Form 8578
Instructions

Intellectual Disability/Related Condition (ID/RC) Assessment

02-2012

Note: For CLASS and DBMD use only:

PURPOSE

Form 8578 is to be used by applicable Department of Aging and Disability Services (DADS) programs, including Intermediate Care Facilities for Persons with Intellectual Disability/Related Conditions (ICF/ID-RC), Home and Community-based Services (HCS) Program, Texas Home Living (TxHmL) Program, Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), and other newly developed programs, as well as the Local Authority (LA), when documenting information needed to:

PROCEDURE

When to Prepare

Form 8578 is completed with information from the applicant or provided by an interested party on behalf of the applicant when an LOC assessment is requested. Once an individual is enrolled in a program, this form is completed for every LOC action. Additionally, as necessary, this form is used to document the information used in determining an LON.

Use Form 8578 to:

Transmittal

Form Retention

Retain copies of all forms for the length of time instructed by DADS. The facility must keep the records of individuals under 18 years of age for three years beyond their 18th birthday even if the retention period exceeds six years.

Physician's Signature (Complete for ICF/ID Only.)

For individuals enrolling in the ICF/ID program, Items 19 and 48-55 must be completed, and a physician must sign the paper copy (Item 52) attesting to the information documented in Items 19 and 48 through 51. The physicianís name must be printed in full in Item 53.

For a subsequent ID/RC, if the physician has delegated the completion of Items 19 and 48-55 to an advance practice nurse (APN) or a physician assistant (PA), the APN or PA must sign the paper copy (Item 52 attesting to the information documented in Items 19 and 48-51). The APNís or PAís full name must be printed in Item 53. The physicianís license number must be noted in Item 55 and the APNís or PAís license number noted in Item 72.

For individuals enrolling in or participating in the HCS or TxHmL Program, Items 48-55 are optional. However, if any information is entered in any of the Items 48-55, then all the items must be completed.

Source of Forms and Information Regarding the ID/RC Assessment

The blank Form 8578 can be reproduced as needed. The form is also available online through the DADS website (www.dads.state.tx.us/forms).

If you have any questions regarding Form 8578 or instructions, refer to the following:

ICF/ID, HCS and TxHmL: Call the DADS Utilization Management and Review, ICF/ID, HCS and TxHmL Program Enrollment/Utilization Review (PE/UR) message line at 512-438-5055.

CLASS and DBMD: Call DADS Utilization Management and Review, CLASS and DBMD PE/UR staff at 512-438-3609.

Purpose Code 4 Special Instructions (ICF/ID, HCS and TxHmL)

When a Purpose Code 4 (Change LON on Existing Assessment) is entered in Item 13, only the following items are entered on the assessment:

1. Facility/Provider Name
2. Contract No.
3. Mailing Address
4. Name
5. Applicant's Address
6. Component Code
7. Case No.
8. Medicaid No.
9. HIC/Medicare No.
10. Date of Birth
11. Social Security No.
12. Date Completed
13. Purpose Code
18. Recommended LON

ICAP Data

31. Broad Independence
32. General Maladaptive
33. ICAP Service Level

Behavioral Status

34. Behavior Program
35. Self-injurious Behavior
36. Serious Disruptive Behavior
37. Aggressive Behavior
38. Sexually Aggressive Behavior

Nursing

39. Service Provider
40. Frequency Code

Provider Certification

56. Signature – RN/LVN/QIDP/QDDP/Case Manager/LA Service Coordinator/HCS Provider Representative
57. Print Full Name of RN/LVN/QIDP/QDDP/Case Manager/LA Service Coordinator/HCS Provider Representative
58. Date of signature

Requested Begin/End Dates

Item Name

59. Begin Date (Begin date cannot precede the data entry date.)

DETAILED INSTRUCTIONS

Refer to the following table for a description of the form contents:

Form Items

The following table describes the fields as they are displayed on the form.

Item Name Contents
1. Facility/Provider Name The name of the facility, if the individual lives in an ICF/ID. The name of the provider agency, if the individual is receiving waiver services.
2. Contract No. Contract number under which services are provided to this individual.
3. Mailing Address Provider's mailing address.
4. Name (Last/First/Middle) Individual's last name, first name and middle name or initial.
5. Applicant's Address Individual's current mailing address, including street or P.O. Box, city, state and ZIP.
6. Component Code Code to indicate the agency component at which the individual is or will be receiving services. Applicable for HCS, ICF/ID and TxHmL.
7. Case No. Individual's local case number assigned by the agency component. Applicable for HCS, ICF/ID and TxHmL.
8. Medicaid No. Individual's Medicaid number, if known.
73. CARE ID Individual's Client Assignment and REgistration (CARE) system identification number (ID), if known. Applicable for HCS, ICF/ID and TxHmL.
9. HIC/Medicare No. Individual's Health Insurance Claim (HIC) number and letters or Medicare number, if known.
10. Date of Birth Individual's date of birth in MM-DD-YYYY format.
11. Social Security No. Individual's nine-digit Social Security number.
12. Date Completed Date the form is completed by the RN/LVN/QIDP/QDDP/Case Manager/LA Service Coordinator/HCS Provider Representative.
13. Purpose Code Code to indicate the purpose of this assessment.
2 = No Current Assessment
3 = Continued Stay Assessment
4 = Change LON on Existing Assessment (LON increase requires supporting documentation to be forwarded to DADS Access and Intake, Utilization Management and Review, IDD Waivers PE/UR, P. O. Box 149030, MC W-355, Austin, TX 78714-9030)
E = Request LOC and LON for a gap in ID/RC Assessments.
14. Date of Physical Examination Date of the most recent physical evaluation in MM-DD-YYYY format.
15. Legal Status Code to indicate the individual's legal status.
0 = Minor – younger than 18 years of age (with parent/guardian)
1 = Minor (ward of the state)
2 = Minor w/conservator
3 = Adult w/guardian of estate and person
4 = Adult w/guardian of estate
5 = Adult w/guardian of person
6 = Adult w/limited guardianship
7 = Adult w/temporary guardian
8 = Adult w/no guardian
16. Previous Residence Code to indicate the individual's previous residence/location/program before the current enrollment.
1 = Home (not enrolled in any program)
2 = Hospital
3 = Another ICF/ID community-based facility
4 = HCS, TxHmL, CLASS or other waiver services
5 = State hospital or state supported living center
6 = Nursing facility
7 = Other
8 = Cannot determine
17. Recommended LOC Code to indicate the LOC recommended by the provider.
0 = Denial of LOC (enter in provider comments section [CARE])
1 = LOC I
8 = LOC VIII
18. Recommended LON Code to indicate the LON recommended by the provider.
1 = LON 1 (Intermittent)
5 = LON 5 (Limited)
8 = LON 8 (Extensive)
6 = LON 6 (Pervasive)
9 = LON 9 (Pervasive +)
Note: See Calculating Level of Need chart.
Applicable for HCS, ICF/ID and TxHmL.

Diagnosis

Item Name Contents
19. Primary Diagnosis Individual's current primary diagnosis as determined by a physician. A primary diagnosis is the condition chiefly responsible for the request for programmatic services.
20. Code Code of primary diagnosis listed in the International Classification of Diseases (ICD).
Note: This code must match the primary diagnosis entered in Item 19 on the original (hard) copy.
21. Version Code Version of the ICD used for the individual's primary diagnosis.
22. Onset Month and year of the onset of the individual's disabling condition.
23. Medical Diagnosis/DBMD Second Condition Any current medical diagnoses that the individual may have as determined by a licensed physician. Used to indicate factors that have a direct bearing on the required treatment or care or DBMD second condition.
24. Code Code from the ICD indicating the individual's current medical diagnosis or DBMD second condition.
25. Version Code Version of the ICD used for the individual's current medical diagnosis or DBMD second condition.
26. Psychiatric Diagnosis/Additional Diagnosis(es) Diagnosis if the individual has any current mental disorder, behavioral health disorder(s) or DBMD additional condition as diagnosed by a licensed professional in accordance with the Diagnosis and Statistical Manual of Mental Disorders (DSM) or ICD.
27. Code Code from the DSM or ICD for the individual's psychiatric diagnosis or DBMD additional condition.
28. Version Code Version of the DSM or ICD used for the individual's psychiatric diagnosis or DBMD additional condition.

Cognitive/Adaptive Functioning

Item Name Contents
29. IQ Current IQ score, if obtainable. If IQ cannot be ascertained for an individual because of the severity of the disability (such as profound intellectual disability), enter 019 as the score.
Note: This item is optional if LOC VIII is requested. This is not required for CLASS or DBMD.
68. IQ Instrument 01 = Wechsler Intelligence Scale for Children (WISC)
02 = Wechsler Adult Intelligence Scale (WAIS)
03 = Wechsler Preschool and Primary Scale of Intelligence (WPPSI)
04 = Stanford-Binet form LM (S-B LM)
05 = Cattell Intelligence Test Scale
06 = Peabody Picture Vocabulary Test (PPVT)
07 = Beta
08 = Other
09 = WISC (Revised)
10 = WAIS (Revised)
11 = PPVT (Revised)
12 = Slosson Intelligence Test (SIT)
13 = Leiter International Performance Scale (LIPS)
14 = WISC III
15 = WAIS III
16 = LIPS-Revised
17 = S-B 4th
18 = S-B 5th
19 = WISC IV
20 = SIT-Revised
Note: This item is optional if LOC VIII is requested. This is not required for CLASS or DBMD.
30. ABL Code to indicate the individual's ABL.
01 = Mild
02 = Moderate
03 = Severe
04 = Profound
Note: CLASS and DBMD providers reference ABL conversion chart.
69. ABL Instrument 01 = Vineland
02 = Inventory for Client and Agency Planning (ICAP)/Other
03 = Vineland ABL Standard Score
04 = Vineland Adaptive Behavior Scales, Second Edition (Vineland-II)
05 = Scales of Independent Behavior – Revised (SIB-R)
06 = American Association of Intellectual and Developmental Disabilities (AAIDD) Adaptive Behavior Scales (ABS)
70. ABL Assessment Date To be used by CLASS and DBMD. Date that adaptive behavior level was assessed using one of the approved instruments.
71. Level of Consciousness 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 CLASS or DBMD.
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
74. Score Identified by ABL Instrument To be used by CLASS and DBMD. The provider notes the assessment score as identified by the selected ABL instrument in the applicable format.
75. Functional Assessment To be used by CLASS and DBMD. The provider notes the total number of Yes responses in Section 4 A.-F. of Form 8662, Related Conditions Eligibility Screening Instrument.

ICAP Data (not required for DBMD and CLASS)

Item Name Contents
31. Broad Independence Domain score calculated from the Inventory for Client and Agency Planning (ICAP) assessment.
32. General Maladaptive Score with + or −, as applicable (CARE system only accepts "−" from key above "p" on computer keyboard).
33. ICAP Service Level Individual's actual service level obtained from the ICAP assessment.

Behavioral Status (for ICF/ID, HCS and TxHmL only)

Item Name Contents
34. Behavior Program Y (Yes) or N (No) to indicate whether or not a behavior program is in place for the individual.
Note: If a value of N is entered, Items 35-38 must have a value of 0.
35. Self-injurious Behavior (Behavior examples include self-inflicted tissue damage, including that related to property destruction, pica and excessive food consumption for individuals with Prader-Willi syndrome.)
Code to indicate Level of Caregiver Preventive Intervention:
0 = Not applicable or not on behavior program
1 = Requires additional staff supervision to prevent dangerous behavior (this code indicates a Behavior increase request)
2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior (this code indicates a request for LON 9)
Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).
36. Serious Disruptive Behavior (Behavior examples include threatening strangers, running into traffic and public disrobing.)
Code to indicate Level of Caregiver Preventive Intervention:
0 = Not applicable or not on behavior program
1 = Requires additional staff supervision to prevent dangerous behavior
2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior
Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).
37. Aggressive Behavior (Behavior examples include physical attacks against others.)
Code to indicate Level of Caregiver Preventive Intervention:
0 = Not applicable or not on behavior program
1 = Requires additional staff supervision to prevent dangerous behavior
2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior
Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).
38. Sexually Aggressive Behavior (Behavior examples include sexual assault, pedophilia and public masturbation.)
Code to indicate Level of Caregiver Preventive Intervention:
0 = Not applicable or not on behavior program
1 = Requires additional staff supervision to prevent dangerous behavior
2 = Requires constant one-on-one supervision during waking hours to prevent extremely dangerous behavior
Note: If a value of 1 or 2 is entered, then a Behavior Program must be in place for the individual (Item 34=Y).

Nursing

Item Name Contents
39. Service Provider Code to indicate the licensed or registered professionals who provide nursing services to the individual.
15 = Registered Nurse
16 = Licensed Vocational Nurse
40. Frequency Code Code to indicate the frequency of nursing services for the individual
0 = Individual does not have these services included in the IPP, ISP or IPC
1 = 15 minutes or less per week (0-13 hours per year)
2 = 16-30 minutes per week (14-26 hours per year)
3 = 31-60 minutes per week (27-52 hours per year)
4 = 61-149 minutes per week (53-130 hours per year)
5 = 150-180 minutes per week (131-156 hours per year)
6 = 181 or more minutes per week (157+ hours per year)

Day Services

Field Name Contents
41. Service Code to indicate if the individual participates in day services (group settings that are not individualized, including sheltered workshops and enclaves).
0 = Individual does not participate
1 = Individual does participate
42. Frequency Code Code to indicate the frequency of the individual's participation in day services.
0 = Individual does not participate in day services
1 = up to 5 hours per week
2 = 6-10 hours per week
3 = 11-15 hours per week
4 = 16-20 hours per week
5 = 21-25 hours per week
6 = 26 or more hours per week
43. Funding Code Code to indicate funding for the day services.
0 = Individual does not participate in day services
1 = Medicaid funding
2 = Texas Education Agency funding
3 = Funding from other state agencies
4 = General Revenue funding
5 = Other funding sources (church, senior citizen center, Salvation Army, etc.)

Employment Services

Item Name Contents
44. Service Code to indicate the individual participates in employment services.
0 = Individual does not participate
1 = Individual participates in short-term employment services (for example, employment assessments, job development)
2 = Individual participates in long-term employment services (for example, ongoing, long-term support to maintain individualized, competitive employment)
3 = Individual participates in both short-term and long-term employment services (both 1 and 2)
45. Frequency Code Code to indicate the frequency of the individual's participation in employment services.
0 = Individual does not participate
1 = up to 5 hours per week
2 = 6-10 hours per week
3 = 11-15 hours per week
4 = 16-20 hours per week
5 = 21-25 hours per week
6 = 26 or more hours per week
46. Funding Code Code to indicate funding for employment services.
0 = Individual does not participate
1 = Medicaid
2 = Texas Education Agency
3 = Department of Assistive and Rehabilitative Services
4 = General Revenue
5 = Other (non-state agency)

Functional Assessment

Item Name Contents
47. Ambulation Code to indicate the individual's ambulation.
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 = Wheelchair is the most appropriate method of ambulation.

Physician's Evaluation and Recommendation (Complete for ICF/ID Only.)

Item Name Contents
48. Does medical regimen of the individual need to be under the supervision of an M.D./D.O.? Check Yes or No to indicate whether or not the individual's medical regimen needs to be under the supervision of an M.D. or D.O.
Note: Yes must be indicated for the individual to be eligible for ICF/ID program.
49. Will the health status of the individual prevent participation in the active treatment of the ICF/ID program? Check Yes or No to indicate whether or not the individual's health status will prevent participation in the active treatment of the ICF/ID program.
Note: No must be indicated for the individual to be eligible for ICF/ID program.
50. To your knowledge, does the individual have a condition of intellectual disability (previously referred to as "mental retardation") and/or a related condition? Check Yes or No to indicate whether or not the individual has a condition of intellectual disability and/or a related condition.
Note: Yes must be indicated for the individual to be eligible for ICF/ID program.
51. Do you certify that this individual requires ICF/ID or ICF/ID-RC care? Check Yes or No to indicate whether or not you certify that this individual requires ICF/ID care.
Note: Yes must be indicated for the individual to be eligible for ICF/ID program.
52. Signature – I attest to Item 19 and Items 48-51 only. Signature of the M.D./D.O./Advance Practice Nurse/Physician Assistant.
For admission to ICF/ID, signature of the M.D./D.O. is required. Signature by designee is allowed for subsequent ID/RC Assessments.
53. Print full Name Physician's or Advance Practice Nurse/Physician Assistantís printed full name.
54. Date Completed Date of Physician's or Advance Practice Nurse/Physician Assistantís signature.
55. Physician License No. Physician's license number.
72. I attest that I have been delegated Items 19 and 48-51 by the physician whose license is noted in Item 55 and I am an APN/PA with the following valid license no.: Advance Practice Nurseís or Physician Assistantís license number.

Provider Certification

Item Name Contents
56. Signature of RN/LVN/QIDP/QDDP/Case Manager/LA Service Coordinator/HCS Provider Representative Signature of RN/LVN/QIDP/QDDP/Case Manager/LA Service Coordinator/HCS Provider Representative responsible for the completion of this form.
Note:  The following may sign for each program:
HCS – LA Service Coordinator (initial only), HCS Provider Representative (all others)
TxHmL – LA Service Coordinator
ICF/ID – RN, LVN, QIDP/QDDP
CLASS – RN, LVN, QIDP
DBMD – RN, QIDP, Case Manager
57. Print Full Name of RN/LVN/QIDP/QDDP/Case Manager/LA Service Coordinator/HCS Provider Representative Printed full name of RN/LVN/QIDP/QDDP/Case Manager/LA Service Coordinator/HCS Provider Representative who signed the form.
58. Date Date of the signature of the RN/LVN/QIDP/QDDP/Case Manager/LA Service Coordinator/HCS Provider Representative who signed the form.

Requested Begin/End Dates

Item Name Contents
59. Begin Date Requested effective date of the LOC determination/LON assignment.
60. End Date Requested end date of the LOC determination/LON assignment. Note: Use end date only for Purpose Code E for ICF/ID, HCS and TxHmL.

For Departmental Use Only

Item Name Contents
61. LOC (Level of Care)
Code to indicate the assigned level of care.
0 = Denial of LOC
1 = LOC I
8 = LOC VIII
62. LON (Level of Need)
Code to indicate the assigned LON.
0 = Denial of LON
1 = LON 1 (Intermittent)
5 = LON 5 (Limited)
8 = LON 8 (Extensive)
6 = LON 6 (Pervasive)
9 = LON 9 (Pervasive +)
Note: See Calculating Level of Need Chart.
63. Effective Date Effective date of the LOC determination/LON assignment.
64. Expiration Date Expiration date of the LOC determination/LON assignment.
65. Name of Reviewer Name of DADS staff person reviewing the assessment and assigning the LOC/LON.
66. Date Reviewed Date the assessment was reviewed.
67. Name of Physician Name of the DADS physician or designated staff person who reviews the assessment when LOC has been denied (if applicable).

ABL Determination for CLASS and DBMD Programs

ICAP Conversion
Service Level Adaptive Behavior Level

7,8,9

I

4,5,6

II

2,3

III

1

IV


SIB-R Conversion
RMU Range Adaptive Behavior Level

82/90 – 100/90

I

34/90 – 81/90

II

5/90 – 33/90

III

0/90 – 4/90

IV

Calculating Level of Need (LON)

LON Description ICAP Service Level Service Score Range Other
1 Intermittent 7, 8 or 9 >+ 70  
5 Limited 4, 5 or 6 40 – 69  
8 Extensive 2 or 3 20 – 39  
6 Pervasive 1 1 – 19  
9 Pervasive + Any Any Must have a value of 2 in at least one of the following items:
35. Self-injurious Behavior
36. Serious Disruptive Behavior
37. Aggressive Behavior
38. Sexually Aggressive Behavior

Behavior Increase (both ICF/ID and HCS):

If at least one of the behavior Items 35 through 38 is a value of one, then a behavior increase is indicated. If the level of need has a value of 1, 5 or 8, then the requested LON will be increased one level when the ID/RC is electronically transmitted to DADS. Documentation justifying the behavior increase must be submitted to DADS within seven calendar days of the electronic transmission of the ID/RC.

Medical Increase (ICF/ID only)

If Item 40, Nursing: Frequency Code, has a value of 6 indicating that 181 or more minutes per week of nursing services are provided and Item 39, Nursing: Service Provider, has a value of 15 or 16 (15=Registered Nurse, 16=Licensed Vocational Nurse), then a medical increase is indicated. If the level of need has a value of 1, 5 or 8, then the level of need will be increased one level when the ID/RC is electronically transmitted to DADS. Documentation justifying the medical increase must be submitted to DADS within seven calendar days of the electronic transmission of the ID/RC.

LON 9 (both ICF/ID and HCS):

If at least one of the behavior Items 35 through 38 is a value of two, then a LON 9 is indicated and the requested LON will be increased to a LON 9 when the ID/RC is electronically transmitted to DADS. Documentation justifying an initial LON 9 request must be submitted to DADS within seven calendar days of the electronic transmission of the ID/RC.

Other

1: A LON 6-Pervasive will never be increased to a LON 9-Pervasive + when requesting a behavior or medical increase.

2: In ICF/ID, an individualís LON can only be increased one time. For example, if an individualís ID/RC satisfies both the behavior criteria for an increase and the nursing criteria for an increase, then the LON is only increased one level.

3: Cost caps for individuals enrolled in HCS are based on their LON. If the information on the ID/RC indicates an individual receives 181 or more minutes per week of nursing services and these services are provided by a registered nurse (RN) or a licensed vocational nurse (LVN), then that individual's cost cap will be increased to the LON 6 cost cap if the current LON has a value of 8.