Moms In Motion, LLC - EDCD Qualification Survey
To qualify for the EDCD Waiver, an individual needs to meet criteria in the four following areas: 1. Financial Limits, 2. Functional Needs, 3. Medical Nursing Needs, 4. Risk of Nursing Facility placement. The purpose of this survey is for individuals interested in applying for the EDCD Waiver to determine if they would likely meet the functional needs and medical nursing needs criteria and provide information regarding the imminent risk criteria for this waiver. The results of this survey are for informational purposes only. For an official screening for this waiver, the individual must contact their local Department of Social Services. Also, a financial application for Medicaid must be completed. The financial criteria for Medicaid based on a waiver approval is very different from that of Medicaid not based on a waiver approval.
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Please review each activity and select the option that best describes the
individual's needs to complete the activity entirely and safely.
Bathing
Getting in and out of tub, preparing bath, washing, towel drying.
  Does Not Need Help In/Out of tub/shower, turns on and adjusts water, bathes entire body, or takes full sponge bath independently.
Mechanical Help Only Regularly utilizes equipment or device (chair/stool, grab bars, long-handled brush, etc.
Human Help Only Supervision (Verbal Cues, Prompting) - for safety, initiation or completion and/or physical assistance (Set up, Hands-On Care).
Mechanical and Human Help Requires both Mechanical and Human Help.
Performed By Others Completely bathed by other(s), plays no active role in completion of task.
Dressing
Getting clothes from closets and/or drawers, putting them on, fastening, and taking them off. Clothing refers to clothes, braces, and artificial limbs worn daily. Individuals who wear pajamas or gowns with robe and slippers as their usual attire are considered dressed.
  Does Not Need Help Completes the dressing process without help from others.
Mechanical Help Only Needs equipment or a device such as a long-handled shoehorn, zipper pulls, specially designed clothing, or a walker with an attached basket to complete the dressing process.
Human Help Only Requires supervision, and/or prompting, and/or verbal cues to complete the dressing process. Usually requires assistance from another person who helps in obtaining clothes, fastening buttons, etc.
Mechanical and Human Help Requires both Mechanical and Human Help.
Is Dressed Completely dressed by other(s), play no active role in completion of task.
Is Not Dressed Bedfast individuals who are not changed.
Toileting
Ability to get to and from the bathroom, get on and off the toilet, clean oneself, manage clothes, and flush. A commode at any site may be considered the "bathroom" only if in addition to meeting the criteria for "toileting" the individual empties, cleans, and replaces the receptacle, such as the bed pan, urinal, or commode, without assistance from other(s).
  Does Not Need Help Ability to use restroom, clean self, and re-dress self independently.
Mechanical Help Only Regularly utilizes equipment or device (handrails, walkers, canes, raised toilet seat, etc.).
Human Help Only Supervision (Verbal Cues, Prompting) - for safety, initiation, or completion - Physical Assistance (Set up, Hands-On Care)
Mechanical and Human Help Requires both Mechanical and Human Help.
Performed By Others Completely taken through toileting process without helping.
Transferring
Ability to move between bed, chair, and/or wheelchair. If individual needs help with some transfers but not always, select the highest level of need.
  Does Not Need Help Moves self easily through all transfers without equipment or human assistance.
Mechanical Help Only Regularly utilizes equipment or device (lifts, hospital beds, sliding boards, pulleys, etc.) independently.
Human Help Only Supervision (Verbal Cues, Prompting) - for safety, initiation, or completion and/or physical assistance (Set up, Hands-On Care).
Mechanical and Human Help Requires both Mechanical and Human Help.
Performed by others Lifted and placed elsewhere without helping.
Is Not Performed Confined to Bed.
Bowel Function
The physiological process of elimination of feces.
  Continent Voluntarily controls the elimination of feces.
InContinent < weekly Involuntary elimination of feces less than weekly (e.g., every other week).
External/Internal device self care Has an artificial anus established by an opening into the colon (colostomy) or ileum (ileostomy), and he/she completely cares for the equipment (Also includes individuals who are able to dispose correctly of adult diapers).
Incontinent >= weekly Frequent incontinence accidents occurring weekly or more.
Ostomy Has equipment used for bowel functions and another person cares for the equipment.
Bladder Function
The physiological process of elimination of urine.
  Continent Voluntarily empties his or her bladder.
InContinent < weekly Involuntary emptying or loss of urine less than weekly (e.g., Every other week).
External/Internal/Ostomy Device - Self Care Completely cares for urinary devices (changes the catheter or external device, irrigates as needed, empties and replaces the receptacle) and the skin surrounding the ostomy (Also includes individuals who are able to dispose correctly of adult diapers).
Incontinent >= weekly Frequent incontinence accidents occurring weekly or more.
External/Internal/Ostomy Device - NOT Self-Care Individual has a urosheath or condom with a receptacle attached to collect urine. Another person cares for the individual's external device.
Eating
The process of getting food/fluid by any means into the body. This activity includes cutting food, transferring food from a plate or bowl into the individual's mouth, opening a carton and pouring liquids, and holding a glass to drink. This activity is the process of eating food after it is placed in front of the individual.
  Does Not Need Help Makes food, eats independently, cleans up, etc. without assistance or specialized tools.
Mechanical Help Only Regularly utilizes equipment or device (hand splints, adapted utensils, and/or nonskid plates).
Human Help Only Feeds self, but needs verbal cues, and/or prompting to initiate, in order to complete the eating process. Needs assistance to bring food to the mouth, cut meat, etc.
Mechanical and Human Help Requires both Mechanical and Human Help.
Performed By Others Spoon fed - Does not bring any food to his/her mouth and is fed completely by others. Fed by syringe or tube - Fed a prescribed liquid diet via a feeding syringe, NG-tube (tube from the nose to the stomach) or G-tube (opening into the stomach). Fed by I.V. - Fed a prescribed sterile solution intravenously.
Behavior
Behavior Pattern is the manner of conducting oneself within one's environment and the community. When answering this question, consider if modifications to environment/schedule which have been put into place to limit behaviors were removed what would that behavior be. (i.e. Individual is not disruptive in church because family stopped going to/taking individual to church = Disruptive).
  Appropriate Behavior is stable and fitting for all different environments.
Wandering/Passive < Weekly Wanders off or becomes passive, but not enough to present an issue with managing behavior.
Wandering/Passive Weekly or More Wanders and becomes passive enough that maintaining safety and behavior is a challenge to manage.
Disruptive/Aggressive/Abusive >= Weekly Behavior is manifested by acts detrimental to the life, comfort, safety, and/or property of the individual and/or others.
Semi-Conscious or Comatose (unconscious) state Behavior is undetermined due to comatose state.
Orientation
Orientation is an individual's awareness within his or her environment in relation to time, place and person.
  Oriented Aware of Person, Place, and Time all of the time.
Disoriented Some Spheres Some Times Unaware of 1-2 spheres (Person, Place, Time) occasionally.
Disoriented Some Spheres All Times Unaware of 1-2 spheres (Person, Place, Time) at all times.
Disoriented All Spheres Some Times Unaware of 3 spheres (Person, Place, and Time) occasionally.
Disoriented All Spheres All Times Unaware of 3 spheres (Person, Place, and Time) at all times.
Comatose Orientation is undetermined due to comatose state.
Joint Motion
  This is the individual’s ability to move his or her fingers, arms, and legs (active range of movement (ROM)) or, if applicable, the ability of someone else to move the individual’s fingers, arms, and legs (passive ROM).
With In Normal Limits Can move joints freely with no resistance or pain.
Limited Motion Can move joints but with partial resistance and/or pain.
Instability Corrected Can move joints freely with no resistance or pain after being corrected by surgery or use of an appliance.
Instability Uncorrected Cannot move joints freely without resistance and/or pain.
Immobile .Cannot move joints freely at all.
Mobility
  The extent of the individual's movement outside his or her usual living quarters. Evaluate the individual's ability to walk steadily and his or her level of endurance.
Does Not Need Help - Goes Outside Independently Able to walk outside of home without assistance whenever desired.
Goes Outside - Mechanical Help Only Regularly utilizes equipment of device (splint, special shoes, leg braces, crutches, walkers, wheelchairs, etc.).
Goes Outside - Human Help Only Supervision (Verbal Cues, Prompting) - for safety, initiation, or completion and/or physical assistance (Set up, Hands-On Care).
Goes Outside - Mechanical and Human Help Requires both Mechanical and Human Help.
Confined - Moves About Able to walk out of room/around home whenever desired, but unable to leave home.
Confined - Does Not Move About Typically does not leave room.
Medication Administration
Medication Administration refers to the person(s) who administers medications or, if the individual is being referred elsewhere, the person(s) who will administer medications following referral.
  W/O Assistance/No Medications Is able to administer and monitor medication without assistance.
Administered/Monitored by Non-Professional Is unable to administer or monitor medication by self, needs help of another person.
Administered/Monitored by Professional Nursing Staffs Is unable to administer and monitor medication by self, needs help of trained health professional.
Do you have any of the following Medical Nursing Needs?
Routine care of colostomy or ileostomy, or management of neurogenic bowel and bladder.
Use of physical (e.g., side rails, poseys) or chemical restraints.
Routine skin care to prevent pressure ulcers for individuals who are immobile.
Care of small uncomplicated pressure ulcers and local skin rashes.
Management of those with sensory, metabolic, or circulatory impairment with demonstrated clinical evidence of medical instability.
Administration of oxygen.
Application of aseptic dressings.
Routine catheter care.
Respiratory therapy.
Therapeutic exercise and positioning (ROM exercises).
Chemotherapy and/or radiation.
Dialysis.
Suctioning.
Tracheostomy care.
Supervision for adequate nutrition and hydration for individuals who show clinical evidence of malnourishment or dehydration or have a recent history of weight loss or inadequate hydration which, if not supervised, would be expected to result in malnourishment or dehydration.
Individual's medical condition requires observation and assessment to assure evaluation of the person's need for modification of treatment or additional medical procedures to prevent destabilization, and the person has demonstrated an inability to self-observe or evaluate the need to contact skilled medical professionals.
Due to the complexity created by the person's multiple, interrelated medical conditions, the potential for the individual's medical instability is high or medical instability exists.
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