MassHealth Evaluation for Personal Care Attendant (PCA) Services Consumer Name: Communication Difficulties Site of Evaluation: Date of Evaluation: Type of Evaluation: Initial Re-eval List of Medications†: Evaluators should consult 130 CMR 422.410 for a definition of the ADLs and IADLs described below. Day/Evening PCA Activity-ADLs (6:00 A.M. – Midnight) Status* PCA Time (in Mins.) Frequency Day Week Total Mins. per Week Equipment Used Comments (attach additional sheet if needed) Mobility – Transfers (specify type and level) Assistance with Medications Bathing (includes transfers) Tub Bed Bath Shower Washing Hair General Grooming Dressing Undressing Weekly Day/Evening PCA Minutes Subtotal (Page 1): Attach additional sheet if necessary * I = Independent; A = Physical Assistance Required; D = Dependent PCA-2 Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid Page 1 of 7 (Rev. 05/04) MassHealth Evaluation for Personal Care Attendant (PCA) Services (cont.) Consumer Name: Date of Evaluation: Day/Evening PCA Activity-ADLs (6:00 A.M. – Midnight) Status* PCA Time (in Mins.) Frequency Day Week Total Mins. per Week Equipment Used Comments (attach additional sheet if needed) Passive Range of Motion (ROM) UEs LEs Eating Bladder Care (specify type) Bowel Care (specify type)\ Weekly Day/Evening PCA Minutes Subtotal (Page 2): * I = Independent; A = Physical Assistance Required; D = Dependent Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid Page 2 of 7 MassHealth Evaluation for Personal Care Attendant (PCA) Services (cont.) Consumer Name: Date of Evaluation: Day/Evening PCA Activity-ADLs (6:00 A.M. – Midnight) Status* PCA Time (in Mins.) Frequency Day Week Total Mins. per Week Equipment Used Comments (attach additional sheet if needed) Laundry Shopping Housekeeping Meal Preparation and Clean-up Other (specify) Weekly Day/Evening IADL Minutes Subtotal (Page 3): Weekly Day/Evening ADL minutes (page 1+2) Total Weekly Day/Evening PCA minutes: Total Weekly Day/Evening PCA Hours (Round up to nearest 15-minute unit. For example, 23.3=23.5; 42.7=42.75.): * I = Independent; A = Physical Assistance Required; D = Dependent Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid Page 3 of 7 MassHealth Evaluation for Personal Care Attendant (PCA) Services (cont.) Consumer Name: Date of Evaluation: Night PCA Activity (repositioning, toileting, etc. — specify below) Night PCA Activity (Midnight - 6:00 A.M) (describe the ADL for which physical assistance is needed) Status* PCA Time (in Mins.) Frequency per Night Total Mins. per Night Equipment Used Comments (attach additional sheet if needed) Total PCA Minutes per Night: Total Billable Hours per Night (round up to nearest hour — enter “2” if less than two hours): Total Weekly Billable Night PCA Hours Case Summary/Additional Comments: Day/evening PCA hours requested per week: Night PCA hours requested per night * I = Independent; A = Physical Assistance Required; D = Dependent Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid Page 4 of 7 MassHealth Evaluation for Personal Care Attendant (PCA) Services (cont.) Consumer Name: Date of Evaluation: Evaluator Signoffs Requested PCA Activity Time We confirm that the consumer meets the criteria of the MassHealth PCA Program and requires physical assistance for the following number of hours of PCA activity time: Day/evening PCA hours requested per week: Night PCA hours (if any) requested per night: Surrogate (check only one of the two boxes below) I/we have conducted an assessment of the consumer’s ability to independently manage the PCA program in accordance with 130 CMR 422.422(A) and have determined that: Based on our assessment, the consumer appears to have the necessary cognitive and emotional ability and skills to perform all of the tasks of managing PCA services and does not require a surrogate. Based on our assessment, the consumer does not have the necessary cognitive or emotional ability and skills to perform some or all of the tasks of managing PCA services and requires a surrogate. Surrogate name, address, and phone number: Surrogate’s relationship to consumer: Print Name and title of assessor: Signatures Occupational Therapist Evaluator: Date: Registered Nurse Evaluator: Date: I was evaluated in person and I have reviewed this evaluation: Date: Consumer or legal guardian signature (include surrogate signature as appropriate): * I = Independent; A = Physical Assistance Required; D = Dependent Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid Page 5 of 7 MassHealth Evaluation for Personal Care Attendant (PCA) Services (cont.) Consumer Name: Date of Evaluation: Physician or Nurse Practitioner Signoff Enclosed is (Check One): documentation of verbal authorization from physician or nurse practitioner in accordance with 130 CMR 422.416(A)(4)(b). The PCA agency must obtain physician or nurse practitioner signoff within 60 days after the request for prior authorization is sent to MassHealth; or physician or nurse practitioner sign-off (see below). I understand that a MassHealth PCA consumer must have a long-term, chronic disability that results in a need for physical assistance with two or more of the following activities of daily living: mobility; assistance with medications; bathing or grooming; dressing/undressing; range of motion; eating and toileting. In my opinion the consumer meets these criteria. I find the consumer is medically appropriate for nonskilled PCA services and is sufficiently medically and emotionally stable to benefit from PCA services. The consumer is able to direct his or her own care or has a surrogate who accepts formal responsibility to direct the care. The consumer requires ______ hours per week of day/evening PCA services. The consumer requires ______ hours per week of night PCA services (from midnight to 6:00 A.M.) Physician or nurse practitioner signature: Date: Name of physician or nurse practitioner (print): Date: Physician/nurse practitioner address: Telephone number: * I = Independent; A = Physical Assistance Required; D = Dependent Executive Office of Health and Human Services Office of Medicaid Page 6 of 7 MassHealth Evaluation for Personal Care Attendant (PCA) Services (cont.) Consumer Name: Date of Evaluation: Occupational Therapy Functional Status Report An occupational therapist (OT) must complete this form for all initial evaluations for PCA services and for reevaluations for PCA services when the consumer’s medical condition or functional status has changed. 1. How does the consumer’s diagnosis manifest as a disabling condition? 2. How does the consumer’s disability affect his or her ability to perform ADLs and IADLs? 3. What is the level of assistance required to complete ADLs? 4. Describe the consumer’s functional status, including specific level of assistance required for transfers, if applicable. 5. Has the consumer been evaluated for adaptive equipment or assistive devices? Yes No If yes, describe results of evaluation. OT Signature: Date: * I = Independent; A = Physical Assistance Required; D = Dependent Commonwealth of Massachusetts Executive Office of Health and Human Services Office of Medicaid Page 7 of 7