Virginia Law

PATIENT ASSESSMENT CRITERIA.

1. HEALTH STATUS -- To meet this category:

a.

Two or more questions must be answered with a 4, or Question No. 10 must be answered yes.

Rarely

Some-
times

Often

Regu-
larly

b.

How often is nursing care or nursing supervision by a licensed nurse required for the following:

1

2

3

4

1.

Medication administration and/or evaluation for effectiveness of a medication regime? ((70) Receiving Medications and History of Seizures pg.4)

1

2

3

4

2.

Direct services: i.e., care for lesions, dressings, treatments, (other than shampoos, foot powder, etc.)?

1

2

3

4

3.

Seizures control? ((68) History of seizures pg.4)

1

2

3

4

4.

Teaching diagnosed disease control and care, including diabetes?

1

2

3

4

5.

Management of care of diagnosed circulatory or respiratory problems?

1

2

3

4

6.

Motor disabilities which interfere with all activities of daily living--bathing, dressing, mobility, toileting, etc.?

1

2

3

4

7.

Observation for choking/aspiration while eating, drinking?

1

2

3

4

8.

Supervision for use of adaptive equipment, i.e., special spoon, braces, etc.? (physical aids pg.4)

1

2

3

4

9.

Observation for nutritional problems (i.e., undernourishment, swallowing difficulties, obesity)?

1

2

3

4

10.

Is age 55 or older, has a diagnosis of a chronic disease and has been in an institution 20 years or more?

yes

no

2. COMMUNICATION -- To meet this category:

a.

Three or more questions must be answered with a 3 or a 4.

No assis-tance

Prompt-ing/
Struc-turing

Super-vision

Some Direct Assis-tance

Total
Assis-tance

b.

How often does this person:

1.

Indicate wants by pointing, vocal noises, or signs? ((62)(c) Preverbal Expression pg.2)

1

2

3

4

2.

Use simple words, phrases short sentences? ((67) Sentences pg.2)

1

2

3

4

3.

Ask for at least ten things using appropriate names? ((67) Vocabulary pg.1)

1

2

3

4

4.

Understand simple words, phrases or instructions containing prepositions: i.e., on in behind? ((27) Complex Instructions pg.3)

1

2

3

4

5.

Speak in an easily understood manner? ((66) Speech pg.1)

1

2

3

4

6.

Identify self, place of residence, and significant other, ((47) Awareness of Others, pg.3)

1

2

3

4

3. TASK LEARNING SKILLS -- To meet this category:

a.

Three or more questions must be answered with a 3 or a 4.

Regu-
larly

Often

Some-times

Rarely

b.

How often does this person:

1.

Pay attention to purposeful activities for 5 minutes? ((42)(2) Attention pg.3)

1

2

3

4

2.

Stay with a three-step task for more than 15 mintues? ((42) (5) Attention pg. 3)

1

2

3

4

3.

Tell time to the hour and understand time intervals? ((33) (b) Time pg. 3)

1

2

3

4

4.

Count more than 10 objects? ((31) (5) Numbers pg.3)

1

2

3

4

5.

Do simple addition, subtraction ((31) (6)Numbers pg.3)

1

2

3

4

6.

Write or print ten words? ((59) (3) Writing pg. 2)

1

2

3

4

7.

Discriminate shapes, sizes, or colors?

1

2

3

4

8.

Name people or objects when describing pictures? ((67) (4) Vocabulary pg. 1)

1

2

3

4

9.

Discriminate between one, many, lot? ((31) (2) Numbers pg. 3)

1

2

3

4

4. PERSONAL/SELF CARE -- To meet this category:

a.

Question No. 1 must be answered with a 4 or a 5, or

b.

Question No. 2 must be answered with a 4 or a 5, or

c.

Questions No. 3 and 4 must be answered with a 4 or a 5?

NOTE: The yes or no questions are for the purpose of identification of needs to be included in the plan of care. Questions answered yes or no are not part of the scale.

No Assis-tance

Prompt-ing/
Struc-turing

Super-vision

Some Direct Assis-tance

Total
Assis-tance

d.

With what type of assistance can this person currently:

1.

Perform toileting functions: i.e., maintain bladder and bowel continence, clean self? etc. ((31)(5) Toilet Training pg. 1)

1

2

3

4

5

(a) has toileting accidents more than twice a day? ((31)(2) Toilet Training pg. 1)

yes

no

(b) has toileting accidents at night?

yes

no

(c) Flushes toilet, pulls up clothes? ((36) Self Care at Toilet pg. 2)

yes

no

2.

Perform eating/feeding functions: i.e., drinks liquids and eats with spoon or fork, etc? ((28)(3) Use of Table Utensils pg. 1)

1

2

3

4

5

(a) Feeds self with spoon neatly? ((28)(3) Use of Table Utensils)

yes

no

(b) Spilling? ((3) (3) Drinking pg. 1)

yes

no

3.

Perform bathing functions (i.e., bathe, runs bath, dry self, etc.)? ((44)(5) Bathing pg. 2)

1

2

3

4

5

(a) Washes hands and face with soap? ((39) (40) Washes Hands and Face pg. 2)

yes

no

(b) Dries hands and face? ((42) Washes Hands and Face pg. 2)

yes

no

(c) Care for hair, nails, beard?

yes

no

4.

Dress self completely i.e., including fastening, putting on clothes, etc. ((5) (6) Dressing pg. 2)

1

2

3

4

5

(a) Dresses upper body, but needs help with fastening?

yes

no

(b) Dresses self but needs assistance with pulling, or

yes

no

(c) Putting on most clothing, fastening, shoes? ((50) (3) Dressing (52) Shoes pg. 2)

yes

no

5. MOBILITY -- To meet this category:

a.

Any one question must be answered with a 4 or a 5.

NOTE: The yes or no questions are for the purpose of identification of needs to be included in the plan of care. Questions answered yes or no are not part of the scale.

No Assis-tance

Prompt-ing/
Struc-turing

Super-vision

Some Direct Assis-tance

Total
Assis-tance

b.

With what type of assistance can this person currently:

1.

Move (walking, wheeling) around environment? ((59) Ambulation pg. 1,(79) Physical Aids pg. 4)

1

2

3

4

5

(a) Walk with assistive device, person? ((59) Ambulation pg. 1, Physical Aids pg. 4)

yes

no

(b) Walk on level ground for 50 yards with or without assistive device? ((73, 74, 76) Physical Aids, pg. 4)

yes

no

(c) Transfer to/from a wheelchair? ((75) Physical Aids pg. 4)

yes

no

2.

Rise from lying down to sitting positions, sits without support? ((27) Body Balance pg. 1)

1

2

3

4

5

3.

Turn and position in bed, roll over?

1

2

3

4

5

6. BEHAVIOR -- To meet this category:

a.

Any one question must be answered with a 3 or a 4.

Rarely

Some-times

Often

Regu-
larly

b.

How often does this person:

1.

Engage in self-destructive behavior? ((61) Maladaptive Behavior pg. 4)

1

2

3

4

2.

Threaten or do physical violence to others? ((52) Maladaptive Behavior pg. 4)

1

2

3

4

3.

Throw things, damage property, have temper outbursts? ((53, 55) Maladaptive Behavior pg. 4)

1

2

3

4

4.

Respond to others in a socially unacceptable manner (without undue anger, frustration or hostility)? ((50) Interactions with Others pg. 3)

1

2

3

4

7. COMMUNITY LIVING SKILLS -- To meet this category:

a.

Any two of questions 2, 5, or 7 must be answered with a 4 or a 5, or

b.

Three or more of questions 1 through 8 must be answered with a 4 or a 5.

No Assis-tance

Prompt-ing/
Struc-turing

Super-vision

Some Direct Assis-tance

Total
Assis-tance

c.

With what type of assistance would this person currently be able to:

1.

Prepare simple foods requiring no mixing or cooking? ((38) Food Preparation pg. 3)

1

2

3

4

5

2.

Take care of personal belongings, room (excluding vacuuming, ironing, clothes washing/drying, wet mopping)? ((43) Personal Belongings pg. 3)

1

2

3

4

5

3.

Add coins of various demonima1 nations up to one dollar? ((57) Money Handling pg. 2)

1

2

3

4

5

4.

Use the telephone to call home, doctor, fire, police?

1

2

3

4

5

5.

Recognize survival signs/words: i.e., stop, go, traffic lights, police, men, women, restrooms, danger, etc.? ((68) Reading pg. 2)

1

2

3

4

5

6.

Refrain from exhibiting unacceptable sexual behavior in public? ((63, 64, 65) Maladaptive Behavior pg. 4)

1

2

3

4

5

7.

Go around cottage, ward, building, without running away, wandering off, or becoming lost? ((56) Sense of Direction pg. 2, (57) Maladaptive Behavior pg. 4)

1

2

3

4

5

8.

Make minor purchases i.e., candy, soft drink, etc.? ((58, 4) Purchasing pg. 2)

1

2

3

4

5