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State of Maryland Medical Assistance Manual Revised April 2014

Client Name_____________________________________ Table II. Rehabilitation (PT/OT/Speech Therapy services) Must be current ongoing treatment.

Review Item (Please indicate the number of days per week each service is required.) # of days service is required/wk. (0-7)

15. Extensive Training for ADLs: (restoration, not maintenance) including walking, transferring, swallowing, eating, dressing and grooming.

16. Amputation/Prosthesis Care Training: For new amputation

17. Communication Training: For new diagnosis affecting ability to communication

18. Bowels and/or Bladder Retraining Program: Not including routine toileting schedule

Part F – Functional Assessment

Review Item Answer

Cognitive Status (Please answer Yes or No for EACH item.) Y

N 1. Orientation to Person; Client is able to state his/her name

2. Medication Management: Able to administer the correct medication in the correct dosage, at the correct frequency without the assistance or supervision of another person.

3. Telephone Utilization: able to acquire telephone numbers, place calls, and receive calls without the assistance or supervision of another person.

4. Money Management: Can manage banking activity, bill paying writing checks, handling cash transactions, and making change without the assistance or supervision of another person.

5. Housekeeping: Can perform the minimum of washing dishes, making bed, dusting, and laundry, straightening up without the assistance or supervision of another person

6. Brief interview for mental status (BIMS). Was the examiner able to administer the complete interview? If yes, indicate the final score. If no, indicate reason. (Examination should be administered in a language in which the client is fluent).

If yes, Score: ____________ If No, check one of the following:  Hearing Loss  Applicant is rarely/never understood  Language Barrier  Refused  Other (specify) _________________

Behavior (Please answer Yes or No for EACH item.)

Answer

Y N 7. Wanders (several times a day): Moves with no rational purpose or Orientation, seemingly oblivious to needs or safety

8. Hallucinations or Delusions (at least weekly): Seeing or hearing nonexistent objects or people, or a persistent false psychotic belief regarding the self, people, or objects outside of self.

9. Aggressive/abusive behavior (several times a week): Physical and verbal attacks on other including but not limited to threatening others, hitting, shoving, scratching, punching, pushing, biting, pulling hair or destroying property.

10. Disruptive/socially inappropriate behaviors including but not limited to making disruptive sounds self-abusive acts, inappropriate sexual behavior, disrobing in public, smearing/throwing food/feces, hoarding, rummaging through others’ belongings constantly demanding attention, urinating in inappropriate places.

11. Self-injurious behavior (several times a month): Repeated behaviors that cause injury to self, biting, scratching, picking behaviors, putting inappropriate object into any body cavity, (including ear, mouth, or nose) head slapping or banging.

DHMH Form 3871B Rev 10/11 (3 of 4)