Appendix 114-B Assessment Instruments for Non-Medicaid Home and Community Based Services: Determination of Need – Revised (DON-R) | HCBS-5300-MANUAL

Assess the client’s ability to feed themselves a meal using routine or adapted table utensils and without frequent spills.

Essential components of eating are:

When a special diet is needed, do NOT consider the preparation of the special diet when scoring this item (see “Preparing Meals” and “Routine Health” items).

If the client scores at least one (1) in level of impairment, evaluate whether someone (including telephone reassurance) is available to assist or motivate the client in eating. Is there someone available:

Assess the client’s ability to shower, bathe, or take sponge baths to maintain adequate hygiene and cleanliness. Consider minimum hygiene standards, medical prescription, or health related considerations such as incontinence, skin ulcer, lesions, and frequent profuse nose bleeds. If the consumer can give himself or herself periodic baths, but cannot bathe with the frequency needed because of incontinence, assign a higher score accordingly. If the consumer takes sponge baths and that is adequate, score only on getting in/out of the tub.

Essential components of bathing are:

If the client scores at least one (1) in level of impairment, evaluate the continued availability of resources to assist in bathing. Is there someone available:

Assess client’s ability to take care of personal appearance, grooming, and hygiene activities. If a professional has instructed the client to visit a podiatrist for toenail care, consider that an impairment.

Essential components of grooming are:

If the client scores at least one (1) in level of impairment, evaluate the assistance needed for grooming. Is there someone available:

Assess the client’s ability to dress and undress as necessary to carry out the client’s activities of daily living in terms of appropriate dress for weather or street attire as needed. If the client chooses night wear for day wear as a preference, do not score an impairment; however, if this is because of dexterity, score as mild impairment. Also include ability to put on prostheses or assistive devices. Consider fine motor coordination for buttons and zippers, and strength for undergarments or heavier items such as a winter coat. Do not include style or color coordination.

Essential components of dressing are:

If the client scores at least one (1) in level of impairment, evaluate whether someone is available to help dressing and/or undressing the client at the times needed by the client. Is there someone available:

Assess the client’s ability to get into and out of bed or other usual sleeping place, including pallet or arm chair. Include the ability to reach assistive devices and appliances necessary to ambulate, and the ability to transfer (from/to) between bed and wheelchair, walker, etc. Include the ability to adjust the bed or place/remove handrails, if applicable and necessary. Do not assess mobility around the home in this domain.

Essential components of transferring are:

If the client scores at least one (1) in level of impairment, evaluate the continued availability of resources, (including telephone reassurance and friendly visiting) to assist or motivate the client in getting into and out of bed. Is there someone available:

Assess the client’s ability to take care of bladder/bowel functions by reaching the bathroom or other appropriate facility in a timely manner. Consider the need for reminders. If the consumer has a colostomy that is managed properly, consider this as continent in bowel. Also, account for medical conditions (ex: temporary vs. permanent catheter).

Essential components of continence are:

If the client scores at least one (1) in level of impairment, evaluate whether someone is available to assist or remind the client as needed in bladder/bowel functions. Is there someone available:

Assess the client’s ability to handle money and coins and to pay bills. Include ability to plan, budget, write checks or money orders, exchange currency, and handle paperwork (including applications for benefits). Include the ability to read, write and count sufficiently to perform the activity. Do not increase the score based on insufficient funds.

Essential components of managing money are:

If the client scores at least one (1) in level of impairment, evaluate whether an appropriate person is available to plan and budget or make deposits and payments on behalf of the client. Consider automatic deposits, banking by mail, etc. Is there someone available:

Assess the client’s ability to use a telephone to communicate essential needs. Do not consider the absence of a telephone in the client’s home. The use of an emergency response system (ERS) device should be considered in the “Being Alone” domain.

Essential components of telephoning are:

If the client scores at least one (1) in level of impairment, evaluate whether someone is available to help the client reach and use the telephone or whether someone is available to use the telephone on behalf of the client. Consider the reliability and the availability of neighbors to accept essential routine calls and to call authorities in an emergency if client does not have a telephone in the home. Is there someone available:

Assess the client’s ability to plan and prepare routine hot and/or cold, nutritionally balanced meals. Do not consider the ability to plan therapeutic or prescribed meals. If a client states he or she cannot “cook like they used to”, he or she does not necessarily have an impairment score. The impairment score only looks at the level of impairment within the essential components. When in doubt, consider the essential components of preparing food in order for a person to remain healthy and safe.

Essential components of preparing meals are:

If the client scores at least one (1) in level of impairment, evaluate the continued availability of resources (including restaurants and home-delivered meals) to prepare meals or supervise meal preparation for the client. Consider whether the resources can be called upon to prepare meals in advance for reheating later. Is there someone available:

Assess the client’s ability to do laundry. Include use of coins where needed and use of machines and/or sinks. Only consider ability to access laundry facilities if they are inside the home. The consumer should be able to tell whether or not garments are clean.

Essential components of laundry are:

If the client scores at least one (1) in level of impairment, evaluate the continued availability of laundry assistance, including washing and/or dry cleaning. If public laundries are used, consider the reliability of others to insert coins, transfer loads, etc. Is there someone available:

Assess the client’s ability to do routine housework to maintain basic sanitary, hygienic, and safety conditions in the home. Do NOT include laundry, washing or drying dishes. In most cases, a consumer’s refusal to do housework is not considered an impairment.

Essential components of housework are:

If the client scores at least a one (1) in level of impairment, evaluate the continued availability of resources, including private pay household assistance and family available to maintain the client’s living space. When the client lives with others, do not assume the others will clean up for the client. This item measures only those needs related to maintaining the client’s living space and does not measure the maintenance needs of living space occupied by others in the same residence. Is there someone available:

If hoarding is suspected as a contributing factor to a consumer’s performance in this domain, consider the person completely unable to perform housework. Hoarding is a severe psychological condition for which highly specialized and extensive intervention is required. Resources to remediate this issue may be inadequate, unavailable, or inappropriate.

Assess the client’s ability to get to and from essential places outside the home. Consider ability to negotiate stairs, streets, porches, sidewalks, entrance and exits of residence, vehicle, and destination in all types of weather. Consider the ability to plan and secure appropriate and available transportation and to know locations of home and essential places. Lack of appropriate and available transportation as needed, will increase the score. However, in scoring, do not consider the inability to afford public transportation. Consider whether there are structural or safety issues with home entries and exits, such as faulty stairs or railings, or uneven surfaces. Consider the consumer’s ability to get from one location to another location without becoming confused or lost.

Essential components of outside home are:

If the client scores at least one (1) in level of impairment, evaluate the continued availability of escort and transportation, or someone to go out on behalf of the client.

Is there someone available:

Assess the client’s ability to follow directions from a physician, nurse or therapist, and to manipulate equipment in the performance of routine health care, if needed. Include simple dressings, special diet planning, monitoring of symptoms and vital signs (e.g. blood pressure, pulse, temperature and weight), routine medications, routine posturing and exercise not requiring services or supervision of a physical therapist. Consider the consumer’s ability to understand, recall, and implement the instructions of a health care provider. Score “0” if client has no routine health needs.

Essential components of routine health care are:

If the client scores at least one (1) in level of impairment, evaluate the continued availability of someone to remind, supervise or assist the client in complying with routine medical directions.

Is there someone available:

Assess the client’s ability to perform or assist in the performance of specialized health care tasks which are prescribed and generally performed by licensed personnel including physicians, nurses, and therapists. Include blood chemistry and urinalysis; complex catheter and ostomy care; complex or non-routine posturing/suctioning; tube feeding; complex dressings and decubitus care; physical, occupational and speech therapy; intravenous care; respiratory therapy; or other prescribed health care provided by a licensed professional. If the consumer has diabetes and requires special foot care, she should be assessed for the ability to cooperate with the professional while the care is being provided. Score "0" for clients who have no specialized health care needs.

Essential components of special health care are:

If the client scores at least one (1) in level of impairment, evaluate the continued availability of specially trained resources as necessary to assist with or perform the specialized health care task required by the client.

Is there someone available:

Assess the client’s ability to be left alone and to recognize, avoid, and respond to danger and/or emergencies. Include the client’s ability to evacuate the premises or alert others to the client’s need for assistance, if applicable, and to use appropriate judgment regarding personal health and safety. Also take into account the consumer’s proficiency at making judgments about personal health and safety.

Essential components of being alone are:

If the client scores at least one (1) in level of impairment, evaluate the continued availability of someone to assist or supervise the client as needed to avoid danger and respond to emergencies. Consider the availability of “watchful oversight” such as friendly visiting, telephone reassurance, and neighborhood watch programs.

Is there someone available: