2017 PASRR RFB Appendix G - clinical example - John Doe.doc

Preadmission Screening and Resident Review (PASRR) Level II Screens

DEPARTMENT OF HEALTH SERVICES

STATE OF WISCONSIN

Division of Care and Treatment Services

F-20853 (10/2016) Appendix G

PREADMISSION SCREEN AND RESIDENT REVIEW (PASRR) FOR CURRENT OR PROSPECTIVE NURSING HOME RESIDENTS—LEVEL II SCREEN FACESHEET

An asterisk (*) below denotes personally identifiable information that is necessary for tracking purposes by the Department of Health Services in its efforts to ensure compliance with federal and State regulations. This information is not to be used in any manner outside the scope of the contractual language and applicable laws or regulations.

Check one:

FORMCHECKBOX

Preadmission Screen

FORMCHECKBOX

Change of Status Resident Review (check the reason for referral below):

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Short-term exemption

FORMCHECKBOX

Not previously screened

FORMCHECKBOX

May not need nursing facility care

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May now need specialized services or specialized psychiatric rehabilitative services

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Per DHCAA policy

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May no longer need specialized services or specialized psychiatric rehabilitative services

Check one:

FORMCHECKBOX

Full Screen

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Partial Screen

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Abbreviated Screen

Check the appropriate box:

Screen for a person who may have an intellectual/developmental disability

Screen for a person who may have a serious mental illness

Name – Client *

John Doe County of Responsibility

Utopia

Date of Birth * xx/xx/1956 Gender

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Male

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Female Social Security Number *

999-99-9999

For Preadmission Screens Only—In what type of residence has the person lived (for at least three months) prior to the referral for a Level II Screen? (check one)

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Independent (apartment or house)

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Group Home (CBRF or Adult Family Home)

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With Relative

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ICF/IID

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Hospital

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Assisted Living (RCAC)

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Other—specify:

Was the person in a hospital during the time of the Level II screen?

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Yes

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No

Name – Current or Proposed (if known) Nursing Facility

Cross Wind Manor, Utopia, WI

Legal Status (check one) *

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Voluntary Admission

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Involuntary Admission

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Protective Placement Date of last Watt’s review

Unknown

Name – Guardian or Health Care Agent, if applicable *

Chris and Nancy Doe

Address

112 Maple Street, Utopia, WI

Telephone Number – Home unlisted Telephone Number – Work

Has the Durable Power of Attorney for Health Care document been activated?

FORMCHECKBOX

Yes

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No

PARTIAL LEVEL II SCREEN

Validation of an Intellectual/Developmental Disability Does the data about the person (see the Level II Screen, F-20852, page 1) meet the federal definition of a “developmental disability”?

FORMCHECKBOX

Yes—Continue with the screening process

No—No further Level II screening is needed.

Validation of a Serious Mental Illness Does the data about the person (see the Level II Screen, F-20378, page 1) meet the federal definition of a “serious mental illness”?

FORMCHECKBOX

Yes—Continue with the screening process

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No—No further Level II screening is needed.

Note to Nursing Homes: The nursing home should retain a copy of this facesheet and attached documentation in the person’s current medical record. If the person’s condition or diagnoses change so that he/she later may meet the federal definition of a developmental disability or a serious mental illness, the nursing home will need to submit an updated Level II screen to the appropriate PASRR contract agency.

ABBREVIATED LEVEL II SCREEN

Is an abbreviated Level II screen appropriate because the person qualifies for categorical determination that he/she does not need specialized services or specialized psychiatric rehabilitative services? (Check one)

Yes—there is support for the diagnosis of a severe medical condition AND the social history, progress notes, and other documentation indicate that the person’s level of functioning is so severely impaired by his/her medical condition that he/she could not be expected to actively participate or benefit from specialized services. This concludes the Level II process. Check the type of severe medical condition affecting the person:

Medical condition, including, but not limited to terminal illness (i.e., the individual has a medical prognosis that his/her life expectancy is six months or less if the illness runs its course), coma, ventilator dependence, functioning at a brain stem level, chronic obstructive pulmonary disease, Parkinson’s disease, Huntington’s disease, amyotrophic lateral sclerosis, congestive heart failure, etc. Specify:

Severe cognitive impairments or deficits due to Alzheimer’s disease, dementia, or a related disorder.

Note to Nursing Homes: The nursing home should retain a copy of this facesheet and attached documentation in the person’s medical record.

No—support for the diagnosis of a severe medical condition was not found OR documentation was not found that indicates that the person’s level of functioning is so severely impaired by his/her medical condition that he/she could not be expected to actively participate or benefit from specialized services. If the documentation might exist, but it was not found or included by the PASRR contract agency, contact the appropriate PASRR contract agency to discuss the data that might exist and how to find or obtain the information. Otherwise, proceed to complete a full Level II screen.

APPROPRIATENESS OF PLACEMENT DETERMINATION

Please check one:

Yes, this person is appropriate for a placement in a nursing facility.

This is expected to be a short-term recuperative care stay.

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No, this person does not need placement in a nursing facility; however, he/she may choose to stay because he/she has resided in one or more nursing facilities for at least 30 consecutive months prior to this determination AND he/she was determined to need specialized services (see below).

FORMCHECKBOX

No, this person does not need placement in a nursing facility.

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It is recommended that this person be placed in a FORMCHECKBOX less

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more (check one) restrictive setting than a nursing facility, such as—specify:

NOTE: If a person has both an intellectual/developmental disability and a serious mental illness, the PASRR teams must coordinate their screens; the teams must agree on the placement determination.

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Check this box if the person has both an intellectual/developmental disability and a serious mental illness.

SPECIALIZED SERVICES DETERMINATION

Please check one:

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This person needs specialized services (i.e., inpatient psychiatric hospitalization) to address his/her mental health needs.

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This person needs specialized psychiatric rehabilitation services to address his/her mental health needs.

FORMCHECKBOX

This person needs specialized services to address his/her developmental disability needs.

FORMCHECKBOX

This person does not need specialized services or specialized psychiatric rehabilitative services.

Note to Nursing Homes: The nursing home should retain a copy of this facesheet and attached documentation in the person’s medical record.

PRINT/TYPE Name and Title - QIDP/QMHP Making the Determinations

FORMDROPDOWN

Date Level I Referral was Received

02/05/2017

02/10/2017

Skilled Nursing Care Level Required: Wisconsin administrative code requires that in order for a person who has an intellectual/developmental disability to be admitted to a nursing home, he/she must meet the criteria for a skilled nursing care level (SNF), as established by a Division of Quality Assurance (DQA) surveyor. In certain circumstances, DQA may waive the SNF care level requirement. A care level or waiver must be obtained prior to admission.

Department of Health Services

STATE OF WISCONSIN

Division of Mental Health and Substance Abuse Services F-20852 (Rev. 10/2008)

LEVEL II PREADMISSION SCREEN AND RESIDENT REVIEW (PASRR)

ASSESSMENT FOR PERSONS WITH DEVELOPMENTAL DISABILITIES

WHO ARE APPLYING FOR ADMISSION OR RESIDING IN

MEDICAID-CERTIFIED NURSING FACILITIES

Client’s Name:

John Doe

The following sections (I-XI) comprise the assessment areas of the Level II Screen. After the completion of all eleven sections, a PASRR team member, who meets the QIDP requirements, makes the determination of the need for nursing facility placement and the determination of the need for specialized services. These determinations are to be recorded on the Level II Face Sheet (DDE-853) and summarized on the Evaluation Summary and Notification of Appeal Rights form (DDE-854).

Note: SKILLED NURSING CARE LEVEL REQUIRED – Wisconsin administrative code (HFS 132) requires that in order for a person who has a developmental disability to be admitted to a nursing home, he/she must meet the criteria for a skilled nursing care level (SNF), as established by a Bureau of Quality Assurance (BQA) surveyor. In certain circumstances BQA may waive the SNF care level requirement. A care level or a waiver must be obtained prior to admission.

VALIDATION OF DEVELOPMENTAL DISABILITY:

Does the data about the person meet the criteria for the federal definition of a “developmental disability?”

( Yes (all questions below are answered “yes”). Continue with the screening process.

( No (at least one question below was answered “no”). No further Level II screening is needed.

Also, indicate the result of this determination on the first page of the facesheet.

1. ( Yes ( No Does the person have a diagnosis of mental retardation (as described in the American Association on Mental Retardation’s Manual on Classification in Mental Retardation (1983)), cerebral palsy, epilepsy, or any other condition, other than mental illness, found to be closely related to mental retardation because this condition results in impairment of general intellectual functioning or adaptive behavior similar to that of persons who have mental retardation, and requires treatment or services similar to those required for these persons? Note: If the person has a diagnosis of mental retardation, obtain a copy of documentation that supports the diagnosis, including the psychological evaluation with scores from a standardized intelligence test.

2. ( Yes ( No Was the condition manifested before the person reached age 22?

3. ( Yes ( No Is the person’s condition likely to continue indefinitely?

4. ( Yes ( No Does the person’s condition result in substantial functional limitations in three or more of the following areas of major life activity? (Check all that apply)

( Self-care ( Learning ( Understanding and use of language

( Mobility ( Self-direction ( Capacity for independent living

I.

PREADMISSION QUESTIONS

Why is the person being considered for nursing facility admission?

Been in the facility since xx/xx/2001

What other options have been explored besides nursing facility admission?

Previously was in a community CBRF and attending a sheltered workshop. He still is appropriate for that level of care. County lost funding for community programming for John.

Name/Title/Date of person who completed Section I:

Daniel Zimmerman, QIDP, 02/10/2017

LEVEL II PREADMISSION SCREEN/RESIDENT REVIEW

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

II.

MEDICAL

Attach documents identifying the person’s comprehensive medical history, physical examination results and physician’s orders including orders for medications and treatments (dosage and frequency), diagnostic tests, special diet, and rehabilitation services (include frequency).

If the person is using any medication in the following drug groups, list the medication (even if listed above) and the person’s current response to the medication: hypnotics; antipsychotics; mood stabilizers and antidepressants; antianxiety-sedative agents; and anti-parkinson agents.

Briefly summarize the person’s skills and deficits associated with monitoring and supervising one’s own health status, including self-administration of medications and scheduling of medical treatments.

Not able to handle or participate in managing this.

Based on the above medical section (including any Appendixs), what supports does the person need to maintain or improve his/her independent functioning as it relates to health status?

This gentleman came to this facility nearly 14 years ago after community programs lost funding. He appears younger than his age. Programming of a meaningful nature with people of common ability would likely reduce the need for medication for depression and agitation. His self-worth would be enhanced as well as quality of life.

Name/Title/Date of person who completed Section II:

Daniel Zimmerman, QIDP, 02/10/2017

III.

NUTRITIONAL STATUS

Height:

inches Weight:

pounds

Has the person been: ( gaining weight ( losing weight ( staying about the same in the past six months? (check one)

Amount of weight gain/loss in that period?

6 lbs.

Food Intake: (check all that apply)

( Eats without assistance

( Needs some type of adaptive aid (plate guard, built-up utensil, etc.)

( Needs another person to assist with feeding

( Is fed by syringe

( Feeding tube

( Parenteral/IV

( Mechanically altered diet (ground, pureed, etc.)

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

Is the person on a prescription or special diet?

No

If yes, describe the diet:

Does the person have dentures and/or a removable bridge?

( No

( Yes

If yes, does the person use them on a daily basis?

Does the person have broken or loose teeth?

Does the person have inflamed gums and/or bleeding gums?

( No

Does the person have chewing problems?

If yes, describe:

Does the person have swallowing problems?

If yes, describe:

How does the person communicate food likes and dislikes?

Verbally expresses

Consumes all or almost all food provided most of the time?

If no, describe the person’s eating pattern:

Consumes all or almost all liquids provided most of the time?

If no, describe the person’s fluid intake pattern:

What skills does the person have to monitor her/his nutritional needs?

Likes all foods and liquids, but no skill at limiting.

Based on the areas above, what kinds of supports does the person need to maintain or improve their nutritional status?

He needs monitoring of food intake and caloric content to keep weight in line; this could be handled in a CBRF or adult foster care.

Name/Title/Date of person who completed Section III:

Daniel Zimmerman, QIDP 0210/2017

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

IV.

SELF-HELP DEVELOPMENT

A.

ADL SELF-SUPPORT (Code for person’s PERFORMANCE-Not including setup)

0.

INDEPENDENT - No help or oversight - OR - Help/oversight provided only 1 or 2 times during last 7 days.

1.

SUPERVISION - Oversight, encouragement or cueing provided 3+ times during last 7 days - OR - Supervision plus physical assistance provided only 1 or 2 times during last 7 days.

2.

LIMITED ASSISTANCE - Person highly involved in activity; received physical help in guided maneuvering of limbs or other non-weight bearing assistance 3+ times - OR – More help provided only 1 or 2 times during last 7 days.

3.

EXTENSIVE ASSISTANCE - While person performed part of activity, over last 7 day period, help of following type(s) provided 3 or more times: Weight-bearing support; Full assistance during part (but not all) of last 7 days

4.

TOTAL DEPENDENCE - Full assistance of activity during entire 7 days.

B.

ADL SUPPORT PROVIDED - (Code for MOST SUPPORT PROVIDED during last 7 days; code regardless of person’s self-performance classification)

0.

No setup or physical help from others.

2.

One-person physical assist.

1.

Setup help only.

3.

Two+ persons physical assist. A. B.

Respond in both columns for each area of support.

Self-

Support Support

PERSONAL

HYGIENE

0.

Independent - no help provided.

1.

Supervision - Oversight help only.

3.

Physical help in part of bathing activity.

2.

Physical help limited to transfer only.

4.

Total dependence.

Person believes he/she capable of increased independence in at least some ADLs.

a.

Direct care provider(s) believe person capable of increased independence in at least some ADLs.

b.

Person able to perform tasks/activity but is very slow.

C. (

Major difference in ADL Self-Performance or ADL Support in mornings and evenings (at least a one category change in Self-Performance or Support in any ADL.)

d.

e.

NONE OF ABOVE

e.

( No change

( Improved

( Deteriorated

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

Based on the areas above, what kinds of supports does the person need to maintain or improve their self-help skills?

With supervision and minimal assistance with bathing, ADL needs should be able to be met in a community setting.

Name/Title/Date of person who completed Section IV:

Daniel Zimmerman, QIDP 0210/2017

V.

SENSORIMOTOR DEVELOPMENT (Ambulation, positioning, and transfer skills were covered in the preceding section.)

Motor Development: (check all that apply)

( Balance—adequate balance while standing

( Balance—partial or total lack of ability to balance self while standing

( Trunk—adequate control in turning, balancing, and positioning body

( Trunk—partial or total lack of ability to turn, balance, or position body

( Arms—adequate function

( Arm(s)—partial or total lack of voluntary movement (( L ( R)

( Hands—adequate gross and fine motor dexterity

( Hand(s)—lack of dexterity (( L ( R) List examples of difficulties:

( Legs—adequate function

( Leg(s)—unsteady gait

( Leg(s)—partial or total lack of voluntary movement (( L ( R)

( Amputation(s)--identify:

( Hemiplegia/Hemiparesis

( Quadriplegia

( Contractures--(arms, legs, shoulders, hands) Identify:

( Bedfast all or most of the time

Mobility Aids: (check all that apply)

( None

( Manual wheelchair (( usually wheels self ( usually someone else wheels)

( Power wheelchair (person operates)

( Brace/Prosthesis--Describe:

( Lifted mechanically--Describe:

( Other mobility aids--Describe:

Based on the above, and any other documentation (attach), what supports does the person need to improve her/his motor function/capabilities? (Include supports from other people, training needs, as well as prosthetic, orthotic, corrective or mechanical supportive devices):

John functions well in this area ------ no supports are needed.

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

Vision: Ability to see in adequate light and with glasses if used. (check one)

( Adequate--sees fine detail, including regular print in newspapers/books.

( Impaired--sees large print, but not regular print in newspapers/books.

( Highly Impaired--limited vision; not able to see newspaper headlines; does appear to follow objects with eyes.

( Severely Impaired--no vision or appears to see only light, colors, or shapes.

Visual Limitations: (check all that apply)

( Has difficulty locating objects without assistance

( Difficulty traveling (bumps into people/objects)

( Misjudges placement of body when seating self

Visual Appliances: (check all that apply)

( Glasses ( Contact lenses

( Other (describe):

Based on the above, and any other documentation (attach), what supports does the person need to improve her/his vision and/or supports to aid in reducing the barriers imposed by limitations in vision?

No limitations in this area.

Hearing: (with hearing appliance, if used) (check one)

( Hears adequately--normal talk, TV, phone

( Minimal difficulty when not in quiet setting

( Hears in special situations only--speaker must adjust tonal quality and speak distinctly

( Highly impaired/absence of useful hearing

Hearing Devices/Techniques: (check all that apply)

( Hearing aid, present and used

( Hearing aid, present and not used (Why not?)

( Hearing aid, not present (Why not?)

( Other receptive communication technique used (e.g., lip reading, signing) Describe:

Based on the above, and any other reports/evaluations (attach), what devices/techniques are needed to help the person improve his/her receptive functional capabilities?

No limitations in this area.

Name/Title/Date of person who completed Section V:

Daniel Zimmerman, QIDP 02/10/2017

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

VI.

COMMUNICATION

Modes of Expression (Check all used by resident to make needs known)

( Person cannot communicate basic needs

( Speech

( Writes messages to express or clarify needs

( Sign language

( Gestures/Sounds

( Communication board

( Other--Describe:

( Primary language is other than English. What Language?

Making Self Understood (Expresses information—however able) (check one)

Person is understood

( Is usually understood--difficulty finding words or finishing thoughts

( Is sometimes understood--ability is limited to making concrete requests

( Is rarely/never understood

Ability to Understand Others (Understanding verbal information content--however able) (Check one)

( Person understands

( Usually understands--may miss some part/intent of message

( Sometimes understands--responds adequately to simple, direct communication

( Person rarely/never understands

Change In Communication--person’s ability to express, understand, or hear information has changed over last 6 months (check one)

( No change

( Improved, and if so, why?

Based on the above, and any other reports/evaluations (attach), what supports does the person need to improve her/his communication capabilities (both receptive and expressive, including non-oral communication systems)?

I had no difficulty conversing with John. He is obviously functions in a range of intellectual disability based on his short, simple sentences. He can, however, make sensible reasonable conversation.

Name/Title/Date of person who completed Section VI:

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

VII.

AFFECTIVE AND SOCIAL DEVELOPMENT (attach a copy of the person’s social history)

Skills involved with expressing emotions, making judgments, making independent decisions, interpersonal skills, rec-leisure skills, and relationships with others. (Indicate with a number)

1 never does

2 rarely does

3 sometimes does 4 almost always does

Based on the above, and any other reports/evaluations (attach), what supports does the person need to develop behaviors and skills relating to his/her own emotions as well as skills that enable the person to establish and maintain appropriate roles and fulfilling relationships with others?

John has many assets in this area on which to build. Increasing his ability to make decisions/choices and increasing self-direction are primary needs in this area, along with expanding his repertoire of leisure activities.

Name/Title/Date of person who completed Section VII:

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

VIII.

FUNCTIONAL LEARNING SKILLS

Skills involved in processing information received by the senses (memory, reasoning, and problem solving) (Indicate with a number all that apply)

1 never does

2 rarely does

3 sometimes does 4 almost always does

Based on the above, and any other reports/evaluations (attach), what supports does the person need to improve her/his functional learning capabilities?

John was working at Goodwill Industries until community funding ran out. Alternatives similar to this were not sought out or made available ------ rather, he was placed in the nursing home. Work activities would be appropriate for John and are expected to have therapeutic benefits for him.

Name/Title/Date of person who completed Section VIII:

IX.

INDEPENDENT LIVING DEVELOPMENT

Does the person have skills in the following areas? (Indicate with a number)

1 does not do

2 does with assistance 3 does independently

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

Based on the above, and any other reports/evaluations (attach), what supports does the person need to improve his/her personal independence and social responsibility expected of their age and cultural group?

In the current arrangement, John does not have opportunities to function independently in the above areas. It is expected that John has the capacity to re-establish and maintain skills in this area so he can exercise greater independence and self-direction.

Name/Title/Date of person who completed Section IX:

X.

VOCATIONAL SKILLS

Vocational development refers to work interests, work skills, present and future employment options, etc. (Check all that apply.)

( Person is presently involved in a sheltered work program (with main emphasis on production, piece work, etc.)

( Presently involved in a pre-vocational training program (with main emphasis on learning work related skills)

( Presently involved in a supported employment program (working at an integrated job site with supports)

( Presently involved in a day services program where the primary focus is not related to work or learning work skills (e.g., recreation/leisure activities, social skills development, ADL skills development, etc.)

( Person expresses (however able) an interest in working/having a job/getting job training

( Others familiar with the person recommend work or work skills training

( Person has previously had work skills training

( Person has previously worked (no longer works). Describe nature of the work and why discontinued:

Briefly describe what the person does during a typical week (i.e., Mon-Fri., 8:00--4:00) and where the activity occurs:

He goes to whatever activities are offered at the facility. He follows what is going on with other residents and staff. Walks a lot. Likes to assist staff.

Based on the above sections, and any other reports/evaluations (attach), what supports does the person need to develop vocational/work interests, skills, and employment options?

Needs a reassessment to determine the vocational skills he may have retained. He has not been offered any work opportunities, so it is unknown if he is interested in working again.

Name/Title/Date of person who completed Section X:

FOR PERSONS WHO HAVE A DEVELOPMENTAL DISABILITY

XI.

CHALLENGING BEHAVIORS

The presence of identifiable maladaptive or inappropriate behaviors of the person based on systematic observation. Source(s) of following information (including name and title/relationship):

(Indicate with a number)

1 never

4 more than once per month, but not daily

2 rarely

5 on a daily or near daily basis

3 not more than once per month

Is there a written behavior management program (not including programs that only involve the use of physical restraints or psychotropic medications)

Has there been a change in the person’s overall behavior in the past 6 months?

( No change ( Improved ( Deteriorated

If improved or deteriorated, why? Behavior was exacerbated in mid-1993 when his dosage levels were reduced.

Based on the above sections, and any other reports/evaluations (attach), what supports or interventions are needed to reduce maladaptive behaviors and improve the person’s ability to function safely and independently?

Maladaptive behaviors occur infrequently. He receives medications to manage symptoms of depression and agitation.

Name/Title/Date of person who completed Section XI:

SOCIAL HISTORY

NAME:

John Doe

BIRTHPLACE:

Utopia, WI

DOB:

xx/xx/1956

SOCIAL SECURITY:

999‑99‑9999

DATE OF ADMISSION:

2/2/2001 (Re‑admission)

3/8/1997 (Original)

MARITAL STATUS:

Single

EDUCATION:

No Formal Education

DIAGNOSES:

1.

Childhood Encephalitic Mentally Retarded

2.

Agitated Behavior

3.

Past Planus and Congenital Clubbing, (R) Foot

4.

Onychomycosis, all toenails, both feet

5.

Severe Dyshidrosis, eczematous skin changes, hands, feet, lower extremities

6.

Edema (R) Lower Extremity

7.

Gynecomastia

John Doe is a readmission to the Cross Wind Manor following a brief hospitalization at St. Mary’s Hospital for agitated behavior.

Previous records indicate that John was born to Chris and Nancy Doe of Utopia, Wisconsin. It is known that his mother was a resident at the Utopia County Home for a number of years and has since passed away.

John has one sister, Mrs. Jill Jones, residing at Route 1, Utopia, WI. She and her husband are frequent visitors and also invite him to their home. His sister was a resident at Northern Colony and Training School of Chippewa Falls, WI.

John has another sister, Miss Janet Doe. Records indicate that the last known address is 1111 N. Zimmerman Street, Milwaukee, WI. Janet has not been in contact with John for a number of years, and the family is unaware of her whereabouts, or if she is even alive.

History indicates that John was committed to the Northern Colony and Training School at Chippewa Falls on xx/xx/1964 at the age of 8. Records indicate that he was quiet and well behaved. He could talk, but refused to do so. His speech at the present time is inarticulate and non‑structured. He was able to feed himself, but needed assistance with dressing and grooming, and other personal cares. It appears that his mother was a resident of the Colony at this time also. He resided at Northern Colony and Training School until his discharge on xx/xx/1990.

Appendix G Social History: (Continued)

John Doe

On xx/xx/1990 John was transferred to the Utopia County Home as he was considered a resident of Utopia County and was transferred back to his county of residence.

There are no records available from 1990‑1994. However, reports state that he had difficulty adjusting to this living situation. He did marginally well, but difficulties with other residents resulted in outbursts of anger.

In August 1994, he was transferred to the Tail Wind Nursing Home in Utopia, WI where he was unable to adjust. Difficulties in management, inappropriate behavior toward female residents resulted in his placement to the Utopia County Hospital. He was placed in a sheltered self‑care unit (Ward AB).

In March 1997, John was admitted to Cross Wind Manor to provide a less institutionalized setting. He was reported to be enthusiastic about his placement as he considered Mr. and Mrs. Sam Smith as his “ma and pa.”

John was given a trial placement of two weeks at the Eastside Group Home in Utopia, WI on xx/xx/2001. After the trial period it was decided that he was not functioning any better in that setting and that it would be in his best interest to return to Cross Wind Manor. On xx/xx/2001 he was transferred, and has made his residence at Cross Wind Manor until the present time.

John is known to need a structured environment with careful supervision and maintenance. He attends Goodwill Industries on a weekly basis to maintain his skill level. He is regarded as having reached his maximum potential, and has been given a waiver from Active Treatment. He considers Cross Wind Manor his home and becomes very anxious if feeling threatened by a transfer to another facility.

John does have a guardian, George Doe of Utopia, WI. Mr. Doe is John’s first cousin.

DISCHARGE PLANNING:

No plan for discharge.

Dan Zimmerman, Social Worker

Appendix G Social Review - John Doe (undated)

Psychosocial Development John interacts well with staff and peers. He is willing to participate in every activity suggested by staff. However, he is shy and becomes extremely anxious and frustrated if put in the center of an activity. He continues to need staff direction to participate in a structured and cooperative game, due to cognitive limitations. He does go to Goodwill Industries one day a week, and behavior is reported as “good.” He continues to need “time out” approximately every 2 hour, to walk and decrease anxiety, and will return to an activity in a short period of time, only a few minutes. He attends Senior Citizen Dinner each Wednesday, however, needs encouragement to eat appropriately, staying seated to finish his meal, and not over-eating, and not eating too fast (finishes a meal in less than five minutes). He enjoys bowling weekly, and on occasion will become frustrated, walking away from the group. This behavior is ignored, and the “cooling off” period does well to minimize anxiety and temper outbursts. He will return to the group in a relative short period of time, less than a minute, and be friendly and continue as though nothing happened.

Health Profile John suffered from encephalitis as a child, which caused his cognitive impairments. He has a congenital clubbing of his right foot. He has lotion applied BID to his feet, as he tends to have chronic skin problems. On occasion he will have sores on feet due to improper tying of his shoes. He wears custom made shoes that fit his feet very well. He also has Selsun lotion applied to his scalp prn. John is over-weight. He is presently on a regular diet with smaller portions. He will tend to eat other residents’ foods, but is reminded not to do this by staff. He receives Mellaril 25 mg. TID and Triavil 2-25 mg. BID for anxiety. Psychological evaluation reveals a verbal testing of 36, abstract reasoning of 36, and short-term memory of 36. He has seen a psychiatrist in the past for increased anxiety, but has not needed to be seen in the last year as is doing well on present medication.

Portion of a Social Service Information document:

Social Evaluation and Recommendations: John is being admitted to Cross Wind Manor following a brief hospitalization at St. Mary’s Hospital for agitated behavior. He continues to be highly agitated and needs reassurance and redirection during times of stress. Psychiatric consultation should be considered if anxiety does not decrease. Resident is known to be a cooperative, happy individual for the most part, until this latest episode of agitation. Attendance at Goodwill Industries should be discontinued until behavior is under control.

Dan Smith, SW xx/xx/2001 Appendix G Psychological Services, Inc.

REPORT OF PSYCHOLOGICAL SERVICES

NAME:

John Doe

DATE SEEN:

xx/xx/1997

ADDRESS:

Cross Wind Manor

AGE:

41 years

Utopia, WI

BIRTHDATE:

xx/xx/1956 BACKGROUND INFORMATION: Mr. Doe is a 51 year old, single male who was admitted to the Cross Wind Manor in 1997. He was born in Utopia, Wisconsin and is described as having had no formal education. His mother is Nancy, who is reported as having been a patient at the Utopia County Hospital for a number of years and who passed away. No information was available on his father. At age eight he was committed to Northern Wisconsin Center for the Developmentally Disabled.

Mr. Doe has a diagnosis of Mental Retardation due to encephalitis. He is currently taking Triavil, Mellaril and Tylenol.

Mr. Doe was pleasant, cooperative and attentive in the evaluation process. The obtained results were viewed as a fair representation of current functioning.

TESTS ADMINISTERED:

1) Stanford‑Binet Intelligence Scale: 4th Edition

2) Vineland Adaptive Behavior Scale

TEST RESULTS AND INTERPRETATIONS: Mr. Doe was administered the Stanford-Binet Intelligence Scale: 4th Edition. He obtained the following scores:

SUMMARY OF SUBTEST SCORES

Full Scale IQ Verbal Reasoning = 36

Abstract/Visual Reasoning = 36

Quantitative Reasoning = 36

Short Term Memory = 36

A Full Scale IQ score of 36 is within the severe range of mental retardation. It should be noted that his performance was, for the most part, consistent in the various subtests.

Appendix G Psychological Report

John Doe

Mr. Doe was also administered the Vineland Adaptive Behavior Scale. He obtained the following scores:

Grp. %ile Age Equiv.

Domain Scores:

Communication

Daily Living Skills

Socialization <20

.1

.1

.1

1-1

6-3

5-11

A Standard Score of 33 on the Vineland Adaptive Behavior Scale is directly comparable to an IQ score of 33 and would suggest personal and social sufficiency within the severe range of mental retardation. His overall performance was better than approximately .1% of the people his age within the national normative group while approximately 99.9% score higher than Mr. Doe scored. When comparing his performance to ambulatory mentally retarded people within a residential facility, his performance was better than approximately 78% of the people his age within the national normative group while approximately 22% score higher than Mr. Doe scored. It should be noted that a relative weakness was noted in the communication domain with a relative strength in the daily living skills domain.

Diagnostically, Mr. Doe is functioning in the severe range (318.1) intellectually and also in the severe range with respect to adaptive function. Maladaptive behavior was noted for the less serious concerns such as sleep upset, poor concentration, coordination problems relative to toileting and becoming upset easily.

See attached for Subdomain Scores.

SUMMARY AND RECOMMENDATIONS: Mr. Doe is a 41-year-old male who was intellectually functioning within the severe range. It is recommended that Mr. Doe’s communication skills be enhanced by the working with words and pictures to increase his communication, both in terms of receptive language and expressive language. Mr. Doe should be required to do any daily living skills that he is capable of completing with only the assistance he requires. Focus on the value of money, utilizing coins is suggested, as well as a focus on daily orientation such as the day of the week, recognizing morning, afternoon and night and working on the function of time.

John Smith, Ph.D.

LICENSED BY PSYCHOLOGY EXAMINING BOARD‑STATE OF WISCONSIN

CERTIFIED BY THE NATIONAL REGISTER OF HEALTH SERVICE PROVIDERS

Appendix G

VINELAND SUMMARY – SUBDOMAINS

RESIDENT’S NAME: John Doe Age: 51

High

Moderately High

Adequate

Moderately Low

Low 131 to above 160

115 to 130

85 to 115

70 to 84

Below 20 to 69

What resident understands

Expressive What resident says

Written What resident reads & writes

How resident eats, dresses, & practices personal hygiene

Domestic What household tasks resident performs

Community How resident uses time, money, the telephone & job skills

How resident interacts with others

Relationships

Play & Leisure Time How resident plays & uses leisure time

Coping Skills How resident demonstrates responsibility & sensitivity to others

How resident uses arms & legs for movement & coordination

Fine

How resident uses hands & fingers to manipulate objects

RFB No. S-0627 DCTS-17 Appendix G – Clinical Example/Test Case – John Doe