- Form 8662, Related Conditions Eligibility Screening Instrument, must be completed, printed and submitted with Form 3650. (For ICF-MR/RC Level VIII only.)
- Approved Diagnostic Codes for Persons with Related Conditions lists the approved codes.
- To provide the Texas Department of Aging and Disability Services (DADS), Community Living Assistance and Support Services (CLASS), Consolidated Waiver Program (CWP), or Deaf Blind-Multiple Disabled (DB-MD) Waiver Program with the information necessary to determine an individual's eligibility for CLASS/DB-MD Level-of-Care VIII or CWP Level-of-Care I or VIII.
- To provide DADS with a record of level-of-care action for each applicant/participant in the CLASS/CWP/DB-MD waiver programs, for use in conducting billing services and demonstrating compliance with federal utilization review requirements.
When to Prepare
For the CLASS/CWP programs only:
The CLASS/CWP, Form 3650 (updated July 2002) is completed by the Direct Services Agency (DSA)/Home and Community Support Services Agency (HCSSA) registered nurse (RN), and the applicant's/participant's physician on behalf of an individual to request a Level-of-Care for an applicant/participant in a ICF-MR/RC waiver. Once an individual is enrolled into the CLASS/CWP programs, the DSA/HCSSA RN completes this form for every level-of-care action. A physician, physician assistant, or nurse practitioner must attest to Items 18 and 76-82.
For the DB-MD program only:
Form 3650 is completed by the case manager, DB-MD provider/RN, if appropriate, and the physician on behalf of an individual to request a Level-of-Care for a DB-MD applicant/participant. Once an individual is enrolled into DB-MD, the case manager and provider/RN complete this form for every level-of-care action. A physician, physician assistant, or nurse practitioner must attest to Items 18 and 76-82.
Use Form 3650 to:
- obtain a level-of-care entry into the CLASS/CWP/DB-MD programs;
- request a change in a Level-of-Care assignment; and
- request an annual reconsideration of Level-of-Care
For all Initial Level-of-Care (for the CLASS program only)
- Mail the original form to the Texas Department of Aging and Disability Services, CLASS State Office, Community Care Policy Section.
- A copy of the Adaptive Behavior Level (ABL) Instrument.
- A copy of the Related Conditions Eligibility Screening Instrument must accompany Form 3650 each year of submittal.
Note: DADS will return the original Form 3650 to the provider. Retain the original Form 3650 in the applicant's/participant's case record.
For all Initial Level-of-Care (for the CWP Program only)
- Fax a copy of Form 3650 to the DADS case manager.
- A copy of the Inventory for Client and Agency Planning (ICAP).
- A copy of the Addendum to Level-of-Care for the DB-MD program (if filling a DB-MD slot).
- A copy of the Related Conditions Eligibility Screening Instrument (if filling a CLASS or DB-MD slot).
- The DADS case manager will fax the completed Form 3650 to the HCSS agency.
- The HCSS agency keeps a photocopy in agency files.
For all Initial Level-of-Care (for the DB-MD program only)
- Mail the original form to the Texas Department of Aging and Disability Services, Community Care Policy Section.
- A copy of the Adaptive Behavior Level (ABL) Instrument, and the Addendum to level-of-care for the DB-MD program for an initial LOC and every five years following the initial LOC only.
- A copy of Attachment A, Related Conditions Eligibility Screening Instrument, must accompany Form 3650 each year of submittal.
Form 3650 can be accessed at the following Internet link: www.dads.state.tx.us/news_info/publications/handbooks/#forms
Keep copies of all forms for five years after a recipient's discharge or death.
Complete Form 3650: Enter correct data in the spaces provided on the form. If an item must be changed or deleted on Form 3650, draw a line through the incorrect entry, date and initial all changes and deletions. The signature and initials of the person making the changes must appear on the form in the Comments section.
Use numbers in place of Roman numerals.
Leave items blank that are not applicable to the applicant or program.
01. Medicaid No. — Enter the individual's Medicaid number. Leave this item blank if the individual is in the process of applying for Medicaid.
02. Social Security No. — Enter the individual's nine-digit social security number.
03. HIC/Medicare No. — Enter the individual's Health Insurance Claim (HIC) number and letters or Medicare number, if known.
04. Name — Enter the individual's last name, first name, and middle name or initial. Use the name as it appears on the individual's social security card and/or Medicaid Card (leave one space between last name, first name, and middle).
05. Date of Birth (mm/dd/yyyy) — Enter the individual's birth date in month/day/year order.
06. Date Completed (mm/dd/yyyy) — Enter the date that Form 3650 is completed.
07. Date of Physical Examination —
For the CLASS program: Enter the date of the applicant's/participant's most recent physical examination or the DSA/RN nursing assessment.
For the CWP/DB-MD programs: N/A
08. Sex — Enter "M" for male or "F" for female.
09. Legal Status — Not applicable for the CLASS/CWP/DB-MD programs.
10. Recommended Level-of-Care —
For the CLASS/DB-MD programs: Enter 8, if the individual has a primary diagnosis on the approved ICD-9 list, Clinical Modification Diagnosis Codes for Persons with Related Conditions.
For the CWP program: Enter 1, if the individual has a primary diagnosis of mental retardation.
11. Applicant's Address — Enter the address of the individual's current residence.
12. Vendor Number — Enter the provider's Texas Medicaid Healthcare Partnership (TMHP)/contract vendor number.
13. ABL Instrument — Enter the name of the ABL instrument (ICAP, SIB-R, VABS, or AAMR) used to assess the applicant's/participant's adaptive behavior level.
- Inventory for Client and Agency Planning (ICAP),
- Scales of Independent Behavior – Revised (SIB-R),
- Vineland Adaptive Behavior Scales (VABS), or
- American Association on Mental Retardation Adaptive Behavior Scales (AAMR).
14. ABL Assessment Date — Enter the initial date that the ABL assessment was completed. Note: An ABL assessment is valid for five years.
15. Current Residence — Enter one of the following codes to identify the individual's current residence location or program immediately before the current enrollment.
1 = Home (not enrolled in any program)
2 = Hospital
3 = Another ICF/MR community-based facility
4 = HCS, HCS-O, or DB-MD provider services
5 = State hospital or state school
6 = Nursing facility
7 = Other
8 = Cannot determine
16. Purpose — Enter one of the following codes to identify the purpose of this assessment:
2 = Initial level-of-care (for enrollment into CLASS/CWP/DB-MD programs).
3 = Continued stay review (annual reassessment).
4 = Request for change in level-of-care, initiated by the program provider.
5 = Request for change in level-of-care, initiated by DADS.
E = Reconsideration of LOC for the CLASS/CWP/DB-MD programs when there is a gap in LOC submission period.
17. Waiver —
- Enter H to identify the CLASS waiver program.
- Enter C to identify the CWP waiver program.
- Enter D to identify the DB-MD waiver program.
18. Primary Diagnosis — Enter the individual's current primary diagnosis (not symptoms) as determined by a physician. A primary diagnosis is the condition chiefly responsible for the request for program services. In most cases, this condition will be the main focus for attention or treatment. Although standard medical abbreviations may be used, avoid abbreviations that may be interpreted for more than one diagnosis. To qualify for an ICF-MR/RC level-of-care, a related condition must be the primary diagnosis for ICF-MR/RC services. (See Attachment B for an ICD-9-CM list for related conditions diagnoses.) It must be an approved related condition to qualify for the CLASS/CWP program.
For the CWP program only: To qualify for an ICF-MR Level of Care 1, mental retardation must be the primary diagnosis entered for Item 18.
To qualify for the DB-MD waiver program, the primary diagnosis must be deafness, blindness, or a syndrome causing deaf-blindness (such as rubella syndrome).
Onset — Mo./Yr. (for a primary diagnosis of a related condition)
Enter the month and year that the severe and chronic disability, resulting from a related condition, became evident. This is not the date of the diagnosis, but it is the date the symptoms of the diagnosis were clearly identified as a disabling condition. This date must be before the applicant's 22nd birthday for the diagnosis to be considered a related condition. This date must be before the individual's 18th birthday for the diagnosis to be considered mental retardation.
Items 19.-22. Current Medical Diagnoses — Enter any other current medical diagnoses the individual may have as determined by a physician. These diagnoses are used to indicate other factors that have a direct bearing on the required treatment or care. If more than four diagnoses are present, list those diagnoses that best describe the need for ICF-MR or ICF-MR/RC care. Do not enter past diagnoses from which the individual has recovered. Enter only current diagnoses that support the individual's requirement for services.
Codes — Enter the appropriate code from the International Classification of Diseases-9th Revision-Clinical Modification Manual (ICD-9CM). On Form 3650, the name of the diagnosis(es) and the diagnosis(es) code must match.
Items 23.-24. Psychiatric Diagnoses — Enter the diagnosis if the individual has any current mental disorder(s) as defined in the Diagnosis and Statistical Manual of Mental Disorders (DSM). (Not all individuals will have psychiatric diagnoses.)
Codes — Enter the appropriate code from the DSM.
25. Weight — Enter the individual's weight. Enter the most current measurements available. (Obtain measurements if not documented.)
26. Height — Enter the individual's height. Enter the most current measurements available. (Obtain measurements if not documented.)
27. Diet — Enter the type of modified diet (by name). If the individual is on a regular diet, then enter "regular diet."
Cognitive Functioning (Base rating on observed performance.)
28. IQ — For persons with the diagnosis of mental retardation only. Enter actual IQ score, if obtainable. If IQ cannot be ascertained due to the severity of the cognitive impairment, use a comparable score from a professionally accepted scale.
Not applicable for the CLASS/DB-MD programs.
29a. Service Level Score — Enter the service level score and/or the scale score based on the results of the ABL assessment. For the ICAP assessment, enter the "Client's ICAP Service Score," page 16 of the ICAP booklet - (Table 1).
29b. ABL (Adaptive Behavior Level). — Enter the ABL using numbers 1, 2, 3, or 4.
01 = Mild ABL deficit
02 = Moderate ABL deficit
03 = Severe ABL deficit
04 = Profound ABL deficit
For the CLASS program only: Attach supporting documentation when the applicant's/participant's ABL does not fall within the established eligibility categories of 2, 3, or 4 for the Level-of-Care VIII criteria. Note: Supporting documentation includes letters from the case manager and direct services agency supporting continuation, denial or termination of CLASS services, PACP, nursing assessment, ISP, and a copy of the previous year LOC.
For the DB-MD program only: Attach supporting documentation when the IQ and ABL do not fall within the established eligibility categories of level-of-care criteria.
Items 30. - 39. Specialized Adjunctive Services — Use the following Frequency and Service Provider codes to complete this section. If not applicable, enter 0. Include only the professional services paid through the CLASS/CWP/DB-MD waiver programs.
For an initial Level-of-Care determination, enter 0 for Items 30-39.
All responses must relate to professional services documented in the Individual Service Plan (ISP), Individual Plan of Care (IPC), or Individual Program Plan (IPP).
Do not include:
- professional services provided to the applicant/participant or program provider as non-waiver cost, such as free professional services received from a school district or volunteer or other third party; and
- services offered less than 60% of the time during which the level-of-care is valid, such as annual evaluations, checkups, or short-term therapy.
Frequency Codes —
0 = Individual does not have these services included in the IPP, ISP, or IPC
2 = 15 min. or less per week
3 = 16-30 min. per week
4 = 31-60 min. per week
5 = 61-120 min. per week
6 = 121-180 min. per week
6 = 181 or more min. per week
Service Provider Codes Licensed, Certified, or Registered Professionals —
01 = Physical Therapist
02 = Physical Therapist Assistant
03 = Physical Therapist Aide
04 = Occupational Therapist
05 = Occupational Therapist Assistant
06 = Occupational Therapist Aide
07 = Speech/Language Pathologist
08 = Audiologist
09 = Psychiatrist
12 = Psychologist
13 = Social Worker (SWA, LSW, LMSW)
14 = Licensed Counselor
15 = Registered Nurse
16 = Licensed Vocational Nurse
17 = Respiratory Therapist
18 = Dietitian
19 = Recreation Therapist
20 = Other
Facility/Provider Name — Enter the provider agency name.
Mailing Address — Enter the provider's mailing address.
Items 40. - 50. Health Status Concerns
Using the codes listed for Items 40-50, indicate those conditions which the individual has exhibited during the past four weeks.
40. Special Nourishment — Indicate any specialized nutrients.
0 = None ordered or performed
1 = Supplemental oral nourishment
2 = Parenteral nutrition (PN)
3 = Enteral nutrition (EN)
41. RN/LVN Supervision — Indicate any area of care for the individual requiring RN/LVN supervision.
0 = Does not require daily, direct RN/LVN supervision.
1 = Requires direct supervision once or twice daily by an RN/LVN.
2 = Requires direct supervision three or more times daily by an RN/LVN.
3 = Requires 24-hour, on-site availability of an RN/LVN. (Nursing staff do not have to be awake.)
42. Urinary Tract Care — Catheterization – Insertion of a catheter to
- obtain a urine specimen,
- determine residual, or
- perform intermittent drainage of the bladder.
Foley-Type Catheter — Presence of, reinsertion, and care of an indwelling catheter that is retained in the bladder.
Suprapubic Catheter — Presence of an indwelling catheter retained in the bladder and is maintained through an abdominal incision above the pubic arch.
0 = None
1 = Catheterization – including intermittent
2 = Foley (indwelling catheter)
3 = Suprapubic catheter
43. Ostomy Care — Enter one of the following codes only if the procedure is performed.
0 = None
1 = Tracheostomy care
2 = Gastrostomy care
3 = Colostomy care
4 = Ileostomy care
5 = Other
44. Paralysis — Paralysis (or the symptoms of) is the loss of movement of the extremity(ies) and/or loss or all sensation and reflexes.
0 = None
1 = One limb (extremity) affected
2 = Two limbs (extremities) affected
3 = Three limbs (extremities) affected
4 = Four limbs (extremities) affected
45. Contractures — Contractures are the permanent shortening or tightening of a muscle; fixed high resistance to the passive stretch of a muscle.
0 = None noted
1 = One limb (extremity) affected
2 = Two limbs (extremities) affected
3 = Three limbs (extremities) affected
4 = Four limbs (extremities) affected
Items 46.- 47. Decubitus/Stasis Ulcers Stage
Ischemic ulceration and/or necrosis of tissues overlying a bony prominence that has been subjected to prolonged pressure or friction.
46. Decubitus-Stage — Enter the stage level of the individual's most severe lesion within the past four weeks.
0 = None noted.
1 = Stage I – a persistent redness that does not disappear when pressure is relieved.
2 = Stage II – a skin blister or a superficial break in the skin.
3 = Stage III – a full thickness of skin is lost, exposing the subcutaneous tissues.
4 = Stage IV – a full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone.
47. Decubitus-Care — The level of caregiver assistance in treating the individual's decubitus/stasis ulcers.
0 = Individual does not have decubitus/stasis ulcers
1 = Intervention by a caregiver
2 = Intervention by a nurse
3 = Intervention by a doctor
4 = Required hospitalization
Items 48.- 49. Prosthetic Devices
48. Prosthetic Devices Assistance — Assistance required for the individual to APPLY and REMOVE protective, supportive, prosthetic, or adaptive devices. (Does not include devices not applied to individual, such as wheelchair, plate guards, canes, etc. May include eating, dressing, or personal hygiene devices.)
0 = Individual does not have prosthetic device
1 = Individual independently applies prosthetic devices
2 = Individual needs physical assistance to apply devices
3 = All prosthetic devices are applied to individual by caregiver
49. Prosthetic Devices — The total amount of caregiver time required for the application and removal of protective, supportive, prosthetic adaptive devices on the individual in one 24-hour period.
0 = Not applicable or individual applies device
1 = Less than 5 minutes daily
2 = 6-15 minutes daily
3 = 16-30 minutes daily
4 = 31 minutes to 1 hour daily
5 = Over 1 hour daily
50. Seizure – Convulsion — Individual may or may not exhibit clonic/tonic muscle activity, lose consciousness, or become incontinent.
0 = None known
1 = Past history of seizures (none within four weeks)
2 = Controlled with medications all the time
3 = Controlled with medications most of the time (no more than two seizures in the last month)
4 = Poorly controlled with medications (three or more seizures within the last month)
Items 51. - 61. Functional Assessment
The following qualifiers and definitions are important for completing the Functional Assessment section:
- Time period — The individual should be assessed with reference to his status during the last four weeks. However, if the individual has experienced a drastic change in his functional status in the last four weeks, and this change appears to be permanent, responses should be based on current observations/interviews. For an applicant, assessment should be based on current observations/interviews.
- Frequency — Since the individual's psycho-social/behavioral condition may fluctuate during the day or over the past four weeks, the individual should be assessed in terms of his status 60% or more of the time. Professional judgment and caregiver consultation may be necessary to determine if the status is over 60% or more of the time.
- Cause — The assessor should enter the response that describes the condition, regardless of the cause.
51. Mobility/Ambulating — Mobility refers to the ability to move about. Ambulation refers to the ability to walk.
1 = Walks independently; walks with no supervision or physical hands-on assistance. May require mechanical devices (such as cane, crutch, or walker) but not a wheelchair.
2 = Walks with intermittent supervision or physical hands-on assistance for difficult maneuvers (such as for stairs, ramps);may or may not require the use of mechanical devices (such as cane, crutch, or walker) but not a wheelchair.
3 = Walking requires constant supervision and/or physical hands-on assistance (with or without mechanical devices but not a wheelchair).
4 = Transports self in wheelchair independently; may require intermittent supervision or physical hands-on assistance for difficult maneuvers (such as elevators, ramps, longer distances, or transfers); may be able to walk, but generally does not walk.
5 = Individual is transported in wheelchair or other mobility device; constant supervision and/or physical hands-on assistance is required for all maneuvers.
6 = None of the above.
52. Creative Ambulation — Refers to movement by scooting or crawling, etc.
0 = Does not apply. Individual is ambulatory, transported in a wheelchair, non-mobile, or does not move self.
1 = Uses creative mobility independently with no supervision or physical hands-on assistance; may require mechanical devices (such as scooter board) but not a wheelchair.
2 = Uses creative mobility with intermittent supervision or physical hands-on assistance for difficult maneuvers (such as for stairs, ramps); may or may not require the use of mechanical devices (such as scooter board) but not a wheelchair.
3 = Creative mobility requires constant supervision and/or physical hands-on assistance (with or without mechanical devices).
4 = Individual's primary means of mobility is a wheelchair; however, uses creative mobility in familiar settings.
53. Transferring — The process of moving between positions, such as from a wheelchair to or from a bed, a chair, or a standing position (excluding transfers to and from bath and toilet).
0 = Does not apply. Individual is ambulatory.
1 = Transfers independently. Individual completes transfers without supervision or physical hands-on assistance; individual may use equipment (such as hand railings or trapeze).
2 = Transfers with intermittent supervision or physical hands-on assistance; individual requires intermittent supervision and/or physical hands-on assistance only for difficult transferring maneuvers (such as transferring between wheelchair and auto).
3 = Transfer requires one person to provide constant supervision, steadiness, and/or physical hands-on assistance; individual may participate in transfer.
4 = Transfer requires two people to provide constant supervision, steadiness, and/or physical hands-on assistance; individual may need lifting equipment.
54. Continence — Ability to consciously control bladder and/or bowel.
1 = Continent
2 = Incontinent occasionally (2-4) times a week
3 = Daily incontinence - once daily
4 = Nocturnal (night) incontinence only
5 = Frequent incontinence (two or more times daily)
6 = Neurological incontinence (incapable of benefiting from toilet training)
7 = Catheter or ostomy present
Process of getting to and from toilet (including bedpan, bedside commode, or urinal); transferring on and off toilet; cleansing oneself after elimination; and adjusting clothes.
1 = Independent, toilets without physical, hands-on assistance, and/or verbal cueing; may require special equipment, such as raised commode seat and handrails.
2 = Intermittent assistance, requires frequent (not constant) one-to-one, physical, hands-on assistance, and/or verbal cueing, for some tasks such as adjusting clothes and washing hands.
3 = Constant assistance, requires one-to-one, physical hands-on assistance, and/or verbal cueing, during the entire process; if the caregiver assisting is not present at all times, the individual will not complete the activity.
4 = Not toileted, dependent on devices such as protective padding, diapers, incontinent pads, a catheter, or ostomy.
56. Eating — Process of eating at meals.
1 = Eats independently, eats (with utensil) without physical hands-on assistance.
2 = Eating requires intermittent assistance, requires occasional or frequent (but not constant) physical hands-on assistance to complete a meal.
3 = Eating requires constant assistance requires constant, one-to-one, physical hands-on assistance to complete a meal.
4 = Totally fed by hand, a caregiver performs the entire activity; may be able to chew and swallow but does not participate in the process of getting food and fluids from a receptacle into the body.
5 = Non-oral nourishment, primary source of nutrition is received by non-oral route such as nasal-gastric tube, gastrostomy, parenteral, or enteral feeding.
57. Eating Disorders —
0 = None noted/reported
1 = Rumination
2 = Choking
3 = Bulimia/Anorexia
4 = Prader Willi
5 = Pica
6 = Other
58. Administration of Medication —
How the individual's prescriptions and/or over-the-counter medications are administered.
1 = Independently takes medication
2 = Requires supervision
3 = Medications are administered by qualified caregiver
4 = Administered by a family member
59. Personal Hygiene — Activities to maintain personal cleanliness, including bathing, shaving, oral care, hair care, nail care, and menstrual care.
1 = Independent, requires no prompting to correctly complete most tasks
2 = Requires prompting or constant supervision
3 = Requires physical hands-on assistance in completing procedure
4 = Does not participate in personal hygiene tasks, caregiver must perform tasks for individual
5 = Actively resists most hygiene tasks
60. Dressing — Putting on and taking off clothing.
1 = Independent in dressing tasks, requires no reminders
2 = Dresses self with verbal prompting or constant supervision
3 = Dresses self with physical hands-on assistance
4 = Totally dressed by caregiver
5 = Actively resists being dressed by others
61. Managing Money —
1 = Independent in managing own money
2 = Manages own money with assistance
3 = Responsible party manages
Items 62. - 68. Sensory/Perceptual Status
Answer the following questions according to the status of the individual during the past four weeks. If the individual is an applicant without documented medical history, base responses on current observations/ interview.
62. Visual Status — Ability to see in adequate light (with appliances, if used, such as glasses, contact lenses, or magnifying glass). This item refers to the individual's functional vision. If an individual has vision in only one eye, double or multiple vision, visual field deficits, or disorders of ocular motility, indicate the most accurate description of the person's functional vision (for example, a person who has excellent acuity in a limited field may be considered to have a moderate visual loss).
1 = Sees adequately in all situations; sees fine detail; and sees and identifies people and objects in immediate environment (such as their room).
2 = Minimal vision loss; sees large print, simple pictures, and television; cannot discern detailed text in newspapers or books.
3 = Moderate loss; sees fingers at arm's length and obstacles in path; cannot discern newspaper headlines; usually compensates for visual defect by scanning environment.
4 = Highly impaired or no functional vision; only distinguishes shadows; absence of functional vision (for example, cannot locate objects without hearing or touching them).
63. Auditory Status — This item refers to the individual's functional auditory status.
0 = Cannot determine
1 = Hearing within normal limits
2 = Hearing corrected with adaptive device
3 = Hearing impaired even with adaptive device (or cannot tolerate device)
4 = No functional hearing
64. Expressive Communication — This item refers to the individual's functional expressive communication.
0 = No observable impairment
1 = Conversational speech with occasional difficulty in finding words or expressing ideas
2 = Conversational speech with difficulty in expressing long or complex ideas
3 = Consistent expression with gestures or single words and short phrases
4 = Expresses needs with single words or gestures that may be ineffective, incomplete, or difficult to understand
5 = No functional speech or gestures
65. Receptive Communication —
0 = No observable impairment
1 = Follows conversation with little difficulty
2 = Responds appropriately to simple sentences in verbal or written communication but may need repetition and may fail to grasp details
3 = Consistently responds to single word verbal, written, or gestural communication
4 = Inconsistently responds (less than 50% of the time) to single-word verbal, written, or gestural communication
5 = Does not respond appropriately or follow directions in response to repeated verbal, written, or gestural communication
66. Augmented Communication —
0 = Does not use augmentative communication devices or gestural communication system
1 = Uses a letter, word, or picture communication system or functional gestures to make needs known
2 = Uses sign language or computer-based augmentative communication system
67. Orientation/Memory —
0 = Undetermined
1 = Good mental clarity; oriented to person, place, and time; may have occasional episodes of disorientation or forgetfulness; requires assistance from caregiver for reorientation less than once a day
2 = Recurrent episodes of disorientation or forgetfulness; requires assistance for reorientation once daily
3 = Frequent inability to remember identity, dates, or time; to recognize familiar people or environment; and to recall recent significant events requires reorientation two to six times daily from caregiver, including assistance in activities of daily living
4 = Incoherence, total disorientation; inability to function in a familiar environment; requires maximum assistance in all activities of daily living
68. Level of Consciousness — The state of awareness, varying from alert wakefulness to a complete lack of responsiveness. This item must be number 1, 2, or 3 for the individual to be eligible for the CLASS/CWP/DB-MD waiver programs.
1 = Alert — responds quickly to verbal stimuli or/and the environment
2 = Lethargic — easily aroused, but drowsy; may follow two-part commands
3 = Stupor — very hard to arouse; may require vigorous stimuli; may follow simple commands
4 = Comatose — unable to arouse; does not respond to vigorous stimuli; unable to follow commands
Items 69. - 75. Behavioral Status
69. Behavior Program —
Is this individual on an individualized behavior management plan as documented on the IPP and ISP/IPC?
1 = Yes
2 = No (score 0 on Items 70-75)
3 = No (completed for information use – DB-MD/CWP programs only)
Code each applicable behavior type (70-75) with one of the following frequency codes.
70. Non-injurious stereotypic behavior (Example: self-stimulation)
71. Self-injurious behavior or pica behavior
72. Non-injurious disruptive behavior (Examples: cursing, disrobing, yelling, or noncompliance)
73. Property destruction
74. Aggressive behavior (may cause physical injury to others)
75. Sexually aberrant behavior
Frequency of Caregiver Intervention Codes:
0 = Not applicable or not on behavior program
1 = Less than monthly
2 = Monthly
3 = Weekly
4 = Two or more times per week
5 = Daily
6 = Multiple times per day/constant
7 = For aggressive behavior only: The individual has required physical restraint by caregiver to prevent injury to others three or more times in the previous six months, as documented in the participant's case record.
Note: If an individual's behavior frequency changes, a new Form 3650 should be completed.
Items 76. - 82. Physician's Evaluation and Recommendation
Note: A physician, physician assistant, or nurse practitioner must attest to items 18 and 76-82 on Form 3650. The physician assistant or nurse practitioner signs his name and dates the form, then types or prints his last name. The appropriate title designator/abbreviation must be part of the signature.
76. Supervision MD/DO — This item must be "yes" for the individual to be eligible for the CLASS/CWP/DB-MD waiver programs.
77. Health Status — This item must be "no" for the individual to be eligible for the CLASS/CWP/DB-MD programs.
78. Condition of Mental Retardation/Related Condition — This item must be "yes" for the individual to be eligible for the CLASS/CWP/DB-MD waiver programs.
79. ICF-MR or ICF-MR/RC Care — This item must be "yes" for the individual to be eligible for the CLASS/CWP/DB-MD waiver programs.
Signature – MD/DO — Date — The physician, physician assistant, or nurse practitioner signs his name and dates the form, then types or prints his last name. It is preferable that the designation MD or DO be included as part of the physician's signature. It is acceptable, however, for the physician to circle the appropriate designation, that is, MD or DO.
80. Last Name of MD/DO — Type or print the physician's, physician assistant's, or nurse practitioner's last name.
81. Telephone Number — Type or print the physician's, physician assistant's, or nurse practitioner's telephone number, include area code.
82. License Number — Type or print the physician's, physician assistant's, or nurse practitioner's license number.
Signature – RN/LVN/QMRP/Case Mgr. — Date — The RN responsible for the completion of this form signs and dates it, including title with signature. Type or print this person's telephone number in the comment section.
Signature – Case Manager — Date — For the DB-MD program only: The case manager responsible for the completion of this form signs and dates it, including title with signature. Type or print this person's telephone number in the comment section.
83. Last Name or RN/LVN/QMRP/Case Mgr. —
For CLASS/CWP programs only: Type or print the last name of the RN appearing in the signature, to the left.
For DB-MD program only: Type or print the last name of the case manager/provider RN appearing in the signature, to the left.
DADS-Departmental Use Only
Items 84-89 are completed by the Texas Department of Aging and Disability Services.
84. LOC (level-of-care) — DADS reviewer enters the appropriate level-of-care code.
0 = Denial of LOC
1 = LOC I (CWP program only)
8 = LOC VIII
85. Effective Date — DADS reviewer enters the effective date of the level-of-care, the date that the form is recorded completed/accurate by DADS.
86. Date Signed by the Reviewer — DADS reviewer enters the date that the form is reviewed and processed by DADS.
87. Expiration Date — DADS staff enter the expiration date of the current level-of-care. This date will be the "to" date on the applicant/participant's Individual Service Plan (ISP) or Individual Plan of Care (IPC). The "to" date of the ISP/IPC is the last day of the ending month. The LOC is valid through the effective period of the ISP/IPC.
Note: An LOC expiration date may be less than the ISP "to" date.
88. Date Form Received by DADS — DADS staff enter (stamp-in) date the form is received or the date of the proof of mailing (certified or registered mail) is signed by DADS staff.
89. Signature – DADS Reviewer — This DADS reviewer signs and dates the form.
Comments — Self-explanatory.