Update is for adding new service requests with
  minimal or no change in DON-R, or if you have new
  information to add to DON-R within _at_ 30 days of
  last screen/rescreen. This does NOT count as a
  screening on your screening report.

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Document EVERYTHING

• Dont list No Caregiver if you are listing
  Informal Supports. Anyone providing informal
  supports is considered a caregiver
• If you talk to someone other than the PRIMARY
  caregiver or client, document BOTH the name and
  relationship of person you talked to
• Ask pointed questions to fully justify your score
  (i.e. client needs help with dressing vs. client
  cannot manage buttons/zippers, cant bend to put
  on shoes socks due to SOB, cant raise arms over
  head to pull on shirt due to arthritis)
• If its not in the CHAT file, for all practical
  purposes, it was NOT done!

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Purpose of DON-R

• To determine an applicants
• Level of Impairment
• AND
• Unmet Need for Care

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DON-R and IR/A

• The DON-R should prompt IR/A.
• Never assume a client/caregiver knows all of the
  services available. If the referral was made for
  HDM, listen for cues that a client may also need
  HMK, ADC, Respite, Transportation, CCSP, Home
  Mods/Repairs or other IR/A. If an answer
  indicates other services are needed, document in
  the comments section, esp. if they refuse the
  service (i.e. other HCBS services or CCSP).
• IR/A calls will often prompt screening as well!

8
Paint a Picture with Your Comments!
ASK YOURSELF THIS QUESTION

• Given only the information provided in my
  documentation, would someone else score this
  DON-R like I did?

9
Level of Impairment

• How well can the client perform the task?
• 0 Can do with little or no difficulty
• 1 Can do most of this task, but requires some
  help to complete the task
• 2 Can do some of this task, but needs help 50
  or more of the time to do well
• 3 Cant do any of this activity and is reliant
  upon someone else to do it for them.

10
Ask Yourself This Question

• Can this client be any worse off than he/she is
  now and still be alive?
• If so, the answer should PROBABLY not be a 3! If
  the client can get worse and is already scored a
  3, how will you reflect the deterioration in a
  rescreen?
• 3 gt 3

11
Unmet Need for Care

• If there is an impairment, how is the need being
  met?
• 0 This need is adequately met
• 1 This need is met, but not often and/or well
  enough to meet clients standards
• 2 This need is met rarely and/or poorly
  clients health is impacted
• 3 This need is not being met clients health
  at risk

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Unmet Need for Care

• Document availability of caregiver
• Consider and document impact on client if care or
  assistance is not provided
• You should consider and document the level of
  stress or burnout of the caregiver even if they
  are meeting the clients needs.

13
Eating Level of Impairment (LOI)

• Consider ALL of the following abilities
• Chewing
• Swallowing
• Cutting food into manageable bites
• Drinking beverages
• Holding and using utensils
• DOCUMENT any impairments to justify your score
  an impairment in only one of these abilities
  usually does NOT justify a score of 3!

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Scoring Eating LOI

• 0 No problem
• 1 Takes a very long time, dropping some food or
  spills
• 2 Difficulty picking up food, drops a lot, AND
  some difficulty swallowing/choking, needs spoon
  fed but is able to chew and swallow without
  prompting.
• 3 Cannot chew/swallow is tube fed.

15
Scoring Eating Unmet Need

• Consider the Impairment
• Consider the Need for and Availability of
  Assistance
• Consider and Document the Impact of the
  Unavailability of Assistance (i.e. if client has
  frequent spills, is someone available to make
  sure client has adequate nutritional intake)

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Inappropriate Score/Documentation

• Example 1No documentation as to WHY this is an
  impairment. Has client choked due to falling
  asleep while eating? If so, document this, but
  you cant score a 1 and then put no physical
  impairment.
• Example 2 How does this affect clients ability
  to feed himself? Difficulty using utensils? Does
  he actually need assistance that he is not
  getting (re unmet need)?

17
Bathing LOI

• Assess clients ability to shower, bathe or
  sponge bathe for the purpose of maintaining
  adequate hygiene to meet the clients standards
• Consider health related considerations such as
  incontinence and skin breakdown
• Evaluate ability to regulate water temp
• Evaluate ability to wash/dry self

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Scoring Bathing LOI

• 0 No problem meeting clients minimum standard
  for adequate hygiene (no health risk)
• 1 Minimal difficulty performing this task (i.e.
  must use handrails or shower only due to
  inability to get down into tub)
• 2 Cant reach all of the body and/or cant wash
  thoroughly risk of skin breakdown or health
  deterioration without assistance.
• 3 Cant wash at all (i.e. cannot even sponge or
  sink bathe self)

19
Scoring Bathing Unmet Need

• Consider Level of Impairment and Need for
  Assistance not just that assistance is not
  available, but how it affects clients health
• Consider Caregiver Burden re lifting client
  into/out of tub/shower, if necessary is client
  resistant/combative?
• Consider how often need is/is not being met and
  impact on clients health
• Document ALL factors that contribute to the score
  you assign.

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Inappropriate Score/Documentation

• In example 1, what is it that client is not able
  to do? Mobility impairment does not necessarily
  impair ability to bathe (i.e. sink/sponge
  bathing)
• LOI and Unmet Need of anything other than 0
  REQUIRES documentation.

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Grooming LOI

• Consider ALL of the following
• Oral care
• Hair care (shampooing and combing)
• Fingernail care
• Toenail care (particularly for diabetics)
• Shaving

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Scoring Grooming LOI

• 0 No problem
• 1 Cant do SOME of it, i.e. either cant
  shampoo hair or trim toenails
• 2 Cant do A LOT of it, i.e. unable to shampoo
  hair and trim both fingernails and toenails, but
  can shave and brush teeth
• 3 Cant do ANY of it
• ALL DEFICITS SHOULD BE DOCUMENTED if client
  cant do a part of this activity, then document
  WHY client cant do it (i.e. difficulty raising
  arms, memory impairment, etc)

23
Scoring Grooming Unmet Need

• Consider Need for and Availability of Assistance
• Consider Impact of Availability of Assistance on
  Clients Health/Wellbeing
• Consider Caregiver Burden (i.e. is client
  resistant/combative with caregiver assisting with
  task?)

24
Inappropriate Score/Documentation

• Example 1 WHY are clients spouse and dtr taking
  care of PG? What can client NOT do, and why can
  she not do it?
• Example 2 What part of this task does the SOB
  affect, and what is the unmet need?

25
Dressing LOI

• Assess ability to dress/undress, including
  ability to put on prosthesis, as related to
  carrying out day to day activities (i.e. if they
  dont WANT to get dressed and are not going
  outside of home, it is not an impairment!)
• Evaluate fine motor coordination for managing
  buttons, zippers, undergarments, socks/shoes
• Consider appropriateness of clothing (i.e.
  wearing coats in summertime or shorts in winter
  time)
• Do NOT consider ability to match, coordinate or
  style clothing

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Scoring Dressing LOI

• 0 No problem
• 1 Cant put on one or two items can dress
  without assistance, but caregiver must select
  appropriate clothing
• 2 Cant put on several items is able to assist
  another person by putting arms through sleeves
  and lifting legs, etc
• 3 Cant dress self must be dressed by someone
  else unable to assist in this activity

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Scoring Dressing Unmet Need

• Consider Need for and Availability of Assistance
  (can client do activity with assistive device or
  is assistance of another person needed?)
• Consider Clients Ability to Assist with Activity
• Consider Caregiver Burden (i.e. is client
  resistant/combative is caregiver required to
  lift/move client to perform task how taxing is
  this effort for caregiver?)
• DOCUMENT ALL FACTORS CONTRIBUTING TO THE SCORE
  YOU ASSIGN!

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Inappropriate Score/Documentation

• Why is the Level of Impairment 1 if this person
  can dress herself? If there is an impairment OR
  unmet need for care, it MUST BE documented.

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Transferring LOI

• Assess ability to get in/out of bed or usual
  sleeping place (including couch or recliner)
• Evaluate ability to move to/from bed/chair
  ability to get up/down
• Include ability to reach/use assistive devices
  (i.e. walker, lift chair, wheelchair)
• Consider history of falls, esp. with injury
• DOCUMENT ALL CONTRIBUTING FACTORS

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Scoring Transferring LOI

• 0 No problems
• 1 Rocks and pushes, but gets up alone
• Uses a cane/walker without assistance from
  another person
• 2 Often needs help from another person
  frequent falls resulting in injury
• 3 Always needs physical assistance of another
  person to transfer bedbound
• In most cases, an individual living alone should
  score a 1. Always DOCUMENT the reason you
  scored the way you did!

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Scoring Transferring Unmet Need

• Consider Need for and Availability of Assistance
  (can client do activity with assistive device or
  is assistance of another person needed?)
• Evaluate impact of lack of assistance on clients
  health/safety (document history and frequency of
  falls, with or without injury)
• Evaluate Caregiver Burden (lifting of client,
  etc..)

32
Inappropriate Score/Documentation

• Example 1 Cannot walk is not a 3 transfer
  includes ability to move from bed to wheelchair
  if client is incapable of transferring to or
  using wheelchair, this should also be documented
• Example 2 Weakness does not imply impairment.
  What is it that client cannot do? What is the
  unmet need?

33
Continence LOI

• Assess ability to take care of bladder AND bowel
  functions by reaching bathroom or potty chair in
  a timely manner
• Consider need for reminders or toileting schedule
• Evaluate ability of client to change/clean self
  if using protective undergarments
• Catheters do not imply incontinence!

34
Scoring Continence LOI

• 0 No accidents
• 1 Occasional accidents, but can clean self
• 2 Frequent accidents occasional accidents but
  client unaware of need to change protective
  undergarments
• 3 No control over both bladder and bowel

35
Continence Unmet Need

• Is assistance of another person required to
  maintain continence or cleaning?
• What is the impact of the unmet need on clients
  health/well-being (i.e. skin breakdown, rash,
  impaction, etc)
• Consider caregiver burden (including
  caregiver/client comfort level with performing
  this activity if it affects need being met)

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Catheters, Ostomy, Dialysis and Continence

• Catheter Consider whether or not catheter leaks
  as long as client remains dry, they are not
  incontinent. If client requires assistance ie
  changing catheter, emptying cath bag, could be
  considered requiring min assistance with
  toileting.
• Ostomy Consider whether or not ostomy leaks or
  oozes causing output to irritate skin and the
  need for assistance in changing/cleaning.
• Dialysis If client is receiving dialysis they
  are NOT incont, unless they do still have some
  urine output with accidents.

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Examples

• Example 1What is the impairment? Must be
  documented!
• Example 2 Appropriate LOI of 3 on a dialysis
  client.
• Example 3 Does this client have bowel
  incontinence as well? Do they have any urinary
  output? If so, are they having accidents?

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Money Management LOI

• Assess ability to handle money and pay bills
• Include planning, budgeting, writing checks/money
  orders, and currency exchange
• Consider ability to read, write and comprehend
• Financial ability to pay bills should NOT be
  considered (i.e. not enough money)

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Scoring Money LOI

• 0 Client can do this activity without
  assistance
• 1 Can do activity but someone else
  monitors/assists on occassion
• 2 Client still participates (perhaps cannot
  read/write, but can exchange currency)
• 3 Requires someone else to handle all financial
  business

40
Money Unmet Need

• 0 No unmet need
• 1 Someone is assisting as needed but is not
  available all of the time
• 2 Client requires extensive assistance, but
  does not have anyone to help most of the time
  (i.e. frequent bounced checks, hx of late
  payments, no one to do errand assistance and
  client unable to manage cash)
• 3 Client requires extensive assistance but has
  no one capable of meeting the need (consider APS
  referral in this case)

41
Inappropriate Score/Documentation

• If client manages her own money, theres not an
  impairment. If there is an impairment, what is
  it, and why is unmet need 0? Who is meeting the
  need?
• Visual impairment does not necessarily affect
  money management. If it does, document HOW.
  States he needs help, but with WHAT?
• If client is managing both her money and
  spouses, why is there an impairment?

42
Telephoning

• Assess ability to communicate essential needs
  (can this client dial 911 and tell them the
  nature of the emergency?)
• Evaluate ability to answer, dial, and communicate
  over the telephone
• Do NOT consider the absence of a telephone or
  clients ability to look up numbers in phone book
• Extremely hard of hearing does not make a
  client unable to perform this task

43
Telephoning LOI

• 0 No difficulty
• 1 Slight problems with task (i.e. some
  difficulty hearing, but able to have a phone
  conversation visual impairment makes dialing s
  difficult client has difficulty comprehending
  calls other than from friends/family, i.e. sales
  calls, screenings, etc)
• 2 Client can communicate needs, but is
  extremely hard of hearing and cannot understand
  person on other end of call unable to dial s
  without assistance
• 3 Client is unable to communicate by phone
  would not have ability to dial 911 or communicate
  nature of emergency

44
Telephoning Unmet Need

• 0 Client does not need assistance of another
  person to perform this task (if client completed
  the screening, this should be the score)
• 1 Client requires assistance, but theres
  usually someone there to meet need
• 2 Client requires assistance, but is frequently
  home alone and does not have ERS (i.e. no way to
  call for help if needed when alone)
• 3 Client lives alone, is unable to use the
  phone, and has no one to assist with this need

45
Inappropriate Score/Documentation

• Example 1 does not relate how this affects
  clients ability to use a telephone. Client
  completed the screening, so she apparently can
  understand, make herself understood, and hear
  sufficiently.
• Hearing impairment does not imply that client
  cannot dial 911 and clearly state nature of
  emergency. If client is also unable to dial and
  communicate, documentation should state more than
  just fact that client is very hearing impaired.
• This screening completed with client. No
  impairment. Doesnt care to doesnt count.

46
Scoring Preparing Meals

• Assess ability to plan, prepare nutritionally
  balanced meals
• Evaluate ability to open containers, use kitchen
  appliances and clean area after meal
• Consider clients safety in using utensils, stove
  and microwave

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Preparing Meals LOI

• 0 No problem
• 1 Tiring must sit and rest during prep can do
  simple foods without assistance
• 2 Client cannot perform most of this activity
  cannot operate stove or microwave can ONLY do
  simple foods (i.e. cereal, sandwiches,
  ready-to-eat)
• 3 Client is unable to perform this activity
  (i.e. bed-bound or late-stage Alz)

48
Preparing Meals Unmet Need

• 0 Client does not require assistance or someone
  else is preparing all of the meals
• 1 Someone is assisting with most meals as
  needed client is alone during day but caregiver
  provides breakfast/dinner client can manage
  simple foods for lunch.
• 2 Client is only getting 1 nutritionally
  balanced meal per day eats mostly snacks
• 3 Clients need is not being met this would be
  an appropriate APS referral for neglect or
  self-neglect

49
Inappropriate Score/Documentation

• Example 1 Inconsistent Documentation. Spouse is
  able to do laundry and housework, but not
  cooking. Why?
• Example 2 KT is such an idiot! ? LOI should not
  be 2 just because client does NOT do a lot of
  cooking, and difficulty standing does not
  necessarily affect ability to prepare a
  nutritionally balanced meal.
• Example 3 Husband doesnt know how is not an
  unmet need unless he has Alz. Can he not use
  microwave to prepare frozen meals? Whos
  preparing his meals? What is he eating?

50
Laundry LOI

• Assess ALL of the following abilities
• Sorting
• Carrying
• Loading/unloading
• Folding
• Putting Away
• Operating Washer/Dryer
• Measuring Cleaning Supplies

51
Scoring Laundry LOI

• 0 Client is able to complete this task.
• 1 Client can do with minimal difficulty (i.e.
  difficulty carrying baskets, transferring wet
  clothes)
• 2 Client can do physical tasks with
  cueing/supervision, but cant sort, measure
  cleaning agents or operate machines
• 3 Client cannot do any part of this task

52
Laundry Unmet Need for Care

• 0 Client does not require assistance with
  laundry
• 1 Client needs very minimal asst and need is
  usually met
• 2 Client requires cueing or supervision, but
  has no one to assist on a regular basis
• 3 Clients need is not being met

53
Inappropriate Score/Documentation

• Example 1 This is a caregiver screening her
  ability to do both her laundry and mothers is
  not an impairment. Only score the clients
  ability to do their OWN laundry.
• Example 2 No documentation as to why client is
  COMPLETELY unable to perform this task

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Housework LOI

• Consider minimum hygiene standards for clients
  health and safety
• Do not consider clients refusal/unwillingness to
  do this activity if not related to diagnosis!
• Assess ALL of the following
• Sweeping
• Mopping
• Vacuuming
• Dusting
• Cleaning Spills
• Cleaning Toilets/Bathtub
• Changing bed linens

55
Scoring Housework LOI

• 0 No difficulty
• 1 Unable to do some essential cleaning
• 2 Client is able to do some of the cleaning,
  but hygiene is at risk
• 3 Client is unable to do ANY housework at all

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Unmet Need for Care

• 0 Need is Met
• 1 Need is usually met no risk to clients
  health/hygiene
• 2 Need is usually not met clients
  health/hygiene at risk
• 3 Need is rarely or never met clients
  health/hygiene is compromised (this might be an
  appropriate APS referral)

57
Inappropriate Score/Documentation

• WHY is the dtr taking care of housework and
  laundry? DOCUMENT the reason under the Housework
  Category (i.e. why is she not able to do the
  activity)
• Impairment does not include whether or not a
  client feels like doing the task are they
  CAPABLE of doing the task? If feelings count, Im
  a 3! ?

58
Outside Home LOI

• Assess ability to get to/from ESSENTIAL places
  (i.e. bank, post office/mailbox, medical appts,
  store, and out of home laundry)
• Consider ability to navigate steps uneven
  terrain entry/exit of home, esp. during
  emergency
• Document clients ability/inability to drive and
  reason for inability AS RELATED TO DIAGNOSIS
• Can client arrange for and use alternate
  transportation (i.e. public trans, taxi, etc)?
• Consider whether or not client requires constant
  supervision r/t wandering behavior

59
Scoring Outside Home LOI

• 0 Client is able to drive and do this activity
  without assistance
• 1 Client is able to drive, but has difficulty
  navigating steps and uneven terrain only drives
  in local area
• 2 Client may still be driving, but requires
  some HANDS-ON asst with steps, getting in/out of
  home not able to get to medical appts due to
  inability to drive outside of local area
• 3 Client is not driving cannot get outside of
  home/apt without physical asst (i.e. must be
  carried or pushed in wheelchair)

60
Unmet Need for Care

• 0 No unmet need
• 1 Needs some transfer assistance, but has
  in-home caregiver there most of the time to meet
  need.
• 2 requires extensive assistance caregiver
  overwhelmed or not present most of the time
• 3 need is not met could be appropriate for APS
  referral

61
Inappropriate Score/Documentation

• Does ALZ affect ability to navigate uneven
  terrain, steps, etc or is it a wandering issue?
• Inability to drive is not an impairment Why is
  transfer 1/1 and outside home 2/1? Conflicting
  scores.

62
Routine Health

• Assess ALL of the following
• Ability to follow directions from physicians or
  other healthcare workers
• Consider need for meds set-up and/or reminders
• Ability to manipulate routine equipment such as
• Glucometer
• Nebulizers
• Routine vitals
• BP checks
• Simple dressings

63
Scoring Routine Health LOI

• 0 Client takes meds independently
• 1 Someone else is assisting with med
  set-up/supervision, but client is taking them as
  prescribed
• 2 Client unable to take meds unless reminded,
  then must be handed appropriate meds needs asst
  of another person to monitor vitals, glucometer,
  etc
• 3 Client is on feeding tube, unable to swallow
  meds client is resistant/combative about taking
  meds, i.e. will not swallow, etc

64
Routine Health Unmet Need

• 0 No need for asst or live-in caregiver is
  meeting all need for set-up
• 1 Client requires set-up/supervision, but
  caregiver is out of home when time for some of
  the meds
• 2 Client requires some monitoring has
  neglected some of this task due to unmet need
• 3 Client is frequently missing meds health is
  at risk due missed doses or unmet need for asst
  with glucometer/vitals (this might be an
  appropriate APS referral)

65
Inappropriate Score/Documentation

• Example 1 Scoring should probably be 2, based on
  Alz dx and history of taking incorrectly, but
  Unmet Need should also be higher if caregiver is
  not meeting need most of the time
• Example 2 What does cannot monitor her meds
  mean? Is client taking them without assistance,
  or is dtr actually dispensing them to client? Any
  difficulty swallowing?
• Example 3 Again, why is the spouse
  monitoring/admin the meds? Is client
  resistant/combative? Any difficulty swallowing?
• DOCUMENT, DOCUMENT, DOCUMENT

66
Special Health LOI

• Assess clients ability to BE COOPERATIVE AND
  ABLE TO PARTICIPATE in the performance of
  SPECIALIZED HEALTH CARE PERFORMED BY LICENSED
  PERSONNEL
• Therapy
• Labs
• COMPLEX Cath
• Ostomy Care
• IV Therapy

67
Scoring Special Health LOI

• 0 No problem
• 1 Slightly uncooperative
• 2 Difficult and resistant
• 3 Refuses or is unable to participate becomes
  verbally or physically abusive

68
Items NOT included under Special Health

• Dialysis, unless wound care is needed for shunt
  then you should consider ONLY wound care, not
  need for dialysis
• Diabetes care i.e. checking blood sugars,
  administering insulin

69
Inappropriate Score/Documentation

• Neither of these should be documented under
  Special Health. Both should be under Routine
  Health.
• Example 2 LOI is for an ACTUAL impairment, not
  for a suspected impairment.

70
Being Alone LOI

• Assess ability to be left alone and recognize,
  avoid and/or respond to dangers and/or
  emergencies
• Consider history of accidents, falls and injuries
  sustained while alone
• When scoring higher than 1, document more than
  just fact that client should not be left alone.
  Provide REASON client should not be left alone!

71
Scoring Being Alone LOI

• 0 No problem lives alone
• 1 Lives alone, but has hx of falls with or
  without injury
• 2 Needs help to remain safe in home (client
  moves very slowly would not be able to respond
  quickly in emergency has significant history of
  falls with injury)
• 3 Client cannot be left alone (can neither
  recognize nor respond to danger)

72
Being Alone Unmet Need

• 0 Clients need is met lives alone safely
• 1 Client lives alone, but someone frequently
  checks on him/her caregiver lives in the home
  with client
• 2 Client is frequently left alone and requires
  some assistance to recognize/respond to
  emergencies need is only met by telephone
• 3 Client is always alone rarely has anyone
  checking on him/her, even by phone (this may be
  an appropriate APS referral)

73
Inappropriate Score/Documentation

• Example 1 Why can client not be left alone? And
  if spouse is with her at all times and CANNOT
  leave, why is Unmet Need only 1? Does this truly
  reflect caregiver burden?
• Example 2 Who says client does not need to be
  left alone? Apparently she is capable, because
  family is only trying to check on her. Is
  there a history of problems with her being left
  alone? If so, document!
• Example 3 This client lives alone and completed
  the screening himself ability to use ERS cannot
  be considered an impairment if client does HAVE
  an ERS.

74
Documenting Caregiver Burden

• Need may be met, but the unmet need can still be
  scored high if caregiver is near burnout
• Consider that if the caregivers health is at
  risk due to burnout/stress, someone else will
  have to meet this need. Is someone else available
  in absence of caregiver?
• DOCUMENT CAREGIVER BURNOUT/STRESS if scoring
  unmet need to reflect caregiver stress

75
Undocumented Caregiver Stress
76
CONSISTENCY

• Your DON-R should paint a consistent picture of
  the clients situation.
• If you score a client 3 on Transfer and a 0 on
  Outside Home, your documentation should explain
  how that is possible.
• DOCUMENT, DOCUMENT, DOCUMENT

77
COMMENTS ARE ESSENTIAL

• Any time you select a score other than 0
  (whether for LOI or Unmet Need), you MUST have a
  comment to support that choice AS IT RELATES TO A
  DIAGNOSIS.
• Scoring should be based on statements made by
  client/caregiver during the screening. Dont
  read into what is or is not said. If you have
  questions or doubts, ASK for more detail.

78
Comments and Consistency

• Review your screening when complete, and Remember
  to ask yourself this question
• Given only the information provided in my
  documentation, would someone else score this
  DON-R like I did?
• If someone else reviewed your DON-R and the score
  changed by more than 7 points, either one of you
  scored inappropriately, or your documentation is
  not sufficient

79
Caregiver Screenings

• Caregiver screenings should be completed JUST AS
  THOROUGHLY as a clients screening.
• A Caregiver can become a client at any time. Make
  sure to capture ALL necessary information, even
  if they only need a caregiver meal at the present
  time!

80
THE MOST IMPORTANT POINTS

• Document
• Document
• Document
• Document
• Document
• Document

81
Services and Eligibility

• CCSP document like EVERY screening is a CCSP
  screening (some leeway with income/resources and
  LOC, but HCBS only shouldnt look like its only
  half-done).
• Must be 65 OR disabled (as determined by Social
  Security).
• Must meet Medicaid waiver income/resource
  guidelines,
• Must score 15 on LOI and meet LOC requirements
  for nursing home placement.

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Services and Eligibility

• Home Delivered Meals 60 and MUST BE HOMEBOUND
  (not just unable to drive or without a car offer
  congregate to clients who are not homebound)
• 60 and under must be HOMEBOUND AND DISABLED AND
  living with regular client
• SPOUSE of a regular client is not required to be
  either 60 or Homebound
• No such thing as a caregiver meal for people
  under 60! Only spouse of client can get meal
  under 60 unless DISABLED (as determined by Social
  Security, i.e. drawing a check) and LIVING WITH
  REGULAR client ( then must also be homebound)
• Homemaker 60 with DEMONSTRATED NEED for
  service not required to be homebound

83
Services and Eligibility

• Adult Day Care 60 with DEMONSTRATED NEED for
  service
• Respite Caregiver is NOT required to live
  IN-HOME, but a caregiver MUST EXIST! 60 with
  DEMONSTRATED NEED for service. Not required to be
  homebound if client is NOT homebound consider
  ADC also.
• No Caregiver Not Eligible
• Alzheimers Services (ADC and Respite) MUST have
  diagnosis of Alz or a RELATED dementia (dx) not
  required to be 60, but must meet other
  ADC/Respite Criteria
• Clients do not need to be placed on BOTH Alz and
  Regular Respite and ADC lists. If Alz dx is
  present, use Alz only.

84
Case Scenarios
85
Cost Share

• Example 1
• Client income SSI - 674
• Spouse income 2400
• Cost share0
• No diversion because not more than Medicaid
  limit SSI is ALWAYS NO COST SHARE, regardless of
  spouses income

86
Cost Share

• Example 2
• Clients Income SSA - 489, VA (not Aide and
  Attendant) - 420, Pension - 48
• Pays 44 for Supplemental Health Ins.
• Spouses income 940
• Cost Share 0
• 489 420 48 957 - 44 913 96
  (Medicare B) 1009, which can be diverted to
  spouse (max of 2739 spousal income)

87
Cost Share

• Example 3
• Clients income SSD - 842, QMB, no supplemental
  insurance
• No Spouse
• Cost Share 168
• 842 674 168

88
Cost Share

• Example 4
• Husband and Wife BOTH want CCSP (no diversion if
  both are coming in)
• Her Income SSD - 630
• His Income SSA - 895, no QMB, he pays 80
  Supplemental Insurance
• Her Cost Share0
• His Cost Share237
• 895 96 991 - 80 911 - 674 237