Personal Care/Advanced Personal Care Assessment Instructions
(This form may be used but is not a required form for the waiver)
The PC/APC Assessment must be completed upon initial assessment and at least every 6 months.
The following instructions are to be followed in order to accurately complete the Personal Care/Advanced Personal Care Assessment. A check mark in the appropriate column (1st visit or 2nd visit) to indicate the tasks in which time is required by a PC/APC Aide.
Participant's Name: (Enter the full name of the participant.)
DCN: (Enter the participant’s DCN.)
DOB: (Enter the participant’s date of birth.)
Principal Diagnosis: (Enter the primary diagnosis for which the participant/family is requesting personal care/advanced personal care services.)
For Personal Care Tasks indicate appropriate assessed need in each category of care (dressing, grooming, bed mobility, toileting, bathing):
- Independent: requires no assistance, the participant is able to complete the task alone. No comment required
- Assistance Required: requires the help and/or direction of a caregiver. The participant can complete a part of the task or help to complete it but cannot do it alone. Comment section must give an explanation of the assistance that is required.
- Total Assistance: requires that the caregiver complete the entire task. The participant is unable to do any part of it. No comment required.
Eating: (Indicate if meal preparation is required.)
Ambulating: (Indicate if assistance is required by 1 or 2 persons)
Housekeeping: Indicate tasks that the PCA will be performing.
Advanced Personal Care Tasks Instructions
Indicate the need for any of the tasks in this category. Only APCs who are trained by their employer in these areas may complete these tasks. A PCA is NOT authorized to complete any of the tasks listed in this section. In addition, the APC task is authorized only for the amount of time required to complete these tasks, and not the entire duration of the shift. For example, if there is an APC task needed and it takes 30 minutes to complete and the remainder of the 8-hour shift could be completed by a PCA, then ½ APC hour and 7 ½ PCA hours shall be authorized. Monthly RN authorized visits are required.
Comments: Document the number of hours of care that is required by the participant and the number of hours that the family is available to provide care for the participant. Enter the date of the comment.
Service and Hours Authorized—First Visit: Enter the Type of Service and the number of hours/day or week of medically necessary care that you are authorizing to be provided by MO Health Net Providers.
Service Coordinator Signature—First Visit: Service Coordinator signature and date of 1st visit.
Service and Hours/Units Authorized—Second Visit: Enter the Type of Service and the number of hours/day or week of medically necessary care that you are authorizing to be provided by MO Health Net Providers.
Service Coordinator Signature—Second Visit: Service Coordinator signature and date of 2nd visit.
***This form is designed to be used for the 2 required home visits for each year the participant is receiving Personal Care Services. The form is completed at the first home visit (SCA and other required documents are completed also) and the form can be taken to the home at the 6-month home visit, or the SC can obtain the information and complete the form when he/she returns to the office. This form can be removed from the record in order to take to the participants home for the second home visit.