"Ability to make self understood" means how
you made yourself understood to those closest to you in the last seven days
before the assessment; expressed or communicated requests, needs, opinions,
urgent problems and social conversations, whether in speech, writing, sign
language, symbols, or a combination of these including use of an alternative
communication method:
(1) Understood:
You expressed ideas clearly;
(2)
Usually understood: You had difficulty finding the right words or finishing
thoughts, resulting in delayed responses, or you required some prompting to
make self understood;
(3) Sometimes
understood: You had limited ability, but were able to express concrete requests
regarding at least basic needs such as food, drink, sleep, toilet);
(4) Rarely/never understood: At best,
understanding was limited to caregiver's interpretation of client specific
sounds or body language such as indicated presence of pain or need to
toilet);
(5) Child under three:
Proficiency is not expected of a
child under three and a
child under three
would require assistance with communication with or without a
functional
disability. Refer to the
developmental milestones table in WAC
388-106-0130.
"Active range of motion" means exercises
performed by the client to maintain their joint function to the joint's optimal
range. Exercises may be performed with the assistance of cueing or reminders by
caregivers. A formal, active range of motion program needs to be first
established by a qualified registered nurse or therapist. Range of motion may
be self-directed based upon an occupational or physical therapist assessment
and continued without occupational or physical therapist supervision.
"Activities of daily living (ADL)" means the
following:
(1) Bathing: How you took a
full-body bath/shower, sponge bath, and transferred in/out of
tub/shower.
(2) Bed mobility: How
you moved to and from a lying position, turned side to side, and positioned
your body while in bed, in a recliner, or other type of furniture you slept
in.
(3) Dressing: How you put on,
fastened, and took off all items of clothing, including donning/removing
prosthesis, splints, either braces or orthotics, or both.
(4) Eating: How you ate and drank, regardless
of skill. Eating includes any method of receiving nutrition, such as, by mouth,
tube, or through a vein. Eating does not include any set up help you received,
such as bringing food to you or cutting it up in smaller pieces.
(5) Locomotion in room and immediate living
environment: How you moved between locations in your room and immediate living
environment. If you are in a wheelchair, locomotion includes how
self-sufficient you were once in your wheelchair.
(6) Locomotion outside room: How you moved to
and returned from your immediate living environment, outdoors, and more distant
areas. If you are living in a contracted assisted living, enhanced services
facility, adult residential care, enhanced adult residential care, enhanced
adult residential care-specialized dementia care facility, or nursing facility
(NF), this includes areas set aside for dining, activities, etc. If you are
living in your own home or in an adult family home, locomotion outside
immediate living environment including outdoors, includes how you moved to and
returned from a patio or porch, backyard, to the mailbox, to see the next-door
neighbor, or when accessing your community.
(7) Walk in room, hallway and rest of
immediate living environment: How you walked between locations in your room and
immediate living environment.
(8)
Medication management: Describes the amount of assistance, if any, required to
receive prescription medications, over the counter medications, or herbal
supplements.
(9) Toilet use: How
you eliminated or toileted, used a commode, bedpan, or urinal, transferred
on/off toilet, cleansed, changed pads, managed ostomy or catheter, and adjusted
clothes. Toilet use does not include emptying a bedpan, commode, ostomy, or
catheter bag. This type of set up assistance is considered under the definition
of support provided.
(10) Transfer:
How you moved between surfaces, such as, to/from bed, chair, wheelchair,
standing position. Transfer does not include how you moved to/from the bath,
toilet, or got in/out of a vehicle.
(11) Personal hygiene: How you maintained
personal hygiene tasks, such as combing hair, brushing teeth, shaving, applying
makeup, washing/drying face, hands (including nail care), and perineum,
including menses care. Personal hygiene does not include hygiene tasks
completed in baths and showers.
"Age appropriate" proficiency in the
identified task is not expected of a child that age and a child that age would
require assistance with the task with or without a functional disability. Refer
to the developmental milestones table in WAC
388-106-0130 for the specific
ages.
"Aged person" means a person 65 years of age
or older.
"Agency provider" means a licensed home care
agency or a licensed home health agency having a contract to provide long-term
care personal care services to you in your own home.
"Alternative benefit plan" means the scope of
services described in WAC
182-501-0060 available to persons
eligible to receive health care coverage under the Washington apple health
modified adjusted gross income (MAGI)-based adult coverage described in WAC
182-505-0250.
"Application" means a written request for
medical assistance or long-term care services submitted to the department by
the applicant, the applicant's authorized representative, or, if the applicant
is incompetent or incapacitated, someone acting responsibly for the applicant.
The applicant must submit the request on a form prescribed by the
department.
"Assessment details" means a printed record of
information that the department entered into the CARE assessment describing the
assistance you may need.
"Assessment or reassessment" means an
inventory and evaluation of strengths and limitations based on an in person
interview in your own home or another location that is convenient to you, using
the department's comprehensive assessment reporting evaluation (CARE)
tool.
"Assistance available" means the amount of
assistance that will be available for a task if status is coded:
Partially met due to availability of other informal
support. The department determines the amount of the assistance available using
one of four categories:
(1) Less than
one-fourth of the time;
(2)
One-fourth to one-half of the time;
(3) Over one-half of the time to
three-fourths of the time; or
(4)
Over three-fourths but not all of the time.
"Assistance with body care" means you received
or need assistance with:
(1)
Application of ointment or lotions;
(2) Trimming of toenails;
(3) Dry bandage changes; or
(4) Passive range of motion
treatment.
"Authorization" means an official approval of
a departmental action, for example, a determination of client eligibility for
service or payment for a client's long-term care services.
"Blind person" means a person determined blind
as described under WAC
182-500-0015 by the division of
disability determination services of the health care authority.
"Body care" means how you perform with passive
range of motion, applications of dressings and ointments or lotions to the
body, and pedicure to trim toenails and apply lotion to feet. In adult family
homes, enhanced services facilities, contracted assisted living, enhanced adult
residential care, and enhanced adult residential care-specialized dementia care
facilities, dressing changes using clean technique and topical ointments must
be performed by a licensed nurse or through nurse delegation in accordance with
chapter 246-840 WAC. Body care excludes:
(1) Foot care if you are diabetic or have
poor circulation; or
(2) Changing
bandages or dressings when sterile procedures are required.
"Bowel program" means a regular, ongoing
program, other than oral medications, that must include interventions such as
rectal stimulation using the finger, over the counter suppositories, or enemas
to facilitate evacuation of your bowels. Regimens only promoting bowel
regularity, including oral medications or supplements, nutrition, hydration, or
positioning are not considered in this definition.
"Categorically needy" means the status of a
person who is eligible for medical care under Title XIX of the Social Security
Act. See WAC
182-512-0010 and chapter 182-513
WAC.
"Child" means an individual less than 18 years
of age.
"Client" means an applicant for service or a
person currently receiving services from the department.
"Current behavior" means a behavior occurred
within seven days of the CARE assessment date, including the day of the
assessment. Behaviors that the department designates as current must include
information about:
(1) Whether the
behavior is easily altered or not easily altered; and
(2) The frequency of the behavior.
"Decisions" means your ability (verbally or
nonver-bally) to make, and actual performance in making, everyday decisions
about tasks of daily living in the last seven days before the assessment. The
department codes your ability to make decisions as one of the following:
(1) Independent: Decisions about your daily
routine were consistent and organized; reflecting your lifestyle, choices,
culture, and values;
(2) Difficulty
in new situations: You had an organized daily routine, were able to make
decisions in familiar situations, but experienced some difficulty in decision
making when faced with new tasks or situations;
(3) Poor decisions; unaware of consequences:
Your decisions were poor and you required reminders, cues, and supervision in
planning, organizing, and correcting daily routines. You attempted to make
decisions, although poorly.
(4) No
or few decisions: Decision making was severely impaired; you never/rarely made
decisions;
(5) Child under 12:
Proficiency in decision making is not expected of a
child under 12 and a
child
under 12 would require assistance with decision making with or without a
functional disability. Refer to the
developmental milestones table in WAC
388-106-0130.
"Department" means the state department of
social and health services, aging and long-term support administration,
developmental disabilities administration, or its designee.
"Designee" means area agency on aging.
"Developmental milestones table" is a chart
showing the age range for which proficiency in the identified task is not
expected of a child and assistance with the task would be required whether or
not the child has a functional disability.
"Disability" is described under WAC
182-500-0025.
"Disabling condition" means you have a medical
condition which prevents you from self-performance of personal care tasks
without assistance.
"Estate recovery" means the department's
process of recouping the cost of medicaid and long-term care benefit payments
from the estate of the deceased client. See chapter 182-527 WAC.
"Health action plan" means an individual plan,
which identifies health-related problems, interventions, and goals.
"Home health agency" means a licensed:
(1) Agency or organization certified under
medicare to provide comprehensive health care on a part-time or intermittent
basis to a patient in the patient's place of residence and reimbursed through
the use of the client's medical identification card; or
(2) Home health agency, certified or not
certified under medicare, contracted and authorized to provide:
(a) Private duty nursing; or
(b) Skilled nursing services under an
approved medicaid waiver program.
"Income" means income as defined under WAC
182-509-0001.
"Individual provider" under
RCW
74.39A.240 means a person, including a
personal aide, who, under an individual provider contract with the department,
or as an employee of a consumer directed employer, provides personal care or
respite care services to persons who are functionally disabled or otherwise
eligible under programs authorized and funded by the medicaid state plan,
medicaid waiver programs, or similar state-funded in-home care programs.
"Informal support" means:
(1) Assistance that will be provided with the
client's agreement as expressed in the assessment process without home and
community-based services funding, except as allowed in subsection (3) of this
definition. The person providing the informal support must be age 18 or older.
Sources of informal support include but are not limited to: Family members,
friends, housemates/roommates, neighbors, school, childcare, after school
activities, church, and community programs.
(2) The
department will not consider an
individual provider to be a source of informal support unless:
(a) The individual provider is also a family
member or a household member who had a relationship with the client that
existed before the individual provider entered into a contract with the
department; and
(b) The individual
provider signs a written agreement that states:
(i) The individual provider understands that
the provision of unpaid informal support is voluntary;
(ii) The individual provider understands that
if they decline to provide unpaid informal support that the client's benefit
could increase and that the client could choose to assign those increased hours
to the individual provider;
(iii)
If there is a collective bargaining representative that represents the
individual provider for the purposes of collective bargaining, the individual
provider is informed as to the collective bargaining representative's opinion,
if any, about whether the individual provider should agree to provide unpaid
informal supports;
(iv) The
individual provider understands that the individual provider may stop providing
unpaid informal support at any time by informing the case manager that the
individual provider wishes to stop providing unpaid informal support;
and
(v) The individual provider
understands that if the individual provider is a family member or had a
household relationship with the client prior to becoming the client's
individual provider that they may provide unpaid care to a client above and
beyond the individual provider authorization regardless of whether they are
providing informal support.
(3) Adult day health and adult day care is
coded in the assessment as a source of informal support, regardless of funding
source;
(4) Informal support does
not include age appropriate functioning.
"Institution" means medical facilities,
nursing facilities, and institutions for the intellectually disabled. It does
not include correctional institutions. See medical institutions in WAC
182-500-0050.
"Instrumental activities of daily living
(IADL)" means routine activities performed around the home or in the
community in 30 days prior to the assessment and includes the following:
(1) Meal preparation: How meals were prepared
such as, planning meals, cooking, assembling ingredients, setting out food,
utensils, and cleaning up after meals). NOTE: The department will not authorize
this IADL to only plan meals or clean up after meals. You must need assistance
with other tasks of meal preparation.
(2) Ordinary housework: How ordinary work
around the house was performed such as, doing dishes, dusting, making bed,
cleaning the bathroom, tidying up, laundry).
(3) Essential shopping: How shopping was
completed to meet your health and nutritional needs such as, selecting items).
Shopping is limited to brief, occasional trips in the local area to shop for
food, medical necessities, and household items required specifically for your
health, maintenance, or well-being. This includes shopping with or for
you.
(4) Wood supply: How wood or
pellets were supplied such as, splitting, stacking, or carrying wood or
pellets) when you use wood, pellets, or a combination of both, as the only
source of fuel for heating or cooking.
(5) Travel to medical services: How you
traveled by vehicle to a physician's office or clinic in the local area to
obtain medical diagnosis or treatment. This travel includes driving a vehicle
yourself or traveling as a passenger in a car, bus, or taxi.
"Long-term care services" means the services
administered directly or through contract by the department and identified in
WAC 388-106-0015.
"MAGI" means modified adjusted gross income.
It is a methodology used to determine eligibility for Washington apple health
(medicaid), and is defined in WAC
182-500-0070.
"Medicaid" is defined under WAC
182-500-0070.
"Medically necessary" is defined under WAC
182-500-0070.
"Medically needy (MN)" or "medically needy program
(MNP)" means the state and federally funded health care program
available to specific groups of people who would be eligible as categorically
needy (CN), except their monthly income is above the CN standard. Some
long-term care clients with income or resources above the CN standard may also
qualify for MN.
"New Freedom consumer directed services
(NFCDS)" means a mix of services and supports to meet needs identified
in your assessment and identified in a New Freedom spending plan, within the
limits of the individual budget, that provide you with flexibility to plan,
select, and direct the purchase of goods and services to meet identified needs.
Participants have a meaningful leadership role in:
(1) The design, delivery, and evaluation of
services and supports;
(2)
Exercising control of decisions and resources, and making their own decisions
about health and well-being;
(3)
Determining how to meet their own needs;
(4) Determining how and by whom these needs
should be met; and
(5) Monitoring
the quality of services received.
"New Freedom consumer directed services (NFCDS)
participant" means a participant who is an applicant for or currently
receiving services under the NFCDS waiver.
"New Freedom spending plan (NFSP)" means the
plan developed by you, as a New Freedom participant, within the limits of an
individual budget, that details your choices to purchase specific NFCDS and
provides required federal medicaid documentation.
"Own home" means your present or intended
place of residence:
(1) In a building
that you rent and the rental is not contingent upon the purchase of personal
care services as defined in this section;
(2) In a building that you own;
(3) In a relative's established residence;
or
(4) In the home of another where
rent is not charged and residence is not contingent upon the purchase of
personal care services as defined in this section.
"Passive range of motion" means a maintenance
movement exercise of each joint only to the extent the joint can move. Passive
range of motion is performed by a caregiver because the client is unable to
move the joint without assistance. A formal passive range of motion program
needs to be first established by a qualified registered nurse or therapist.
Passive range of motion may be self-directed based upon an occupational or
physical therapist assessment and continue without occupational or physical
therapist supervision.
"Past behavior" means the behavior did not
occur in the last seven days, but did occur more than seven days from the
assessment date. For behaviors indicated as past behaviors, the department
documents the month and year the behavior last occurred and whether the
behavior is addressed with current interventions or whether no interventions
are in place.
"Personal aide" is defined in
RCW
74.39.007.
"Personal care services" means physical or
verbal assistance with activities of daily living (ADL) and instrumental
activities of daily living (IADL) due to your functional limitations.
Assistance is evaluated with the use of assistive devices.
"Physician" is defined under WAC
182-500-0085.
"Plan of care" means assessment details and
service summary generated by CARE.
"Provider or provider of service" means an
institution, agency, or person:
(1)
Having a signed department contract to provide long-term care client services;
and
(2) Qualified and eligible to
receive department payment.
"Reasonable cost" means a cost for a service
or item that is consistent with the market standards for comparable services or
items.
"Representative" means a person who you have
chosen, or has been appointed by a court, whose primary duty is to act on your
behalf to direct your service budget to meet your identified health, safety,
and welfare needs.
"Residential facility" means a licensed adult
family home under department contract; a licensed enhanced services facility
under department contract; or licensed assisted living facility under
department contract to provide assisted living, adult residential care, or
enhanced adult residential care.
"Self-performance for ADLs" means a code based
on what you actually did for yourself and how much help you received with ADLs,
with the exception of bathing, in the last seven days before your assessment,
not what you might be capable of doing. For codes of supervision, limited
assistance, and extensive assistance, self-performance for ADLs is based on
your level of performance that occurred three or more times in the seven-day
period. Scoring of self-performance for ADL codes of supervision, limited
assistance, and extensive assistance, does not include physical assistance that
occurred less than three times in the seven-day look back period, or set-up
help for any self-performance ADL code.
(1) Based on information provided during your
assessment, the CARE tool assigns a self-performance code to each ADL. When you
received the same type of help (such as oversight, nonweight bearing, or weight
bearing help) with an ADL at least three times, CARE assigns the
self-performance code associated with the most dependent type of help you
received at least three times. Your self-performance level code is:
(a) Independent, if you received:
(i) no help, including oversight,
encouragement, or cueing, or;
(ii)
help including oversight, encouragement, or cueing only once or twice in the
seven-day period;
(b)
Supervision, if you received oversight (monitoring or standby), encouragement,
or cueing three or more times;
(c)
Limited assistance, if you were highly involved in the ADL and received
assistance that involved physical, nonweight bearing contact between you and
your caregiver, or guided maneuvering of limbs three or more times.
(d) Extensive assistance, if you performed
part of the ADL, but on three or more occasions, you needed weight bearing help
or you did not participate in a subtask of the ADL, but did participate in
other subtasks of the ADL.
(e)
Total dependence, if you did not participate at all in the completion of the
ADL. Every time the ADL was completed during the entire seven-day period, you
received complete assistance of all subtasks completed during the entire
seven-day period by others.; or
(f)
Did not occur, if you or others did not perform the ADL over the last seven
days before your
assessment. This means the activity did not happen. For
example, for "walk in room" to have a code of "did not occur" it means in the
last seven days before your
assessment, you did not walk even one time. The ADL
may not have occurred because:
(i) You were
not able such as, you were not able to walk because you are
paralyzed);
(ii) No provider was
available to assist; or
(iii) You
declined help with the task.
(2) When your self-performance code is not
independent, extensive assistance,
total dependence, or did not occur, and you
received help with the ADL at least three times, but not three times of the
same type of help, the CARE tool determines a self-performance code by:
(a) Selecting the three times where you
received the most help; and
(b)
Assigning a self-performance code based on the least dependent type of help of
those three times.
(3)
CARE assigns a self-performance code of:
(a)
Supervision, if oversight, encouragement, or cueing was the least dependent
type of help you received of the three times; or
(b) Limited assistance, if nonweight bearing
help or guided maneuvering of your limbs was the least dependent type of help
you received out of the three times.
(c) For example, if you received oversight
help twice, nonweight bearing help twice, and weight bearing help twice, CARE:
(i) Selects two times of weight bearing help
and one time of non-weight bearing help because these were the three times
where you received the most help; and
(ii) Assigns a self-performance code of
limited assistance because nonweight bearing help was the least dependent type
of help you received out of the three times where you received the most
help.
"Self-administration of medication" means your
ability to manage your prescribed and over the counter medications. Your level
of ability is coded for the highest level of need and scored as:
(1) Independent, if you remember to take
medications as prescribed and manage your medications without
assistance.
(2) Assistance
required, if you need assistance from a nonlicensed
provider to facilitate your
self-administration of a prescribed, over the counter, or herbal medication, as
defined in chapter
246-888 WAC.
Assistance required includes reminding or
coaching you, handing you the medication container, opening the container,
using an enabler to assist you in getting the medication into your mouth,
alteration of a medication for self-administration, and placing the medication
in your hand. This does not include assistance with intravenous or injectable
medications. You must be aware that you are taking medications.
(3) Self-directed medication
assistance/administration, if you are an adult with a functional disability who
is capable of and who chooses to self-direct your medication
assistance/administration as prescribed by your medical professional.
(4) Must be administered, if you must have
prescription or over the counter medications placed in your mouth or applied or
instilled to your skin or mucus membrane. Administration must either be
performed by a licensed professional or delegated by a registered nurse to a
qualified
caregiver (per chapter
246-840 WAC). Administration may also be
performed by a family member or unpaid
caregiver in in-home settings or in
residential settings if facility licensing regulations allow. Intravenous or
injectable medications may never be delegated except for insulin
injections.
"Self-performance for bathing" means what you
actually did in the last seven days before your assessment, not what you might
be capable of doing or how well you performed the ADL of bathing.
Self-performance for bathing is based on your level of performance that
occurred on at least one or more occasions in the seven-day period. Scoring of
self-performance for bathing does not include physical assistance that did not
occur in the seven-day look back period, or set-up help. Your self-performance
level is scored as:
(1) Independent, if
you received no help or oversight to complete the ADL of bathing.
(2) Supervision, if in order to bathe you
received oversight (monitoring or standby), encouragement, or cueing.
(3) Physical help transfer only, if in order
to bathe you had help to transfer only.
(4) Physical help, if in order to bathe you
had hands on assistance with bathing, but you did not receive full caregiver
performance of the ADL of bathing.
(5) Total dependence, if in order to bathe
you received full caregiver performance of the ADL of bathing every time. Total
dependence means complete physical nonparticipation by you in all aspects of
bathing; or the ADL:
(6) Did not
occur, if you or others did not perform the ADL of bathing over the last seven
days before your
assessment. The ADL of bathing may not have occurred because:
(a) You were not able for example, you may be
paralyzed);
(b) No provider was
available to assist; or
(c) You
declined because you chose not to perform the ADL.
"Self-performance for IADLs" means what you
actually did in the last 30 days before the assessment, not what you might be
capable of doing or how well you performed the IADL. Scoring is based on the
level of performance that occurred at least one time in the 30-day period. Your
self-performance is scored as:
(1)
Independent, if you received no help, set-up help, or supervision;
(2) Assistance, if you received any type of
help with the activity, including setup, cueing, or monitoring, or the activity
was fully performed by others in the last 30 days;
(3) Total assistance, if you are a child and
needed the IADL fully performed by others and you are functioning outside of
typical developmental milestones; or
(4) IADL did not occur, if you or others did
not perform the IADL in the last 30 days before the assessment.
"Service summary" is CARE information which
includes: Contacts such as, emergency contacts), services the client is
eligible for, number of hours or residential rates, personal care tasks, the
list of formal and informal providers and what tasks they will provide, a
preferred schedule if identified by the client, identified referrals, and dates
and agreement to the outlined services.
"SSI-related" is defined under WAC
182-512-0050.
"Status" means the level of assistance:
(1) That will be provided by informal
supports; or
(2) That will be
provided to a child primarily due to his or her age.
(3) The
department determines the
status of
each ADL or IADL and codes the
status as follows:
(a) Met, which means the ADL or IADL will be
fully provided by an informal support;
(b) Unmet, which means an informal support
will not be available to provide assistance with the identified ADL or
IADL;
(c) Partially met, which
means an informal support will be available to provide some assistance, but not
all, with the identified ADL or IADL;
(d) Age appropriate or
child under (age),
means proficiency in the identified
task is not expected of a
child that age
and a
child that age would require assistance with the
task with or without a
functional disability. The
department presumes children have a responsible
adult(s) in their life to provide assistance with personal care tasks. Refer to
the
developmental milestones table in WAC
388-106-0130; or
(e) Client declines, which means you will not
want assistance with the task.
"Supplemental security income (SSI)" means the
federal program as described under WAC
182-500-0100.
"Support provided" means the highest level of
support provided (to you) by others in the last seven days before the
assessment, even if that level of support occurred only once. The department
determines support provided as follows:
(1) No set-up or physical help provided by
others;
(2) Set-up help only
provided, which is the type of help characterized by providing you with
articles, devices, or preparation necessary for greater independence in
performance of the ADL. (For example, set-up help includes but is not limited
to giving or holding out an item or cutting up prepared food);
(3) One-person physical assist
provided;
(4) Two- or more person
physical assist provided; or
(5)
ADL did not occur during entire seven-day period.
"Task" means a component of an activity of
daily living. Several tasks may be associated to a single activity of daily
living.
"Turning and repositioning program" is a
consistent and organized method in which your caregiver must position and
realign your body to prevent or treat skin breakdown. This program is needed
because you are physically unable to reposition yourself while sitting or lying
down.
"You/your" means the client.
