Form 2190, Capacity Assessment for Self-Care and Financial Management

Instructions

Updated: 11/2007

Purpose

General Information

The purpose of the Capacity Assessment for Self-Care and Financial Management is to examine a person's:

• decision-making ability;
• ability to communicate a decision;
• ability to provide food, clothing or shelter for one's self;
• ability to care for one's own physical health;
• ability to manage one's own financial affairs and property; and
• need for and type of guardianship.

The assessment is intended to assess the capacity of an elderly person, a person with intellectual disability, a person with a developmental disability or an individual who is suspected of being a person with intellectual disability or a developmental disability. Its use is mandated for referrals to court for guardianship proceedings if the person is served by:

• state supported living centers and state centers;
• local authorities and their subcontractors;
• providers in the ICF/IID or Medicaid waiver programs; and
• nursing facilities.

However, the assessment may be appropriate for court referrals even if the individual is not a resident of such a facility.

Key Definitions

• Assessee — The person being assessed.
• Assessor — The person completing the assessment.
• Developmental disabilities — Defined in the Developmental Disabilities Assistance and Bill of Rights Act of 1984 as severe, chronic mental and/or physical impairments that occur before the age of 22, are likely to continue indefinitely and limit three or more of the following life activities: self-care, self-direction, learning, language, mobility, capacity for independent living and economic self-sufficiency. A developmental disability resulting from a diagnosis of only mental illness before the age of 22 is excluded from this definition for purposes of the capacity assessment for self-care and financial management.
• Elderly person — An individual who is 60 years of age or older, as defined in the Texas Human Resources Code, Chapter 102, Rights of the Elderly.
• Exploitation — The illegal or improper act or process of using a person or the resources of a person for monetary or personal benefit, profit or gain.
• Informant — The person who gives information to the assessor for use in completing the assessment. Anyone who is paid to provide support services is considered a staff informant.
• Intellectual disability — Significantly sub-average general intellectual functioning two or more standard deviations below the age-group mean for the tests used that is concurrent with deficits in adaptive behavior (based on a standardized scale) and originates during the developmental period (up to age 18).

Procedure

The assessment will be administered per appropriate agency guidelines to an individual when incapacity is suspected by the following professionals:

• a representative of an interdisciplinary care plan team in a nursing facility;
• a member of a planning team in HHSC programs.

The capacity assessment also may be initiated by others such as an advocate, relative or friend concerned about an individual's decision-making capacity.

The assessment does not yield scores. However, using the responses to the assessment questions, recommendations can be made regarding the assessed person's capacity to make decisions or care for self and whether a referral to probate court for a guardianship hearing is warranted. The assessment findings would then be an essential part of the information provided to a judge, who would make the legal determination regarding capacity and need for guardianship.

Instructions for Section A, Background Information, address the person to be assessed and other persons participating in the assessment process. It includes basic information about the person being assessed (assessee), the professional responsible for the assessment (assessor) and the informants (for example, relatives, friends or facility staff) providing detailed information about the person. Key information about the informants includes their relationship with the assessee and the frequency of interaction. Assessee-related information includes physical and sensory disabilities, medical condition, relevant diagnoses, current medications and communication ability.

Instructions for Section B, Self-Care and Financial Management Assessment, address a person's ability to maintain his or her own health, safety and financial affairs. The self-care section covers the areas of mental status, personal safety, travel safety, nutrition, clothing, health care and medications. The financial management section addresses basic knowledge of money and financial management.

The assessment areas within each section consist of a series of questions that measure basic awareness, knowledge, understanding, communication and functional ability. For each of these areas, the assessor identifies any limitations that impact the person's ability to make decisions or care for himself or herself, assistance needed, and the current availability of such assistance. The instructions for each area contain examples of the intent of each question. The purpose of these instructions and examples is to increase the reliability of the assessments.

The opportunity for an assessee to perform self-care and financial skills varies by setting. If there has been no opportunity to observe an assessee's performance of a skill, this must be noted in the comment section. When there are questions or disagreements about a skill area, the assessor should set up an opportunity to observe the assessee's performance of a skill.

When a referral to court for a guardianship is initiated, Section 687 of the Probate Code requires a written letter or certificate from a physician verifying the person's incapacity and need for guardianship. The minimum required content is included in the Probate Code, although individual judges may request additional information. If the basis for the incapacity is mental retardation, a psychological evaluation in compliance with regulations is required. This psychological evaluation must be updated within six months of the hearing. It is recommended that the capacity assessment results be shared with the physician or psychologist prior to examination.

Detailed Instructions

Section A — Background Information

Initials of Assessor — Enter the initials of the person preparing the assessment in the space provided at the top left corner of every page.

Reason for the Assessment — Identify the person or entity who made the referral for a capacity assessment. Briefly describe the situation or behavior that led to the decision to conduct the assessment.

Identifying Information

Name of Assessee — Self-explanatory.

Social Security No. — Self-explanatory.

Date of Birth — Self-explanatory.

Sex — Self-explanatory.

Type of Residence — Check the type of residence in which the person lives.

Residential Information

Name of Residence or Provider (if applicable) — Indicate the facility or provider name, as appropriate (corporate or individual). If not in supervised living, enter N/A.

Current Residential Address — Enter the address where the assessee is residing at the time of the assessment. Enter the street address of the residence, not the corporate address.

Residential Telephone No. — Enter the telephone number where the assessee is residing at the time of the assessment. Enter the residential telephone number, not the corporate telephone number.

Previous Placement (if applicable) — Enter the name of the location from which the assessee was admitted to the current residence, if applicable, and type of residence.

Reason for Admission (if applicable) — Enter the reason as stated in the residential record, if applicable (for example, medical condition, change in functional status or support system).

Language

Primary Language — Enter the name of the language (for example, English, Spanish, Vietnamese) preferred by the person being assessed.

Primary Form of Communication — Enter the primary means of communication, such as oral, written, gestural, sign language or communication device, used by the person being assessed to communicate. If the person being assessed is interviewed, it must be conducted through his or her primary form of communication.

Ability to Read — Check all the descriptors that apply.

Ability to Write — Check all the descriptors that apply.

Physical and Sensory Impairments

Enter the type and degree of visual, hearing, mobility, communication or other impairments and list any adaptive devices used by the person being assessed. Describe how each impairment may adversely affect a person's ability in self-care and financial management. Examples of impairments and adaptive devices include:

• Visual — Legally blind and uses corrective lenses.
• Hearing — Severe hearing loss and uses hearing aids.
• Mobility — Partially ambulatory and self-propels with a wheelchair.
• Communication — Inarticulate speech and uses a communication board.
• Other — Neurological or biochemical disorder that causes physical or sensory impairments such as tremors or hallucinations.
• Comatose — A state of profound unconsciousness from which a person cannot be aroused. If the person is diagnosed as comatose, complete only the background information and the general summary section.

Medications

List all medications, including dosages and schedules, being taken at the time of the assessment.

Major Medical or Psychiatric Diagnoses

List all current medical or psychiatric diagnoses.

Financial Assets

Complete this section when asset information is available to supplement the assessment of capacity to manage finances.

Real Estate — Indicate whether the person owns or is purchasing a home or any other real estate.

Monthly Income — Estimate the person's monthly income and indicate income sources, such as governmental assistance, salary, dividends or retirement.

Other Assets — Check all that apply.

Employment Status — Indicate if the person works and describe.

Financial Management Assistance

Check all that apply. Provide name and describe relationship to the person.

Natural Support System

Summarize the type and strength of the assessed person's relationships with family and other people or organizations in the community.

Staff Informant Information

Face-to-face interviews with informants are preferable, but telephone interviews may be used, if necessary. The assessor must obtain, if possible, the assessed person's view of his or her relationship with each staff informant contributing to the capacity assessment. Photocopy this section if there are more than three staff informants.

Name of Informant — Enter the name and title of any person, other than the assessor, who contributed information to the assessment in a professional capacity, but who does not hold the lead responsibility for completion of the document.

Title and Duties — Enter employment title and general description of informant's staff duties.

How long has the staff informant known the person? — Enter how long staff person has known the person being assessed.

How frequently has staff informant interacted with the person? — Enter average frequency of staff contact with the person being assessed for the indicated time period. Check daily only for live-in arrangement or staff providing service seven days a week.

Assessed Person's View of Informant — Enter how the person being assessed feels about his or her relationship with each staff informant. The opinion should be determined when the informant(s) is not present.

Additional Informant Information

The assessor should attempt to seek input on the assessee's capacity from additional informants (for example, relatives, friends or others). Interviews by telephone or correspondence are acceptable. The assessor should obtain the assessed person's view of his or her relationship with each informant contributing to the capacity assessment. Photocopy this section if there are more than two informants.

Absence of Additional Informant Information — Document efforts to obtain information from a key informant who was not available or who declined to contribute information about the assessee.

Name of Informant — Self-explanatory.

Telephone No. — Self-explanatory.

Address — Self-explanatory.

Relationship to Person — Indicate relationship between informant and assessee: friend, relative (for example, spouse, mother or daughter-inlaw) or other (for example, advocate, significant other, attorney or neighbor).

Length of Relationship — Enter how long the informant has known the person being assessed.

Type of Contact — Check the type of contact the informant has with the person being assessed; check all that apply.

Frequency of Contact — Check if daily or report number of contacts per time period.

Assessed Person's View of Informant — Enter how the person being assessed feels about his or her relationship with each informant. Determine this when the informant is not present.

Section B — Self-Care and Financial Management Assessment

Overview

Guardianship is a legal procedure under which a person is declared incapacitated by a court with probate jurisdiction. For the purpose of this particular assessment process, incapacitated means an adult individual who, because of a physical or mental condition, is substantially unable to provide food, clothing or shelter for himself or herself, to care for his or her own physical health or safety, or manage his or her finances, as defined in the Texas Probate Code.

Following an application and hearing, a court may grant another person guardianship of the assessed person. Though guardianship is intended to be a protective mechanism for incapacitated persons, if not properly designed, it has the potential to be overly intrusive and interfere with the person's autonomy. However, when guardianship is properly established, it can actually facilitate autonomy in certain areas. The current assessment process is designed to aid the court in creating guardianships only when necessary and appropriate to the person's needs. Some people need only minimal help with their decisions, while others may need help with almost every decision.

It is important that one not confuse dependency with the need for a guardian. Neither age, communication barriers, physical infirmity, unusual lifestyle or mobility impairment by themselves are synonymous with legal incapacity. Many conditions that affect decision-making abilities may be episodic in nature. It is, therefore, desirable in some circumstances to assess the person on multiple occasions. Likewise, making "bad choices" does not necessarily indicate the need for a guardian. A guardianship referral to court should only be made when the outcome of a capacity assessment suggests a person is unable to care for himself or herself and when he or she lacks decision-making capacity. Finally, guardianship should be sought only when it is clearly in the individual's best interest and the most appropriate alternative.

Purpose

This assessment process should assist in the identification of limitations in a person's decision-making and ability to care for and protect self and manage financial affairs. The answers to the questions indicate whether a person appears to have the capacity to make his or her own decisions or whether he or she would benefit from the protection offered by a guardian. This document provides a standardized approach to gathering information to assist in the assessment of capacity. This assessment process is intended to assess a person's awareness, level of understanding and functional ability within a variety of areas. It is important to remember that this assessment does not constitute a legal finding of incapacity. The assessment is intended as a standardized screening to provide information to judges who make the legal determinations of capacity.

Choosing a Response

The assessor makes a judgment as to the appropriate response based on observations and information provided by the informants and the assessee. The choice of a response may be based on long-term knowledge about the person or direct questioning and observation. The assessor should not automatically assume the person lacks ability when opportunity has not been provided for the person to demonstrate skills.

Yes — Choose this response when the person being assessed is able to communicate or demonstrate knowledge, understanding or ability on a consistent basis or there is evidence the person could perform the skill given the opportunity. If the person is capable of the activity but freely chooses not to do it, a Yes response is still appropriate. However, if this endangers the person or others in any way, this should be described in the narrative.

No — Choose this response when the person being assessed is not able to communicate or demonstrate knowledge, understanding or ability on a consistent basis even if given the opportunity. Choose No if a person is unable to perform all skills in an item reflecting multiple skills (for example, acquire, store and prepare foods).

Yes, with assistance — Choose this response if the person being assessed needs assistance to some degree to perform the activity. This response is appropriate if the person expresses preferences, gives instruction or directs an activity even though the person may require some physical assistance. Do not choose this response if the person is passively receiving the service and is not providing instruction or participating in the activity in any significant way. For example, the person may need physical assistance but is able to direct and choose what clothes to wear.

Disagreement — The assessor must choose the best response from the above options (that is, Yes, Yes with assistance or No) based on observations made and information collected. Any disagreement among the informants or by the assessee on responses to items should also be indicated by checking the disagreement box. The nature of the disagreement must be documented in the comment space. Only in the case of a disagreement would the assessor check two responses.

Conducting the Assessment

The following questions are used to identify the awareness, knowledge, understanding and functional abilities of the person being assessed. The questions appear as they are listed on the form. For clarification, examples are provided for each question. Complete only Section A, Background Information, if the person being assessed is comatose. The background information on a comatose person would be forwarded along with a physician's referral form when there is a guardianship referral to court. Complete the full assessment for all other individuals.

I. Self-Care

A. Mental Status

1. Can the person identify who he or she is? — Example: Can the person communicate his or her first and last name? Nicknames may be used in place of given names.

2. Can the person identify where he or she is? — Example: Can the person communicate the current location by name or type of residence (such as ICF/IID or nursing facility)? Any accurate description is acceptable, however general or specific. If the person cannot communicate the location or identifies an inaccurate location, choose No.

3. Can the person identify the approximate date? — Example: Can the person communicate which day of the week it is or the month and year, such as May 20__?

4. In the area of mental status, the assessor must summarize any problems or any assistance needed. — Document any disagreement among informants or by the assessee on item responses. If No is checked for any item, give a brief explanation.

B. Personal Safety

1. Is the person aware of dangers or unsafe practices that could cause harm, injury or death? — Example: Does the person know not to touch a hot stove or to evacuate if there were a fire in the room?

2. Does the person take appropriate action to avoid dangers? — Example: Does the person know to check the temperature of the water before entering the shower or bath?

3. Does the person know when to seek shelter? — Example: Can the person recognize that poor weather conditions such as a thunder storm or snow storm require him or her to take shelter in a building?

4. Can the person identify the consequences of unsafe conditions and practices in the home environment? — Example: Can the person identify theft of property as a possible consequence of not locking his or her residence or fire as a possible consequence of smoking in bed?

5. Does the person show proper caution with strangers? — Example: Can the person discriminate between strangers and friends, family or staff, and does the person know not to walk off with strangers?

6. Can the person identify abuse (physical, emotional or sexual)? — Example: Does the person know that it is not right for a person to hit him/her?

7. Does the person know what to do if he or she is threatened or abused? — Example: Can the person name someone to tell if he or she has been hit, threatened or victimized by another person?

8. Can the person identify neglect? — Example: Does the person know his/her caretaker is supposed to provide basic necessities? Can the person give an example of a neglect situation?

9. Does the person know what to do if neglected? — Example: Does he or she know an appropriate person to tell if neglected?

10. In the area of personal safety, summarize any problems regarding skills, opportunity to perform skills or decision-making ability, as well as additional assistance needed. — Document any disagreement among informants or by the assessee.

C. Nutrition

1. Can the person communicate the need to eat to others? — Example: Can the person make it known he or she is hungry?

2. Does the person know the difference between food and non-food items? — Example: Does the person attempt to eat non-food items, such as hair, dirt or cigarettes?

3. Does the person understand that an inadequate diet can lead to malnutrition or illness? — Example: Does the person communicate that a variety of foods must be consumed for good health?

4. Can the person acquire, store and prepare food? — Example: Does the person have the ability to shop for food, refrigerate it, if necessary, and cook it?

5. In the area of nutrition, summarize any problems regarding skills, opportunity to perform skills or decision-making ability, as well as additional assistance needed. — Document any disagreement among informants or by the assessee.

D. Clothing

1. Is the person aware of the necessity for clothing? — Example: Does the person know not to walk naked outside?

2. Can the person dress himself or herself appropriately? — Example: Can the person select appropriate articles of clothing from the closets or drawers and put them on?

3. Does the person understand the need to wear clothing consistent with temperature and weather conditions? — Example: Can the person request or choose protective clothing, such as a coat, during cold weather?

4. Can the person communicate that he or she is too hot or too cold for personal comfort? — Example: Can the person communicate to someone to adjust the temperature of the room or the need to change clothing?

5. Can the person acquire and maintain clothing? — Example: Can the person purchase clothing and adequately maintain it in terms of cleanliness and repair?

6. In the area of clothing, summarize any problems regarding skills, opportunity to perform skills or decision-making ability, as well as additional assistance needed. — Document any disagreement among informants or by the assessee.

E. Health Care

1. Can the person communicate that he or she needs treatment for an illness or injury? — Example: Does the person complain to others if not feeling well or seek assistance for injuries?

2. Can the person communicate his or her health needs? — Example: Can the person communicate to someone else about his or her unique health condition, such as diabetes, and the treatment required for it, such as a specialized diet?

3. Does the person understand the consequences of not accepting health assistance or medical treatment? — Example: Does the person understand that failure to follow recommended treatment may increase the severity of an illness?

4. Can the person take care of or obtain treatment for his or her health condition? — Example: Can the person call for appointments and access the health care system?

5. In the area of health care, summarize any problems regarding skills, opportunity to perform skills or decision-making ability, as well as additional assistance needed. — Document any disagreement among informants or by the assessee.

F. Medications

1. Is the person aware of the purpose of medications and when they should be taken? — Example: Can the person state a relationship between medication and relief of symptoms, such as aspirin for a headache?

2. Can the person take medication correctly without supervision or assistance? — Example: Can the person independently take an aspirin when he or she has a headache or independently take prescription medication?

3. Does the person understand the consequences of not taking medications? — Example: Does the person understand that failure to take medications as prescribed may increase the severity of a behavioral or medical problem.

4. Can the person communicate medication problems or needs? — Example: Can the person notify others of an unusual reaction to medication or a need to change or refill a prescription?

5. Can the person acquire medications, store them properly and take them as directed? — Example: Can the person go to the pharmacy/request delivery, purchase medicine and store it properly?

6. In the area of medications, summarize any problems regarding skills, opportunity to perform skills or decision-making ability, as well as additional assistance needed. — Document any disagreement among informants or by the assessee.

G. Travel Safety

1. Does the person routinely travel in the community? — Example: Does the person actually go out into the community regularly versus being restricted to his or her residence because of an impairment? Degree of supervision or assistance is not a factor in assessment of this item.

2. Can the person avoid common dangers when traveling in the community? — Example: Does the person avoid oncoming traffic?

3. Can the person identify his or her address? — Example: Can the person communicate to someone his or her residential street address (or location in a rural area)?

4. Can the person demonstrate the ability to return home or call for assistance if lost or stranded? — Example: Can the person call for help or ask for assistance if lost or stranded?

5. Can the person independently travel to familiar locations in the community using public or other forms of transportation? — Example: Can the person independently walk, catch a bus or drive to familiar locations such as stores or work?

6. Can the person plan trips, access transportation and arrive safely at his or her destination routinely when traveling? — Example: Can the person make local and/or long-distance trips and arrive at an unfamiliar destination safely?

7. In the area of travel safety, summarize any problems regarding skills, opportunity to perform skills or decision-making ability, as well as additional assistance needed. — Document any disagreement among informants or by the assessee.

H. Motor Vehicle Safety

1. Does the person operate a motor vehicle? — Example: Does the person drive a truck, car or motorcycle?

2. Can the person operate a motor vehicle in a safe and legal manner? — Example: Does the person obey traffic laws and have a valid license to operate a motor vehicle?

3. In the area of motor vehicle safety, summarize any problems regarding skills, opportunity to perform skills or decision-making ability, as well as additional assistance needed. — Document any disagreement among informants or by the assessee.

II. Financial Management

1. Is the person aware of the purpose of money? — Example: Can the person communicate for what purpose money is used?

2. Does the person know the values of different denominations of money? — Example: Can the person identify which of two bills has more value?

3. Does the person know the source and amounts of monetary benefits he or she receives on a weekly, monthly or annual basis? — Example: Can the person communicate what his or her income is and the sources of this income?

4. Can the person protect and independently spend a small amount of money? — Example: If the person can protect and independently spend small amounts of money, check the box that corresponds to the amount he or she can manage.

5. Can the person determine the cost of an item and know the proper change? — Example: The person knows the cost of a soft drink is 75 cents and knows that 25 cents is the change that should be received from a dollar.

6. Can the person exercise judgment when making decisions on how to budget money? — Example: Can the person make reasoned judgments about budgeting money for necessities versus budgeting for luxuries? Can the person make a budgeted amount last until the next pay period?

7. Does the person understand the concept of debt? — Example: Does the person understand that if he or she borrows money or charges items, these must be repaid?

8. Can the person receive a bill and pay it? — Example: Can the person pay his or her telephone bill or CD/music club bill?

9. Can the person protect his or her income in a safe manner? — Example: Can the person maintain a savings account or keep cash in a safe manner?

10. Is the person vulnerable to financial exploitation from others? — Example: Does the person give money to others based on manipulation or coercion?

11. Can the person communicate the concept of gift giving? — Example: Can the person communicate that gifts are given as gestures of affection or friendship and are permanent transactions?

12. Does the person understand the concept of a will? — Example: Can the person communicate that a will is the legal way in which money and property are left to others at death? Can the person designate who gets money and property at death?

13. Can the person identify his or her real and personal property and estimate its value? — Example: Does the person know whether he or she owns real estate or personal property and, if so, reasonably estimate its monetary value?

14. Can the person communicate the concept of selling property, real or personal? — Example: Does the person communicate that a sale involves the permanent exchange of property for money or something of similar value?

15. Can the person communicate the purpose of insurance? — Example: Can the person communicate what insurance is, the different types of insurance and why they are needed (for example, that collision insurance can be used to repair a car damaged in a wreck)?

16. Is the person capable of exercising sound judgment as to the type and amount of insurance that would be appropriate for his or her circumstances? — Example: Does the person have more insurance than is needed to protect current assets?

17. Can the person manage and insure his or her property? — Example: Does the person demonstrate the ability to maintain and insure real property, pay taxes or collect rent?

18. Is the person able to request the services of a lawyer and communicate preferences and/or wishes regarding legal instructions, documents and services? — Example: Can the person communicate the terms of a will or other legal actions to an attorney?

19. In the area of financial management, summarize any problems regarding skills, opportunity to perform skills or decision-making ability, as well as additional assistance needed. — Document any disagreement among informants or by the assessee.

III. General Summary — Self-Care Capacity and Financial Management Capacity

The assessor must provide a general summary of the person's decision-making abilities and functioning in the activities of self-care and financial management. The summary should address the person's opportunities to perform the activities. Recommendations should be made regarding services or interventions needed by this person, such as homemaker services or care from a nurse or caseworker. If indicated, recommendations should include assisted decision-making options such as surrogate decision-making or various forms of guardianship. Indicate if the person has an advance directive and/or power of attorney of any type. For guardianship referrals, a physician's statement regarding the person's capacity may need to be submitted to the court along with this assessment.

IV. Assessor Information

Name of Assessor — Enter the name of the person completing the assessment.

Title and Credentials of Assessor — Enter the title of the assessor along with his or her credentials (for example, licensure, certification, degrees).

Employer of Assessor — Enter the employer/agency of the assessor.

Assessor's Business Address — Enter the street address, city, state and ZIP code of the assessor's business.

Assessor's Business Telephone No., Fax No. and E-mail Address (if applicable) — Self-explanatory (include area codes).

V. Signature

The assessor should complete and sign Item A. when the capacity assessment will not likely be forwarded to court for a guardianship determination. If the capacity assessment will be forwarded to court for a guardianship determination, the assessor should complete, sign and have Item B. notarized. A physician's statement may be required to accompany the assessment for court proceedings. (Refer to General Information for clarification.)