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APPENDIX N
CMI 3-17-2009
1. Introduction
1.A. Consumer Identification
1. DATE of Care Management Interview (CMI)
______/______/____________
2. Consumer's LAST Name
3. Consumer's FIRST Name
4. Consumer's NICKNAME or Alias, if used
5. Consumer's MIDDLE Initial
6. Consumer's Name SUFFIX
7. Consumer's GENDER
Male
Female
8. Consumer's ETHNICITY
Hispanic or Latino
Not Hispanic or Latino
Unknown
9. Consumer's RACE
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
Non-Minority (White, Non-Hispanic)
White-Hispanic
Other-Document in Notes
Unknown/Unavailable
10. Consumer's SOCIAL SECURITY NUMBER (SSN)
_________-_________-____________
11. Consumer's MEDICAID NUMBER (if applicable)
1.B. Consumer Demographics
1. Consumer's DATE OF BIRTH (DOB)
______/______/____________
2. TYPE of Residence in which the Consumer currently
resides
Apartment
Assisted Living (AL)
CLA/CRR
Domiciliary Care Home
ICF\MR
Mobile Home
Nursing Home (NH)
Own Home
Personal Care Home (PCH)
Service Supported Housing
Subsidized Housing
Other-Document Details in Notes
Unavailable
2. Consumer's LIVING ARRANGEMENT (Include in the
"Lives Alone" category, Consumers who live in AL, Dom
Care, and PCH, pay rent, and have no roommate.)
Lives Alone
Lives with Spouse only
Lives with child(ren) but not Spouse
Lives with other family member(s)
Other-Document Details in Notes
Don't Know
3. Consumer's MARITAL STATUS
Divorced
Legally Separated
Married
Single
Widowed
Other-Document Details in Notes
Unavailable
4. Consumer REFERRED by:
AAA
Family
Home Health Agency
Hospital
Nursing Home/Rehab Facility
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4. Consumer REFERRED by:
Physician
Self
Social Services Agency
Other-Document in Notes
Unavailable
5. Is Consumer a VETERAN?
Yes
No
6. Type of COMMUNICATION ASSISTANCE required
Language
Language and Mechanical
Mechanical
No assistance
Unknown or Unable to Communicate-Document in Notes
7. Consumer's Primary LANGUAGE
American Sign Language
Arabic
Armenian
Cantonese
Chinese/Other
English
Farsi (Persian)
Filipino (Tagalog)
French
German
Greek
Haitian Creole
Hebrew
Italian
Japanese
Korean
Lithuanian
Mandarin
Mein
Polish
Portuguese
Romanian
Russian
Serbian-Cyrillic
Spanish
Thai
Turkish
Vietnamese
Other-Document in Notes
1.C. Address Information
1. Consumer's RESIDENTIAL Street Address (include
number of house, apartment, or room)
2. Consumer's RESIDENTIAL Municipality Consumer's
RESIDENTIAL Municipality (This is usually a Township or
Boro, and where Consumer Votes, Pays Taxes.)
3. Consumer's RESIDENTIAL County
4. Consumer's RESIDENTIAL State
5. Consumer's POSTAL Address Street or PO Box
6. Consumer's POST OFFICE Location-City or Town
7. Consumer's POSTAL State
8. Consumer's POSTAL Zip Code
9. DIRECTIONS to Consumer's Home
10. Consumer's Primary TELEPHONE Number.
11. What was the outcome when Consumer was offered
a VOTER REGISTRATION Form?
Consumer will submit completed voter registration.
AAA will submit completed voter registration.
Consumer declined-already registered
Consumer declined application
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1.D. Care Management Information
1. PSA number for this assessment:
2. Where was Consumer interviewed?
Domiciliary Care Home
Home
Home of Relative or Caregiver
Hospital
Mental Health Establishment
Nursing Home (NH)
Office
Personal Care Home (PCH)
State Mental Retardation Center
Other-Document in Notes
3. Does the Consumer have a Legal Guardian or Durable
Power of Attorney ?
Guardian, Document Name in Notes
Durable Power of Attorney (POA), Document Name in
Notes
4. Did the Consumer have a representative present and
participating during the completion of the CMI?
Yes, Document Name(s) in Notes
No
1.E. Consumer Contacts
1. EMERGENCY CONTACT: Name of Friend/Relative
2. RELATIONSHIP of Emergency Contact
3. ADDRESS of Emergency Contact
4. Primary TELEPHONE Number of Emergency Contact
5. Alternate TELEPHONE Number of Emergency Contact
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2. Physical Health
2.A. Physician Contacts
1. Does the Consumer have a PRIMARY CARE
PHYSICIAN?
Yes
No
2. Primary Care Physician's NAME
3. Primary Care Physician's Work TELEPHONE Number
4. Primary Care Physician's ADDRESS (Optional)
5. Secondary Care (Specialist) Physician's NAME
6. Secondary Care Physician's Work TELEPHONE
Number
7. Tertiary Care Physician's NAME
8. Tertiary Care Physician's Work TELEPHONE Number
9. HOW OFTEN does the Consumer usually see the
Primary Care Physician?
10. REASON for Last Visit
11. DATE of Last Physician Visit (approximate): If
unsure, document known information in Notes.
______/______/____________
2.B. Use of Alternative Care
1. Does Consumer use an alternative medical care
practitioner(s)? (e.g., acupuncturist, chiropractor,
herbalist, masseur, etc.)
Yes-Document Name in Notes
No
2. Type of Alternative Care Practitioner
3. Address of Alternative Care Practitioner
4. Telephone Number of Alternative Care Practitioner
5. Name of Second Alternative Care Practitioner
6. Type of Secondary Alternative Care Practitioner
7. Address of Secondary Alternative Care Practitioner
8. Telephone Number of Secondary Alternative Care
Practitioner
2.C. Use of Medical Services
1. Has the Consumer received treatment as a patient
(emergency room or admitted) in a hospital in the past
12 months?
Yes
No
2. In past year, how many times has the Consumer
stayed overnight in hospital? Document in the Notes the
Dates of each hospital admission.
3. Why was the Consumer hospitalized in the past 12
months? Use Notes if more space is needed.
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3. Why was the Consumer hospitalized in the past 12
months? Use Notes if more space is needed.
4. Has the Consumer resided in a nursing facility in the
past 12 months (does not include respite)?
Yes
No
5. In the past 12 months, how many days was the
Consumer a resident in a nursing facility (does not
include respite)?
6. Why did the Consumer stay in a nursing facility in the
past 12 months? Use Notes if more space is needed (does
not include respite).
2.D. Illness and Conditions, Eye, Ear, Nose, Throat and
Mouth
1. EYES: Glaucoma/Cataracts/Macular Degeneration or
other eye problems. List diagnosis/condition, symptoms,
and medical need(s) created by Dx, complications,
severity, effects on function, problems, treatments, and
who provides, etc. in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
2. VISION QUALITY: (with glasses or contacts, if they
are regularly used). Document in Notes.
0 - Good
1 - Fair
2 - Poor
3 - Blind
4 - Aid
3. HEARING ABILITY: (with a hearing appliance, if
used). Document in Notes.
0 - Good
1 - Fair
2 - Poor
3 - Deaf
4 - Uses hearing aid
4. HEARING PROBLEMS: not corrected with
aids/devices? Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
5. NOSE CONDITIONS: deviated septum, polyps, nose
bleeds? Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
6. THROAT: Any problems Swallowing? Frequent sore
throats? Cancer? Laryngectomy? List
diagnosis/condition, symptoms, and medical need(s)
created by Dx, complications, severity, effects on
function, problems, treatments, and who provides, etc. in
Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present being treated
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
7. SPEECH QUALITY: List diagnosis/condition,
symptoms, and medical need(s) created by Dx,
complications, severity, effects on function, problems,
treatments, and who provides, etc. in Notes.
0 - Good
1 - Fair
2 - Poor
3 - Aphasic
8. MOUTH CONDITIONS: List diagnosis/condition,
symptoms, and medical need(s) created by Dx,
complications, severity, effects on function, problems,
treatments, and who provides, etc. in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
9. DENTITION: List diagnosis/condition, symptoms,
and medical need(s) created by Dx, complications,
severity, effects on function, problems, treatments, and
who provides, etc. in Notes.
0 - Good
1 - Fair
2 - Poor
3 - Dentures
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2.E. Illnesses and Conditions, Breast, CardioPulmonary, and
other Internal Organs
1. BREAST CONDITIONS: Cysts, lumps/nodules?
Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
2. LUNG/BREATHING PROBLEMS: TB, asthma,
pneumonia, chronic obstructive pulmonary disease
(bronchitis, emphysema), allergies, orthopnea, dyspnea?
Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
3. HEART: Angina, Irregular Heart Rate, Congestive
Heart Failure, High Blood Pressure, Heart Attack .
Document in Notes section.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
4. CIRCULATION PROBLEMS: Leg ulcers, edema
(swelling), varicosities, peripheral vascular disease,
cerebral insufficiency, thrombus, embolus? Document in
Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
5. LYMPH NODES: Enlargement? Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
6. EXTREMITIES: Paralysis, Missing Limbs, Weakness?
Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
7. GASTROINTESTINAL PROBLEMS: Ulcer, bleeding,
colitis, intestinal problems, diverticulosis, jaundice, gall
bladder disease, gastro-esophageal reflux disorder
(GERD)? Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
8. HERNIA: Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
9. PROSTATE PROBLEMS: (Males Only) Document in
Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
10. GYNECOLOGICAL PROBLEMS: (Females Only)
Hysterectomy, disease of uterus/cervix, prolapse of
uterus, ulcers of cervix, or cancer. Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
11. ANORECTAL DISORDERS: Hemorrhoids, prolapse,
fistulas, fissures, pilonidal, cyst? Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
2.F. Illnesses and Conditions, General
1. MUSCULOSKELETAL: Effect of fractures,
osteoporosis, osteoarthritis, rheumatoid arthritis,
contractures? Document in Notes section.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
2. CONDITION OF FEET: Document in Notes.
1 - Good
2 - Fair
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2. CONDITION OF FEET: Document in Notes.
3 - Poor
3. SKIN CONDITIONS: Dry, fragile, rashes, Psoriasis,
open areas, excoriated areas, decubiti (pressure sores,
bed sores), burns, bruises? Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
4. NERVOUS SYSTEM or OTHER RELATED CONDITIONS
(ORC): Effects of a stroke, Parkinson's disease, cerebal
palsy, muscular dystrophy, multiple sclerosis, polio
history, seizures, epilepsy, or transient ischemic attacks?
Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
5. BLOOD DISEASES: Anemia, leukemia? Document in
Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
6. ENDOCRINE (GLANDULAR) DISORDERS: Diabetes,
thyroid, spleen, pancreas, liver, metabolic disorders?
Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
7. KIDNEY/URINARY TRACT PROBLEMS: Urinary
retention, infection, kidney failure? Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
8. CANCER, TUMORS, LEUKEMIA, LYMPHOMA,
HODGKIN'S: Document in Notes.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
2.G. Communicable Diseases, Disabilities and Surgeries
1. COMMUNICABLE DISEASES: Document in Notes
section.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
2. OTHER DISABILITIES OR HEALTH PROBLEMS:
Specify and document in Notes section.
1 - Not present-No diagnosis by skilled medical
professional
2 - Present-Diagnosis and regular plan of care by a skilled
medical professional
3 - Consumer reported-Not treated by a reg plan of care
by skilled med professional
3. RECENT OUTPATIENT SURGERIES:
1 - None
2 - Yes, still being treated
3 - Yes, no longer being treated
4. Document any recent outpatient surgeries.
5. PHYSICAL HEALTH score: Only required for
Consumers being served in the community.
Good physical health
Mildly impaired
Moderately impaired
Severely impaired
2.H. Cognitive and Mental Health Conditions
1. PSYCHIATRIC DISORDERS: Personality disorder,
schizophrenia, anxiety, depression, mood swings, etc?
Document in Notes section.
Not present-No diagnosis by skilled medical professional
Present-Diagnosis and regular plan of care by a skilled
medical professional
Consumer reported-Not treated by a reg plan of care by
skilled med professional
2. DEMENTIA: Alzheimer's Disease, multi-infarct?
Document in Notes section.
Not present-No diagnosis by skilled medical professional
Present-Diagnosis and regular plan of care by a skilled
medical professional
Consumer reported-Not treated by a reg plan of care by
skilled med professional
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3. TRAUMATIC BRAIN INJURY (TBI): Does the
Consumer have a traumatic brain injury sustained
between birth to 22nd birthday? Document in Notes
section.
Not Present-No diagnosis by skilled medical professional
Present-Diagnosis and regular plan of care by a skilled
medical professional
Consumer Reported-not treated by a reg plan of care by
skilled med professional
4. MENTAL RETARDATION: Does the Consumer have a
diagnosis of mental retardation or is s/he known to the
Mental Retardation System? Document in the Notes
section.
Not Present-No diagnosis by a skilled medical professional
Present-Diagnosis and regular plan of care by a skilled
meical professional
Consumer Reported-not treated by reg plan of care by
skilled med professional
5. AUTISM: Does the Consumer have a diagnosis of
Autism? Document in Notes section.
Not Present_No diagnosis by skilled medical professional
Present-Diagnosis and regular plan of care by a skilled
medical professional
Consumer Reported-not treated by reg plan of care by
skilled med professional
6. IRREVERSIBLE CONDITIONS: If cognitively
impaired, has Consumer been medically evaluted to rule
out reversible conditions? If Yes, explain results in Notes
section.
Yes
No
Unknown
7. NEED FOR SUPERVISION: Taking into account
physical health, mental impairment, and behavior, how
long can the Consumer routinely be left alone at home
safely?
Indefinitely.
Entire day and overnight.
Eight hours or more - day or night
Eight hours or more - daytime only
A few hours
Cannot be left alone
2.I. Alcohol, Tobacco, and Drug Use
1. SUBSTANCE USE: Alcohol
Yes - indicate how much daily in Notes
No
2. SUBSTANCE USE: Tobacco
Yes - indicate how much daily in Notes
No
3. SUBSTANCE USE: Drugs.
Yes - indicate type of drugs used and the amount used
daily in Notes
No
4. Treatment/therapy for alcohol/drug abuse:
Document in Notes section.
Not Applicable
Yes-Completed
Yes-Ongoing (Indicate schedule and status in Notes.)
Consumer is not participating/not following treatment
protocol.
2.J. Current Medications
1. Prescribed medications taken now or after discharge
from hospital/other facility.
a. Name and Dose: Record the name of the medication and dose ordered.
b. Form: Code the route of administration using the following list:
1 = by mounth (PO) 7 = topical
2 = sub lingual (SL) 8 = inhalation
3 = intramuscular (IM) 9 = enteral tube
4 = intravenous (IV) 10 = other
5 = subcutaneous (SQ) 11 = eye drop
6 = rectal (R) 12 = transdermal
d. Frequency: Code the number of times per period the med is administered
using the following list:
PR = (PRN) as necessary OO = every other day
1H = (QH) every hour 1W = (Q week) once each week
2H = (Q2H) every 2 hours 2W = 2 times every week
3H = (Q3H) every 3 hours 3W = 3 times every week
4H = (Q4H) every 4 hours 4W = 4 times each week
6H = (Q6H) every 6 hours 5W = 5 times each week
8H = (Q8H) every eight hours 6W = 6 times each week
1D = (QD or HS) once daily 1M = (Q month) once/mo.
2D = (BID) two times daily 2M = twice every month
(includes every 12 hours) C = Continuous
3D = (TID) 3 times daily O = Other
4D = (QID) four times daily
5D = 5 times daily
a. Name and Dose b. Form c. No. Taken d. Freq e. Comments
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2. Over the Counter Medications taken now or after
discharge from hospital/other facility.
a. Name and Dose: Record the name of the medication and dose ordered.
b. Form: Code the route of administration using the following list:
1 = by mounth (PO) 7 = topical
2 = sub lingual (SL) 8 = inhalation
3 = intramuscular (IM) 9 = enteral tube
4 = intravenous (IV) 10 = other
5 = subcutaneous (SQ) 11 = eye drop
6 = rectal (R) 12 = transdermal
d. Frequency: Code the number of times per period the med is administered
using the following list:
PR = (PRN) as necessary OO = every other day
1H = (QH) every hour 1W = (Q week) once each week
2H = (Q2H) every 2 hours 2W = 2 times every week
3H = (Q3H) every 3 hours 3W = 3 times every week
4H = (Q4H) every 4 hours 4W = 4 times each week
6H = (Q6H) every 6 hours 5W = 5 times each week
8H = (Q8H) every eight hours 6W = 6 times each week
1D = (QD or HS) once daily 1M = (Q month) once/mo.
2D = (BID) two times daily 2M = twice every month
(includes every 12 hours) C = Continuous
3D = (TID) 3 times daily O = Other
4D = (QID) four times daily
5D = 5 times daily
a. Name and Dose b. Form c. No. Taken d. Freq e. Comments
3. Date of most recent medication review by doctor? If
exact date unknown document known information in
Notes.
______/______/____________
4. MANAGING MEDICATIONS: Requires assistance in
managing medications?
1 - Independent, does on own
2 - Assistance needed.
3 - Unknown
5. Type of help needed with medications: Check all that
apply. If other assistance required, document in Notes.
None
Administration
Information
Setup
Regular monitoring of effects
Verbal reminders
6. Name and relationship of Person(s) who assists
Consumer with taking medications. If additional space
needed, use Notes.
7. Does the Consumer report drug allergy?
Yes
No
8. If drug allergy, specify medication(s) and type of
reaction.
2.K. Use of Herbs and Other Remedies
1. Uses herbs or other remedies to maintain/improve
health?
Yes
No
2. Document herbs and/or other remedies used, why
they are used and their effects. Document additional
narrative in the Notes section.
3. Who recommended herbs and/or other remedies?
Document in the Notes section.
Self
Other-List in Notes.
2.L. Pharmacy
1. Name of pharmacy?
2. Address of pharmacy?
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2. Address of pharmacy?
3. Telephone number of pharmacy?
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3. Activities of Daily Living
3.A. ADL's
1. BATHING: Rate the Consumer's ability. If response
is 2-5, document in Notes additional help needed,
comments or other relevant information.
1 - Independent, performs safely without assistance.
2 - Uses assistive device, takes long time, or does with
great difficulty.
3 - Does with some help, supervision, set-up, cueing or
coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
2. DRESSING: Rate the Consumer's ability. If
response is 2-5, document in Notes any additional help
needed, comments or other relevant information.
1 - Independent, performs safely without assistance.
2 - Uses assistive device, takes long time, or does with
great difficulty.
3 - Does with some help, supervision, set-up, cueing or
coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
3. GROOMING: Rate the Consumer's ability. If
response is 2-5, document in Notes any additional help
needed, comments or relevant information.
1 - Independent, performs safely without assistance.
2 - Uses assistive device, takes long time, or does with
great difficulty.
3 - Does with supervision, set-up, cueing, or coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
4. EATING: Rate the Consumer's ability. If response is
2-5, document in Notes any additional help needed,
comments or relevant information.
1 - Independent, performs safely without assistance.
2 - Uses assistive device, takes long time, or does with
great difficulty.
3 - Does with supervision, set-up, cueing or coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
5. TRANSFER: Rate the Consumer's ability. If
response is 2-5, document in Notes any additional help
needed, comments or relevant information.
1 - Independent, performs safely without assistance.
2 - Uses special equipment, assistive devices, takes long
time, or great difficulty
3 - Does with supervision, set-up, cueing or coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
6. TOILETING: Rate the Consumer's ability. If
response is 2-5, document in Notes any additional help
needed, comments, or relevant information.
1 - Independent, performs safely without assistance.
2 - Uses assistive device, takes long time, or does with
great difficulty.
3 - Does with supervision, set-up, cueing or coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
7. BLADDER MANAGEMENT: Rate the Consumer's
ability. If response is 2-5, document in Notes any
additional help needed, comments, or relevant
information.
1 - Independent. No accidents or infrequent accidents.
2 - Self care of devices or ostomy/no accidents.
3 - Does with supervision, set-up, cueing or coaxing/assist
with equipment.
4 - Does with hands on help and/or accidents less than
daily.
5 - Does with maximum help and/or daily accidents
8. BOWEL MANAGEMENT: Rate the Consumer's ability.
If response is 2-5, document in Notes any additional help
needed, comments, or relevant information.
1 - Independent. No accidents or infrequent accidents.
2 - Self care of devices or ostomy/no accidents
3 - Does with supervision, set-up, cueing or coaxing/assist
with equipment.
4 - Does with hands-on help and/or accidents less than
daily.
5 - Does with maximum help and/or daily accidents
9. Comments/additional relevant information on ADL's.
11. ADL score.
Excellent ADL capacity
Good ADL capacity
Moderately impaired ADL capacity
Severely impaired ADL capacity
Completely impaired ADL capacity
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4. Mobility
4.A. Mobility
1. WALK INDOORS: If coded 2-5, document in Notes
how Consumer currently manages, any additional help
needed, comments, or relevant information.
1 - Independent, performs safely without assistance.
2 - Uses assistive device, takes long time, or does with
great difficulty.
3 - Does with supervision, set-up, cueing or coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
2. BEDBOUND: Is Consumer bedbound and
non-ambulatory? Document in Notes any help needed,
comments or relevant information.
Yes
No
3. WALK OUTDOORS: If coded 2-5, document in Notes
how the Consumer currently manages, any additional
help needed, comments or additonal relevant
information.
1 - Independent. Performs safely without assistance.
2 - Uses assistive device, takes long time, or does with
great difficulty.
3 - Does with supervision, set-up, or coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
4. CLIMB STAIRS: If coded 2-5, document in the Notes
how Consumer currently manages, any additional help
needed, comments, or relevant information
1 - Independent. Performs safely without assistance.
2 - Uses assistive device, takes long time, or does with
great difficulty.
3 - Does with supervision, set-up, cueing or coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
5. WHEEL IN CHAIR: If coded 2-5 document in Notes
how Consumer currently manages, any additional help
needed, comments, or other relevant informtion.
1 - Independent. Performs safely without assistance.
2 - Uses assistive device, takes long time, or does with
great difficulty.
3 - Does with supervision, set-up, cueing or coaxing only.
4 - Does with hands-on help.
5 - Does with maximum help or does not do at all. Helper
does more than half.
6 - Not Applicable, does not use wheelchair.
6. AT RISK OF FALLING: If yes, document in Notes the
risk factor and any additional help needed, comments, or
relevant information.
Yes
No
7. FALLEN RECENTLY: If Yes, document circumstances
in Notes. document in Notes any additional comments or
relevant information.
Yes
No
8. Enter any additional comments regarding mobility.
9. MOBILITY score.
Independent
Assistive device and/or with difficulty
With difficulty/requires supervision
Hands-on assistance
Maximum assistance
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5. Instrumental Activities of Daily Living
5.A. IADL's
1. MEAL PREPARATION: If rated 2-4 document in
Notes how Consumer currently manages and any
additional help needed.
1 - Independent.
2 - Independent but with great difficulty or with
mechanical help.
3 - With the assistance of a helper.
4 - Unable/helper does.
2. DOING HOUSEWORK: If rated 2-4 document in
Notes how Consumer currently manages and any
additional help needed.
1 - Independent
2 - Independent but with great difficulty or with
mechanical help.
3 - With the assistance of a helper.
4 - Unable/helper does.
3. DOING LAUNDRY. If rated 2-4 document in Notes
how Consumer currently manages and any additional help
needed.
1 - Independent.
2 - Independent but with great difficulty or with
mechanical help.
3 - With the assistance of a helper.
4 - Unable/helper does.
4. SHOPPING: If rated 2-4 document in Notes how
Consumer currently manages and any additional help
needed.
1 - Independent.
2 - Independent but with great difficulty or with
mechanical help.
3 - With the assistance of a helper.
4 - Unable/helper does.
5. USING TRANSPORTATION: If rated 2-4 document in
Notes how Consumer currently manages and any
additional help needed.
1 - Independent.
2 - Independent but with great difficulty or with
mechanical help.
3 - With the assistance of a helper.
4 - Unable/helper does.
6. MANAGING MONEY: If rated 2-4 document in Notes
how Consumer currently manages and any additional help
needed.
1 - Independent
2 - Independent but with great difficulty or with
mechanical help.
3 - With the assistance of a helper.
4 - Unable/helper does.
7. USING TELEPHONE: If rated 2-4 document in Notes
how Consumer currently manages and any additional help
needed.
1 - Independent
2 - Independent but with great difficulty or with
mechanical help
3 - With the assistance of a helper
4 - Unable/helper does
8. HOME MAINTENANCE (chores and repairs): If rated
2-4 document in Notes how Consumer currently manages
and any additional help needed.
1 - Independent
2 - Independent but with great difficulty or with
mechanical help.
3 - With the assistance of a helper
4 - Unable/helper does.
9. Enter any additional comments regarding IADLs.
11. IADL score.
Excellent IADL Capability
Good IADL capacity
Moderately impaired IADL capacity
Severely impaired IADL capacity
Completely impaired IADL capacity
CMI 3-17-2009
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6. Nutrition
6.A. Dietary Habits
1. Generally has good appetite? Specify in Notes if
problematic.
Yes
No
2. Document typical breakfast. (Optional)
3. Document typical lunch. (Optional)
4. Document typical dinner. (Optional)
5. Foods not eaten due to religious practices/cultural
norms? If Yes, document in Notes.
Yes
No
6. Uses dietary supplements or aids?
Yes-List what and why in Notes.
No
7. Any food allergies? If so, document reaction in
Notes.
Yes
No
8. Special diet for medical reasons? Document diet in
Notes.
Yes
No
9. Ability to follow special diet. Document in Notes any
problems following diet.
Not applicable
Partial adherence
Full adherence
Ordered, not followed
10. Height in inches?
11. Weight in pounds?
12. Comments/concerns regarding the Consumer's
nutritional status.
6.B. Nutritional Risk Assessment
1. Changes in lifelong eating habits because of health
problems?
Yes
No
2. Eats fewer than 2 meals per day?
Yes
No
3. Eats fewer than two servings of dairy products (such
as milk, yogurt, or cheese) every day?
Yes
No
4. Eats fewer than five (5) servings (1/2 cup each) of
fruits or vegetables every day?
Yes
No
5. Has 3+ drinks of beer, liquor or wine almost every
day?
Yes
No
6. Trouble eating well due to problems with
chewing/swallowing?
Yes
No
7. Sometimes does not have enough money to buy
food?
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7. Sometimes does not have enough money to buy
food?
Yes
No
8. Eats alone most of the time?
Yes
No
9. Takes 3+ different prescribed or OTC drugs per day?
Yes
No
10. Without wanting to, lost or gained 10 pounds in the
past 6 months?
Gained 10+ pounds
Lost 10+ pounds
No
11. How many pounds lost or gained in past 6 months?
12. Reason for weight change in past 6 months?
13. Not always physically able to shop, cook and/or feed
themselves (or to get someone to do it for them)?
Yes
No
CMI 3-17-2009
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7. Cognitive Functioning
7.A. Consumer Cognitive
1. Consumer presents as alert and without cognitive
impairment? Document in Notes.
0 - No apparent problem
1 - Sometimes a problem
2 - Often a problem
2. Consumer's ability to judge safety? Document in
Notes.
0 - No apparent problem
1 - Sometimes a problem
2 - Often a problem
3. Consumer understands consequences of decisons?
Document in Notes.
0 - No apparent problem
1 - Sometimes a problem
2 - Often a problem
4. Information sources for Consumer's cognitive status?
Consumer
Family
Case record/medical record
Provider
Observation
Other-Describe Details in Notes.
7.B. Short Portable Mental Status Questionnaire - Consumer
1. Consumer knows TODAY'S DATE?
0 - Correct answer
1 - Incorrect or not answered
2. Consumer knows DAY OF THE WEEK?
0 - Correct answer
1 - Incorrect or not answered
3. Consumer knows LOCATION?
0 - Correct answer
1 - Incorrect or not answered
4. Consumer knows TELEPHONE NUMBER (street
address if no phone)?
0 - Correct answer
1 - Incorrect or not answered
5. Consumer knows AGE?
0 - Correct answer
1 - Incorrect or not answered
6. Consumer knows DATE OF BIRTH?
0 - Correct answer
1 - Incorrect or not answered
7. Consumer knows CURRENT PRESIDENT?
0 - Correct answer
1 - Incorrect or not answered
8. Consumer knows PREVIOUS PRESIDENT?
0 - Correct answer
1 - Incorrect or not answered
9. Consumer knows MOTHER'S MAIDEN NAME?
0 - Correct answer
1 - Incorrect or not answered
10. SUBTRACTION TEST: Substract 3 from 20 etc.
17
14
11
8
5
2
7.C. SPMSQ Results
1. Consumer Subtraction Test result?
0 - Correct
1 - Incorrect or Not Answered
2. Highest grade Consumer completed in school? If
unknown, enter 0 and a note describing why it is
unknown.
4. COGNITIVE FUNCTIONING Score: Only required for
Consumers being served in the community.
Intact cognitive functioning
Substantially intact cognitive functioning
Some personal supervision needed
Frequent/regular personal supervision
Constant supervision required
CMI 3-17-2009
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8. Emotional Status & Behavior
8.A. Section 1- Emotional Status
1. Are you able to assess emotional status and
behavior?
Yes
No
2. List any behaviors Consumer is experiencing that are
affecting their physical and emotional well-being.
Document in Notes the behavior and how it/they are
managed.
Worried and/or anxious
Irritable and/or easily upset
Feels lonely
Becomes withdrawn and/or lethargic
Physically and/or verbally aggressive
Fearful and/or suspicious
Feels depressed, very sad or hopeless
Experiencing hallucinations and/or delusions
Has/had suicidal behavior
Gets lost or wanders
Experiences sleep disturbances
Exhibits other unusual behavior
3. Name and relationship of person(s) Consumer goes
to for advice and counsel. If additional space needed,
Document in Notes.
4. Information sources for emotional/behavioral status:
Consumer
Family
Record
Provider
Observation
Other
5. EMOTIONAL BEHAVIOR Score: Only required for
Consumers being served in the community.
Above average emotional functioning
Average emotional functioning
Moderate emotional impairment (alleged or apparent)
Serious emotional impairment (alleged or apparent)
Severe emotional impairment (alleged or apparent)
CMI 3-17-2009
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9. Social Participation
9.A. Basic Questions
1. Is Consumer satisfied with his/her current level of
socialization? If no, explain in the Notes.
Yes
No
2. Enter any additional comments regarding social
participation. Include names and phone numbers of
social supports such as clergy, neighbors, friends and
relatives.
CMI 3-17-2009
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10. Informal Supports
10.A. Primary Helper/Caregiver Section
1. Does Consumer have an identified Primary (informal)
HELPER/Caregiver who provides care on regular basis?
Yes
No
2. Primary HELPER'S Last Name
3. Primary HELPER'S First Name
4. Primary HELPER'S Address
5. Primary HELPER'S Telephone Number
6. Relationship of Primary HELPER to Consumer
Child or child in-law
Friend or neighbor
Spouse
Other-Document Details in Notes
7. Primary HELPER'S Age
8. What type of help does the Consumer's Primary
Unpaid HELPER/Caregiver provide?
ADL assistance
Environmental support
Financial help
Health care
IADL assistance
Medical care
Psychosocial support
Other-Document Details in Notes
10.B. Caregiver Information (MANDATORY for FCSP)
1. CAREGIVER'S First Name
2. CAREGIVER'S Last Name
3. CAREGIVER'S Date of Birth
______/______/____________
4. CAREGIVER'S Social Security Number (SSN)
_________-_________-____________
5. CAREGIVER'S Race/Ethnicity
American Indian/Native Alaskan
Asian
Black/African American
Native Hawaiian/Other Pacific Islander
Hispanic Origin (White)
Missing
Non-Minority (White, Non-Hispanic)
Other-Document in Notes
6. CAREGIVER'S Street Mailing Address of Post Office
Box
7. CAREGIVER'S Postal Location - City/Town
8. CAREGIVER'S State of Residence
9. CAREGIVER'S Zip Code
10. CAREGIVER'S Primary or Preferred Telephone
Number
11. Alternate or Secondary Telephone Number of
CAREGIVER
CMI 3-17-2009
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10.C. Status of Primary Caregiver
1. Factors that might limit the Primary CAREGIVER
Alcohol/drug abuse
Dependent on consumer for housing, money or other
Employed
Financial strain
Lacks knowledge or skills
Lives at a distance
No particular constraints
Not reliable
Poor health, disabled, frail
Poor relationship with consumer
Providing care to others
2. What is the CAREGIVER'S employment status?
Full-time
Fully Retired
Homemaker
Other
Part-time
Retired, works part-time
Unemployed
3. How has your caregiving and social life and/or
employment affected each other?
4. Primary CAREGIVER'S other caregiving
responsibilities? (Children, other adults, etc.)
5. Hours a day Primary CAREGIVER is available to
provide care to Consumer?
6. Hours a day Primary CAREGIVER cares for
Consumer?
7. Document problems with continued caregiving (if
any).
8. Overall, how stressed does the CAREGIVER feel in
caring for the Consumer?
Not stressed
Somewhat stressed
Very stressed
9. Does the Primary CAREGIVER desire service or
support? If yes, document in the Notes what is desired.
Yes
No
10.D. Primary Caregiver Status Continued
1. Respite (relief) available for CAREGIVER when s/he
is unable to provide care?
Yes
No
2. Is respite to Primary CAREGIVER available on short
notice?
Yes
No
3. Significant changes in the CAREGIVER's life in the
last six (6) months?
Yes
No
4. Is CAREGIVER experiencing any emotional concerns
or difficulties?
Yes
No
5. Is CAREGIVER currently receiving assistance to deal
with emotional concerns/difficulties?
Yes
No
6. Does the CAREGIVER participate in support or
discussion group?
Yes, describe group and frequency in Notes.
No
7. Has CAREGIVER been so upset that s/he did
something to Consumer that s/he now regrets? Explain
in Notes.
Yes
No
8. Consumer so upset that s/he did something to the
CAREGIVER s/he regrets? Explain in Notes.
Yes
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8. Consumer so upset that s/he did something to the
CAREGIVER s/he regrets? Explain in Notes.
No
9. Document all CAREGIVER supplies and document
who pays for the supplies.
10. Average monthly cost to family/Consumer for
consumable caregiving supplies purchased for the sole
use of the Consumer?
$
11. Enter any comments regarding the Consumer's
CAREGIVER.
12. Is Caregiver Stress Interview being completed?
(Mandatory for FCSP)
Yes
No
10.E. Primary Caregiver/Representative Cognitive
1. Caregiver/Representative presents as alert and
without cognitive impairment?
Yes
No
2. Caregiver/Representative's ability to judge safety?
Document in Notes.
No apparent problem
Often a problem
Sometimes a problem
3. Caregiver/Representative understands the
consequences of decisions? Document in Notes.
No apparent problem
Often a problem
Sometimes a problem
10.F. Short Portable Mental Status Questionnaire - Primary
Caregiver/Representative. (Optional)
1. Caregiver/Representative knows TODAY'S DATE?
0 - Correct answer
1 - Incorrect or not answered
2. Caregiver/Representative knows DAY OF THE WEEK?
0 - Correct answer
1 - Incorrect or not answered
3. Caregiver/Representative knows LOCATION?
0 - Correct answer
1 - Incorrect or not answered
4. Caregiver/Representative knows TELEPHONE
NUMBER?
0 - Correct answer
1 - Incorrect or not answered
5. Caregiver/Representative knows AGE?
0 - Correct answer
1 - Incorrect or not answered
6. Caregiver/Representative knows DATE OF BIRTH?
0 - Correct answer
1 - Incorrect or not answered
7. Caregiver/Representative knows CURRENT
PRESIDENT?
0 - Correct answer
1 - Incorrect or not answered
8. Caregiver/Representative knows PREVIOUS
PRESIDENT?
0 - Correct answer
1 - Incorrect or not answered
9. Caregiver/Representative knows MOTHER'S MAIDEN
NAME?
0 - Correct answer
1 - Incorrect or not answered
10. SUBTRACTION TEST: Subract 3 from 20, etc?
17
14
11
8
5
2
10.G. Primary Caregiver/Representative SPMSQ Score.
Only if 10.F is completed.
1. What was the result of the Caregiver/Representative
Subtraction Test?
0 - Correct
1 - Incorrect or not answered
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2. Highest grade Consumer's Primary
Caregiver/Representative completed in school? If
Unknown, enter 0 and a note explaining why.
10.H. Caregiver FNM Scores
1. CAREGIVER/INFORMAL SUPPORT
AVAILABILITY/CAPABILITY SCORE
High degree of caregiver/informal support
Usually sufficient caregiver/informal support
Available but fragile and/or not dependable
Available but inadequate
Informal support only, skip 10.H.2, 3, 4
No caregiver/informal supports, skip 10.H.2, 3, 4
2. CAREGIVER/INFORMAL SUPPORT BURDEN SCORE
Supports meet all ADL/IADL needs
Supports meet most ADL/IADL needs
Supports meet half of ADL/IADL needs, burden does not
create risks
Supports meet half of ADL/IADL needs, burden creates
risks
Supports meet little ADL/IADL needs, burden creates
probable risk
3. CAREGIVER/INFORMAL SUPPORT STRESS SCORE
Not Stressed
Moderately stressed
Severely stressed but no immediate danger of breakdown
Stressed to the point of breakdown
4. CAREGIVER/INFORMAL SUPPORT RESPITE
AVAILABILITY SCORE
Respite is available
Respite is occasionally available
Respite is never/almost never available
CMI 3-17-2009
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11. Protective Service Abuse/Domestic Violence
11.A. Questions related to abuse and violence
1. Does Consumer feel safe in his/her current living
situation?
Yes
No
2. Consumer wants to talk to someone at the domestic
violence program?
Yes
No
3. Consumer wants to talk with a protective service
worker?
Yes
No
4. Consumer afraid to stay in his/her current location?
Yes
No
5. Weapons present in the Consumer's current location?
Yes
No
6. Consumer needs a safe place to stay?
Yes
No
7. Consumer wants help from the police?
Yes
No
8. Referral to protective services? If yes, explain why
in Notes.
Yes
No
CMI 3-17-2009
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12. Caregiver Stress Interview. If no Caregiver, Skip this
section.
12.A. Caregiver Concerns
1. Consumer asks for more help than needs?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
2. Does not have enough time due to caring for
Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
3. Stressed between caring for Consumer and other
responsibilities?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
4. Embarrassed over Consumer's behavior?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
5. Angry when around Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
6. Consumer affects relationship with family/friends
negatively?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
7. Afraid of what future holds for Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
8. Consumer dependent on CAREGIVER?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
12.B. Effect on Caregiver
1. Strained when around Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
2. Health suffered due to involvement with Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
3. Not enough privacy due to caring for Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
4. Social life suffered due to caring for Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
5. Uncomfortable having friends over due to caring for
Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
6. Believes s/he only one the Consumer could depend
on?
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6. Believes s/he only one the Consumer could depend
on?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
12.C. Caregiver Problems - MANDATORY for FCSP,
Recommended for others
1. Not enough money to care for Consumer and other
expenses?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
2. Unable to care for Consumer much longer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
3. Lost control of life since Consumer became ill?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
4. Caregiver doesn't want to care anymore?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
5. Uncertain what to do about Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
6. Should be doing more for Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
7. Could be doing better job caring for Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
8. Burdened caring for Consumer?
0 - Never
1 - Rarely
2 - Sometimes
3 - Frequently
4 - Always
CMI 3-17-2009
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13. Formal Services
13.A. General
1. Is Consumer receiving, has recently received or
scheduled to receive formal services?
YES
NO
Unknown
2. Participating in following services or programs? Note
additional comments.
Adult Day Care
Attendant Care
Case Management
Center Services
Congregate Meals
Counseling
Financial Management
Home Delivered Meals
Home Health Aide
Home Support
Job Counseling/Vocational Rehabilitation
Legal Services
Nursing
Occupational Therapy
Ombudsman
Partial Hospitalization
Personal Assistance Services
Personal Care
Physical Therapy
Respite Care
Speech Therapy
Transportation
Other
3. Formal services Consumer has received in past 6
months. Note problems with providers.
0 - Adult Day Care
1 - Attendant Care
2 - Care Management
3 - Center Services
4 - Congregate Meals
5 - Counseling
6 - Financial Management
7 - Home Delivered Meals
8 - Home Health Aide
9 - Home Support
10 - Job Counseling/Vocational Rehabilitation
11 - Legal Services
12 - Nursing
13 - Occupational Therapy
14 - Ombudsman
15 - Personal Care
16 - Personal Assistance Services
17 - Physical Therapy
18 - Respite Care
19 - Speech Therapy
20 - Transportation
21 - Partial Hospitalization
22 - Other
4. Formal services on order/scheduled to begin? Note
problems with providers.
0 - Adult Day Care
1 - Attendant Care
2 - Care Management
3 - Center Services
4 - Congregate Meals
5 - Counseling
6 - Financial Management
7 - Home Delivered Meals
8 - Home Health Aide
9 - Home Support
10 - Job Counseling/Vocational Rehabilitation
11 - Legal Services
12 - Nursing
13 - Occupational Therapy
14 - Ombudsman
15 - Personal Care
16 - Personal Assistance Services
17 - Physical Therapy
18 - Respite Care
19 - Speech Therapy
20 - Transportation
21 - Partial Hospitalization
22 - Other
5. If in hospital or other facility discharge, are services
scheduled to begin upon discharge? If so, document in
the Notes.
Services from formal support/third party
Assistance from family or friends
No assistance or services
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14. Physical Environment
14.A. Current Dwelling Unit
1. Does the Consumer own his/her current residence?
Yes
No
2. Able to remain in current living arrangement? If no,
explain why in the Notes.
Yes
No
Uncertain
14.B. Condition of Home
1. Care Manager able to check condition of living
environment?
Yes
No-Explain why in Notes.
2. Specify conditions making home environment
hazardous or uninhabitable. Document in Notes what
and where the problems are.
Bathroom or toilet room problems
Electrical problems
Inadequate bathing facilities
Inadequate cooling
Inadequate heating
Inadequate stairs, stair railings, or barriers
No running hot water
Poor or no Telephone Accessibility
Presence of Health Hazards (i.e. General clutter,
uncleanliness)
Refrigerator/freezer problems
Security/Safety issues
Stove/Food Prep Area and Storage problems
Unsound building
Unsound furnishings
TV/radio unsafe or unavailable
Washer/dryer unsafe/inaccessible/unavailable
3. Check places having problem(s) with accessibility
(Optional). Document problems in Notes.
Shopping
Banking
Laundry
Doctor/clinics
Pharmacy
Recreational/social activities
4. Condition of Consumer's neighborhood.
5. Does the Consumer need any of the following new,
repaired or additional devices or home modifications to
help him/her to continue to stay in his/her home?
Assistive dressing devices
Assistive feeding devices
Cane or walker
Walk-in Shower
Doorways widened
Eyeglasses
Hearing aid
Kitchen/bathroom modifications
Stair Glide
Other
Ramp
Wheelchair
6. PHYSICAL ENVIRONMENT score. Only required for
Consumers being served in the community.
Good overall
One or two negative features
Substandard overall
Substandard and potentially hazardous
Strongly negative
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15. Financial Resources
15.A. Consumer Income - REQUIRED
1. Medicaid Application Pending/PA-600L being
completed?
Yes
No
2. Refuse to give financial information? With
implementation of mandatory Cost Sharing, information
required for all desiring care managed services.
Yes
No
3. Consumer's Monthly Social Security Income (SS)
$
4. Consumer Supplemental Social Security Income (SSI)
Eligible?
Yes
No
Pending
5. Consumer's monthly Supplemental SSI income.
$
6. Consumer's monthly retirement/pension income.
$
7. Consumer's monthly interest/dividend income.
$
8. Consumer's monthly public assistance?
$
9. Consumer's monthly VA benefits income.
$
10. Consumer's monthly Black Lung income? Do not
consider as income for FCSP determination.
$
11. Consumer's monthly wage/salary/earnings income.
$
12. Consumer's monthly rental income?
$
13. Consumer's other monthly income. Document in
Notes source of income.
$
15.B. Consumer Assets
1. Consumer's Primary savings account balance?
$
2. Consumer's Primary checking account balance?
$
3. Consumer's certificates/other retirement accounts?
$
4. Consumer's real estate assets value?
$
5. Cash surrender value of Consumer's Primary life
insurance policy?
$
6. Consumer's stocks and bonds account balances?
$
7. Other accounts balance? Specify types of accounts in
the Notes.
$
8. Any unusual/excessive expenses.
9. Comments on Consumer's financial situation. If
considering FCSP, summarize TOTAL household financial
situation.
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9. Comments on Consumer's financial situation. If
considering FCSP, summarize TOTAL household financial
situation.
15.C. Caregiver Income - If caregiver is the spouse, all
entries are zero.
1. Caregiver's monthly Social Security income?
$
2. Caregiver's monthly SSI income?
$
3. Caregiver's monthly pension income?
$
4. Caregiver's monthly interest/dividend income?
$
5. Caregiver's monthly income from public assistance?
$
6. Caregiver's monthly VA benefits?
$
7. Caregiver's monthly black lung benefits?
$
8. Caregiver's monthly wage income?
$
9. Caregiver's monthly rental income?
$
10. Caregiver's monthly income from 'other' sources?
List sources in Notes.
$
15.D. Other Family Members' Income - Includes Spouse and
Other Family Members residing in the home.
1. Monthly social security income of other family
members residing with Consumer.
$
2. Monthly SSI income of other family members
residing with Consumer.
$
3. Monthly retirement/pension income of other family
members residing with Consumer.
$
4. Monthly interest/dividend income of other family
members residing with Consumer.
$
5. Monthly public assistance income for other family
members residing with Consumer.
$
6. Monthly VA benefits income of other family members
residing with Consumer.
$
7. Monthly Black Lung income for other family members
residing with Consumer.
$
8. Monthly wage/salary/earnings income of other
family members residing with Consumer.
$
9. Monthly rental income for other family members
residing with Consumer.
$
10. Other monthly income of other family members
residing with Consumer. Document in Notes source of
other income.
$
15.E. Household Income
2. Does the Consumer have Direct Deposit for checks?
If Yes, give details in Notes.
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2. Does the Consumer have Direct Deposit for checks?
If Yes, give details in Notes.
Yes
No
3. Total annual income of Consumer's household?
$
4. Consumer's level of financial assistance eligibility?
Only completed when considering FCSP.
5. FINANCIAL RESOURCES score. Only required for
Consumers being served in the community.
Consumer Alone Annual $32,491 and Above; W/Spouse
$43,711 and Above
Consumer Alone $31,138-$32,490; W/Spouse
$41,889-$43,710
Consumer Alone Annual $29,785-$31,137; W/Spouse
$40,067-$41,888
Consumer Alone Annual $28,432-$29,784; W/Spouse
$38,245-$40,066
Consumer Alone Annual $27,079-$28,431; W/Spouse
$36,424-$38,244
Consumer Alone Annual $25,725-$27,078; W/Spouse
$34,603-$36,423
Consumer Alone Annual $24,371-$25,724; W/Spouse
$32,782-$34,602
Consumer Alone Annual $23,017-$24,370; W/Spouse
$30,961-$32,781
Consumer Alone Annual $21,663-$23,016; W/Spouse
$29,140-$30,960
Consumer Alone Annual $20,309-$21,662; W/Spouse
$27,319-$29,139
Consumer Alone Annual $18,955-$20,308; W/Spouse
$25,498-$27,318
Consumer Alone Annual $17,601-$18,954; W/Spouse
$23,677-$25,497
Consumer Alone Annual $16,247-$17,600; W/Spouse
$21,856-$23,676
Consumer Alone Annual $14,893-$16,246; W/Spouse
$20,035-$21,855
Consumer Alone Annual $13,539-$14,892; W/Spouse
$18,214-$20,034
Consumer Alone Annual $0-$13,538; W/Spouse
$0-$18,213
15.F. Consumer Health Insurance - Required for FCSP
1. Consumer's Medicare A policy number.
2. Consumer's Medicare B policy number.
3. Consumer's Medigap policy number.
4. Consumer's Medicare HMO policy number.
5. Consumer's Medical Assistance number.
6. Consumer's long term care insurance carrier and
policy number.
7. Consumer's other health insurance carrier, if
applicable.
15.G. Spouse Health Insurance - Required for FCSP
1. Spouse's Medicare A policy number?
2. Spouse's Medicare B policy number?
3. Spouse's Medigap policy number?
4. Spouse's Medicare HMO policy number?
5. Spouse's MEDICAID policy number?
6. Spouse's long term care insurance policy number?
7. Spouse's other health insurance policy number?
15.H. Benefits and Entitlements
1. Check all benefits and entitlements for which the
Consumer is eligible and receiving.
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1. Check all benefits and entitlements for which the
Consumer is eligible and receiving.
Food Stamps
PACE
Tax and Rent Rebates
LIHEAP
Medicaid
Section 8
Subsidized Transit
Weatherization
15.I. Financial/Legal Management
1. Select appropriate assistance with legal/financial
matters? Document needs in the Notes.
None
Guardian
Informal Assistance
Lawyer
Power of Attorney
Representative Payee
2. If used, name of legal/financial assistant?
3. Has Durable Power of Attorney (DPOA) for FINANCES
Yes
No
4. What is the name of the Consumer's DPOA for
FINANCES?
5. Has advance medical directives (ie, do not
hospitalize)? If Yes, specify in the Notes.
Yes
No
6. Has a living will?
Yes
No
7. Name of person holding second copy of DPOA/Living
Will.
8. Telephone number of person holding second copy of
DPOA/Living Will.
9. Does the Consumer have a prepaid funeral/burial
fund?
Yes
No
10. What is the name of the bank/institution where the
Consumer's burial account is located?
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16. Preferences
16.A. Care Preferences
1. Preference about who assists him/her with activities
of daily living?
Yes-Document Details in Notes
No
2. If NFCE, what is the Consumer's preferred service
program?
OPTIONS
Family Caregiver Support Program (FCSP)
PDA Attendant Care
PDA Waiver
LTCCAP-Living Independence for the Elderly (LIFE)
3. If determined NFI, what is the Consumer's preferred
service program?
OPTIONS
Family Caregiver Support Program (FCSP)
PDA Attendant Care
Domiciliary Care (Dom Care) or Personal Care Home
(PCH)
4. Additional information regarding Consumer's service
preferences.
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17. Care Management Instrument Results
17.A. Decision Information
1. What was the purpose of completing this
assessment?
Initial Care Management Instrument
Care Management Review
2. CMI completion time in hours and minutes.
3. Is the Consumer clinically eligible for a nursing
facility?
Yes
No
4. Nursing Facility Clincally Eligible (NFCE) Consumer's
contact plan category:
Category 1
Category 2
Category 3
Category 4
5. If NFCE, what is the recommended service program
for the Consumer?
OPTIONS
Family Caregiver Support Program (FCSP)
PDA Attendant Care
PDA Waiver
LTCCAP-Living Independence for the Elderly (LIFE)
7. Having been determined NFI, what is the service
program recommended for the Consumer?
OPTIONS
Family Caregiver Support Program (FCSP)
PDA Attendant Care
Domiciliary Care (Dom Care) or Personal Care Home
(PCH)
8. If Consumer is NFCE served in Community Services
short term (expected less than 180 days), when should a
Care Management Review be conducted, from the date of
last Care Management Review?
30 days
60 days
90 days
120 days
150 days
180 days
9. Does the Consumer have any of the following special
needs for assistance during a public emergency? Check
all that apply. Document needs in Notes.
Services from Medical Professional
Oxygen
Home Dialysis
Medication Maintenance and Management
Essential Personal Care during Emergency Period
PERS (Special arrangements during emergency period)
Supervision during emergency
Assistance with evacuation from place of residence
Wheelchair accessible transportation
Special Heating or Cooling requirements
Special furniture to accommodate medical condition
Special dietary needs
Home delivered meals during quarantine
Medication delivery to place of residence during
quarantine
Other-Document in Notes
17.B. Care Management Certification
1. Name of the Care Manager completing the CMI:
2. Date Assessor/Care Manager signed assessment as
complete:
______/______/____________
3. Name of Registered Nurse reviewing the CMI:
Required if Consumer is NFCE or is in need of Home
Health services and/or medical equipment and supplies.
4. Date of Registered Nurse Review
______/______/____________
5. Name of Supervisor reviewing and approving the
CMI:
6. Date the Supervisor reviewed and approved the CMI:
______/______/____________
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18. Placement Options Information - for PCH and Dom Care
Placement Only
18.A. Housing Preferences- Complete if considering PCH or
Dom Care
1. Willing to share room? Document potential problems
in Notes.
Yes
No
2. Willing to live in home with pets? Document
potential problems in Notes.
Yes
No
3. Willing to live in home with children? Document
potential problems in Notes.
Yes
No
4. Willing to live with someone who drinks alcohol?
Document potential problems in Notes.
Yes
No
5. Willing to live with someone who smokes?
Document potential problems in Notes.
Yes
No
18.B. Additional Housing Preferences - Complete if
considering for PCH or Dom Care
1. Is the Consumer in a relationship? Document
potential problems in Notes.
Yes
No
2. Does the Consumer want to live in particular area?
Document where and potential problems in Notes.
Yes
No
3. Does the Consumer require a first floor bedroom?
Document potential problems in Notes.
Yes
No
4. Does the Consumer have a preference about religion
of provider/others lives with? Document potential
problems in Notes.
Yes
No
5. Additional information regarding Consumer's service
preferences:
6. Further comments on behavior affecting placement.
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Date Title :
Date Title :
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