Consumer Assessment to Manage PCA Services Introduction The Personal Care Management (PCM) agency must conduct a written assessment to determine the consumer’s ability to manage PCA services independently. This assessment must be completed face-to-face for each new consumer before the submission of the prior-authorization request for PCA services to MassHealth or the Massachusetts Commission for the Blind (MCB). A full assessment must also be completed during the PA year and at the time of reevaluation if: • the consumer’s medical, cognitive, or emotional condition changes in a way that affects the consumer’s ability to manage PCA services independently; • the consumer is not managing the PCA program effectively as evidenced by the consumer exhibiting a pattern of overutilization, or inappropriate use of PCA services, and not responding to intervention from a skills trainer; or • at the request of the fiscal intermediary or MassHealth. For all other reviews, the Review of Consumer Assessment to Manage PCA services form should be completed. The result of the Consumer Assessment to Manage PCA Services is a decision that either: • the consumer can manage PCA services independently; or • the consumer requires the assistance of a surrogate. Consumer Name Date of Birth Date of Assessment Name of Assessor Reason for Assessment: Initial assessment Change in condition - if checked, describe: Difficulty managing PCA services Requested by EOHHS or the FI Guardianship Status If the consumer is a minor, or has a court-appointed legal guardian, a surrogate is required. a. Is the consumer a minor child (under 18 years old)? yes no b. Does the consumer have a court-appointed legal guardian? yes no If no to both (a) and (b), proceed to Part I, Section 1, Communication and Decision Making. If yes to (a) or (b), no further assessment is necessary: a surrogate is required. Complete (c) and (d) and proceed to Part III, Decision. c. Print the name of the parent/legal guardian: d. Describe the evidence of guardianship: PCA-CA-1 (01/07) I. Assessment 1. Communication and Decision Making A “yes” response to question (a) or a “no” response to question (b), (c), or (d) indicates that the consumer requires the assistance of a surrogate with communication and decision making. Measures: a. Does the consumer demonstrate cognitive/behavioral disabilities that would impair the consumer’s ability to self-direct his or her care? yes no If “yes,” list the cognitive/behavioral disability: If “yes,” describe how the consumer’s ability to self-direct would be impaired: b. Does the consumer remember important information? yes no c. Can the consumer communicate his or her needs effectively? yes no d. Does the consumer manage his or her own finances? yes no Result: The consumer does not require the assistance of a surrogate with communication and decision making. The consumer requires the assistance of a surrogate with communication and decision making. Notes and Observations: 2. Knowledge of Disability and Related Conditions A “no” response to any question indicates that the consumer requires the assistance of a surrogate with knowledge of disability and related conditions. Measures: a. Is the consumer able to describe his or her disability and related conditions? yes no b. Is the consumer able to describe a plan to manage medications (schedules and dosages)? yes no c. Is the consumer able to describe the use of any assistive devices or adaptive equipment? yes no Result: The consumer does not require the assistance of a surrogate to understand his or her disability and related conditions. The consumer requires the assistance of a surrogate to understand his or her conditions. Notes and Observations: 3. Knowledge of Personal Assistance Needs A “no” response to question (a), (b), (c), or (d) indicates that the consumer requires the assistance of a surrogate to understand personal assistance needs and routines. Measures: a. Is the consumer able to describe a routine day and give examples of assistance needed, such as bathing, toileting, and other personal care? yes no b. Can the consumer describe the preferred transfer method? yes no c. Can the consumer describe meal preparation and dietary needs? yes no d. Can the consumer describe housekeeping needs? yes no Result: The consumer does not require the assistance of a surrogate with knowledge of personal assistance needs. The consumer requires the assistance of a surrogate with knowledge of personal assistance needs. Notes and Observations: 4. Ability to Employ Personal Care Attendants A “no” response to any question indicates that the consumer requires the assistance of a surrogate to employ personal care attendants. Measures: a. Can the consumer describe how to recruit, hire, and schedule a personal care attendant? yes no b. Is the consumer able to describe how to train and supervise a personal care attendant? yes no c. Can the consumer describe the backup plan he or she will use if a personal care attendant is sick or absent? yes no d. Can the consumer complete activity forms correctly? yes no Result: The consumer does not require the assistance of a surrogate to employ personal care attendants. The consumer requires the assistance of a surrogate to employ personal care attendants. Notes and Observations: II. Assessment Summary The consumer needs the assistance of a surrogate in the following areas (check all that apply.) Communication and decision making Understanding of his or her disability and related condition Understanding his or her personal assistance needs and routines Employing personal care attendants III. Decision Check one. The consumer is able to independently perform all tasks required to manage the PCA program and does not require the assistance of a surrogate. The consumer requires the assistance of a surrogate to perform some or all of the PCA management tasks that the consumer is unable to perform. If the consumer is assessed to require a surrogate, one must be identified for PCA services to commence or continue. If the consumer receives skills training that enable the consumer to independently manage the PCA program, revise this form to reflect any changes. IV. Signatures My ability to manage the PCA program has been assessed in person. If I do not agree with the results of this assessment, I must let my PCM agency know. The PCM agency has given me a copy of their process for resolving the disagreement. Signature of Consumer or Legal Guardian Date Printed Name I have assessed this consumer’s ability to manage the PCA program. Signature of Assessor Date Printed Name