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Effective Date: 
11/2014

Documents

 

Instructions

Updated: 9/2017

 

Purpose

Form H2060 and Form H2060-S (Spanish) are used as an instrument for collecting and documenting essential information regarding the applicant's or member's request or need for personal assistance services (PAS).

Form H2060/Form H2060-S is used to:

  • determine if the applicant/member meets the eligibility requirement score for state plan PAS in the STAR+PLUS program;
  • assess the applicant's/member's needs, functional impairments and ability to perform activities of daily living; and
  • determine the weekly minutes/hours of PAS for STAR+PLUS Program and STAR PLUS Home and Community Based Services (HCBS) program.

Form H2060/Form H2060-S information must be kept in the applicant's/member's case file.

 

Procedure

When to Prepare or Update

Each task (Items 1-23 for the STAR+PLUS Program and Items 1-19 for the STAR+PLUS HCBS program) must be given an impairment score and each task must be coded in the service arrangement column. The Task/Hour Guide must be completed for each purchased task and each purchased task must have subtasks marked in Part C.

 
For STAR+PLUS Program

Complete Form H2060/Form H2060-S when:

  • the applicant/member needs an initial assessment;
  • the applicant/member needs an annual reassessment;
  • a member’s need changes or there is change in the member's function; or
  • a member requests PAS.

 

For STAR+PLUS HCBS program

While an impairment score is not required for eligibility for STAR+PLUS HCBS program services, if the STAR+PLUS HCBS program applicant/member requests or expresses a need for PAS, complete Part A, Items 1-19. It is not necessary to ask questions in Items 20-23. Scoring of each item is required for documentation of the applicant’s/member’s impairment and need for services.

Complete the Impairment and Service Arrangement columns. Tasks completed through other agencies and caregivers are also noted on Form H1700-B, Non-STAR+PLUS HCBS Program Services. The Support Score column is not required.

Complete Form H2060/Form H2060-A for the STAR+PLUS HCBS program applicant/member when:

  • the applicant/member needs an initial assessment;
  • the applicant/member needs an annual reassessment;
  • a member’s need changes or there is change in the member's function; or
  • a member requests PAS.

For STAR+PLUS HCBS program Adult Foster Care (AFC) and Assisted Living (AL) applicants/members, complete Part A to indicate specific tasks to be provided by the AFC provider or AL. The AFC provider or AL may perform more tasks but no less than those indicated in Part A. No time is allocated for PAS tasks for AFC or AL applicants/members because PAS is provided by the AFC provider or AL under the AFC or AL contract. A copy of Form H2060/Form H2060-S is shared with the AFC provider or AL.

 

Form Retention

Keep the original of the form in the applicant/member case record. The form is kept for five years after the case is closed.

 

DETAILED INSTRUCTIONS

Applicant/Member Name — Enter the name of the applicant/member.

Medicaid ID No. — Enter the nine-digit Medicaid number of the applicant/member.

Assessment Date — Enter the date the assessment is completed.

Companion Case Name — Enter the name of all persons (if any) residing in the same household who are also receiving STAR+PLUS Program or STAR+PLUS HCBS program purchased attendant care services.

Companion No. — Enter the Companion Medicaid ID number.

Respondent — Enter the member's name, if responding. Enter the name and relationship of the individual responding, if not the member.

 

A — Functional Assessment

Complete Part A during a face-to-face visit with an applicant/member. Score Items 1-2, 4-12 and 14-23; but do not include the score for Item 4 in the Total Score (Item 24).

Score the applicant/member according to the following scale:

0

=

None. No functional impairment. The applicant/member is able to conduct activities without difficulty and has no need for assistance.

1

=

Mild. Minimal/mild functional impairment. The applicant/member is able to conduct activities with minimal difficulty and needs minimal assistance.

2

=

Severe. Extensive/severe functional impairment. The applicant/member has extensive difficulty carrying out activities and needs extensive assistance.

3

=

Total functional impairment. The applicant/member is completely unable to carry out any part of the activity.

An applicant/member has an impairment with respect to a particular activity if he is limited, either physically or mentally, in his ability to carry out that activity.

Numbers 0 and 3 are absolutes in the sense that they indicate no functional impairment or total dependency. Example: If an applicant/member can perform any of the dressing task for himself, a “3” is not appropriate. If he can perform the dressing task completely without difficulty, a “0” is appropriate.

The first time an item is addressed, use the wording of the question as written on Form H2060/Form H2060-S, and then explain or paraphrase, if necessary. Ask follow-up questions if there is a need to verify the first response. Enter a score for each question.

Form H2060/Form H2060-S is designed to assess an applicant's/member's capacity for self-care. Score each item according to this capacity for self-care and not according to the applicant's/member's access to a resource to assist with the task. In scoring each item, use the applicant's/member's response, plus any observations or knowledge of the applicant/member from other sources.

Impairment Column

Use the following examples for each item to help differentiate between scores of “1” and “2.” An applicant/member may score “1”, but not request assistance with a task.

 

1 = Minimal/Mild Impairment

2 = Extensive/Severe Impairment

1.

Bathing

Applicant/member is able to bathe self, but needs supplies laid out.

Applicant/member is able to bathe self, but needs assistance drawing and testing the temperature of the water.

Applicant/member needs standby assistance for safety or reminding/monitoring.

Applicant/member needs minimal assistance getting in and out of tub or shower.

Applicant/member may accomplish bath for self by using a chair or other adaptive device for assistance.

Applicant/member needs extensive help getting in and out of tub or shower.

Applicant/member needs hands on help with actual bathing and drying of body.

Applicant/member must always use adaptive devices and needs assistance with arranging adaptive devices for the bath.

Applicant/member can only manage sponge baths due to disabilities.

Applicant/member requiring a bed bath can assist with some part of the task.

2.

Dressing

Applicant/member needs occasional help with zippers, buttons or putting on shoes and socks.

Applicant/member may need help laying out and/or selecting clothes.

Applicant/member needs reminding or monitoring for completion of dressing.

Applicant/member always needs help with zippers, buttons or shoes and socks.

Applicant/member needs help getting into garments; that is, putting arms in sleeves, legs in pants or pulling up pants.

Applicant/member may dress totally inappropriately without help and/or would not finish dressing without physical assistance.

3.

Exercising

Walking with the Applicant/member. Not scored.

 

4.

Feeding

Applicant/member may need standby assistance but only occasional physical help.

Applicant/member needs verbal reminders or encouragement.

Applicant/member eats with adaptive devices but requires help with applying and positioning.

Applicant/member usually needs extensive hands-on assistance with eating.

Applicant/member may hold eating utensils but needs continuous assistance during meals, and would not complete meal without continual help. Spoon feeding of most foods is required, but applicant/member can eat some finger foods.

5.

Grooming

Impairment score is based on the highest level of impairment scored on any grooming task in (5a-5b).

 

5a.

Shaving, Oral Care and Nail Care

Applicant/member can manage grooming, but needs supplies laid out or handed to him; needs standby for safety and assistance with grooming tools.

Applicant/member can accomplish grooming, but needs reminding/monitoring.

Applicant/member is unable to adequately shave (face or under arms and legs) because of inability to see well, to reach or to successfully use equipment.

Applicant/member is unable to adequately brush teeth and perform oral care.

Applicant/member is unable to adequately care for nails.

5b.

Routine Hair and Skin Care

Applicant/member can manage hair and skin care but needs supplies laid out.

Applicant/member needs reminding to do tasks.

Applicant/member needs assistance to comb or brush hair.

Applicant/member needs assistance applying non-prescription lotion to skin.

Applicant/member is unable to adequately perform washing hair (shampooing), drying hair or setting (rolling/braiding) hair.

Applicant/member is unable to adequately wash hands and face or apply makeup.

6.

Toileting

Applicant/member has instances of urinary incontinence and needs help because of this from time to time. Fecal incontinence does not occur unless caused by a specific illness episode.

Applicant/member may need help with supplies or equipment.

Applicant/member needs some assistance with clothing during toileting.

Applicant/member needs standby assistance.

Applicant/member may have catheter or colostomy bag, and occasionally needs assistance with management.

Applicant/member often is unable to get to the bathroom on time to urinate or has occasional episodes of fecal incontinence.

Applicant/member may wear incontinence products to manage the problem and needs assistance with them.

Applicant/member usually needs assistance with catheter or colostomy bag.

Applicant/member needs assistance with a bedpan or urinal, or with emptying a catheter bag or changing an external catheter or colostomy bag.

Applicant/member needs diapers changed or needs assistance with feminine hygiene products.

7.

Hygiene in Toileting

Applicant/member can usually manage cleaning self after toileting except on occasional days when bending or moving is particularly difficult, or when incontinence occurs.

Applicant/member may have catheter or colostomy bag, and occasionally needs assistance with management.

Applicant/member often needs assistance with cleaning after toileting because of difficulty in reaching, or due to incontinence problems; clothes are sometimes soiled and odorous.

Applicant/member usually needs assistance with catheter or colostomy bag.

8.

Transfer

Applicant/member usually can get out of bed or chair with minimal or standby assistance.

Applicant/member may accomplish transfer without help, but needs standby assistance for safety.

Applicant/member needs some assistance in adjusting or changing position in a bed or chair (positioning).

Applicant/member usually needs hands-on assistance when rising to a standing position or moving into a wheelchair to prevent losing balance or falling.

Applicant/member is able to help with the transfer by holding on and supporting himself.

Applicant/member can assist some with non-ambulatory movement from one stationary position to another (transfer). This task does not include carrying.

9.

Walking
(Ambulation)

Applicant/member walks alone without assistance for only short distances.

Applicant/member can walk with minimal difficulty using an assistive device or by holding onto walls or furniture.

Applicant/member needs assistance in positioning for use of a walking apparatus or putting on and removing leg braces and prostheses for ambulation.

Applicant/member has considerable difficulty walking even with an assistive device.

Applicant/member can walk only with assistance from another person and never walks alone outdoors without assistance.

Applicant/member may use a wheelchair periodically.

Applicant/member needs assistance with wheelchair ambulation. Wheelchair ambulation is defined as pushing the wheelchair for the applicant/member.

10.

Cleaning

Applicant/member can do most tasks around the house, like picking up, dusting, washing dishes, sweeping, straightening the bed, carrying out trash, light vacuuming or cleaning sinks.

Applicant/member cannot move heavy furniture or do extensive scrubbing or mopping.

Applicant/member is able to do only very light housework like dusting, washing a few dishes or straightening up magazines/newspapers.

Applicant/member cannot see well enough or does not have the strength or flexibility to sweep floors, change bed linens or carry heavy objects.

11.

Laundry

Applicant/member does hand washing but has difficulty wringing and hanging heavy laundry to dry.

Applicant/member is able to do most laundry tasks, but needs minimal assistance to put clothes in machines, sort clothes, fold them and put them away.

Applicant/member may have strength but may not be able to see or turn washer dials, or may require supervision/instruction to use a washer.

Applicant/member may do light hand washing but cannot bend or lift or carry loads of clothes to manage most laundry; and cannot hang clothes out at all or get them off a line, but may fold them and help put them away.

Applicant/member may not be able to wring out clothes without help. If a laundromat is used, the applicant/member has considerable difficulty getting there.

Applicant/member has special laundry needs due to incontinence or other physical problems and needs laundry more frequently than once a week.

12.

Meal Preparation

Applicant/member can do some meal preparation, but has some difficulty.

Applicant/member can prepare simple foods or warm up food like frozen meals or food prepared by others.

Applicant/member may have difficulty with cutting meats or other foods.

Applicant/member can prepare foods, but needs assistance with meal planning or minimal assistance in preparing meals.

Applicant/member is unable to cook meals due to physical impairment and can only do minimal preparation of simple cold foods like sandwiches or cereal.

Applicant/member has difficulty opening cans and preparing fresh foods for cooking.

Applicant/member regularly has difficulty seeing or turning burners on and sometimes forgets to turn them off.

Applicant/member needs prepared meals pureed or ground up for serving.

13.

Escort

Not scored.

 

14.

Shopping

Applicant/member decides what to buy, but needs assistance preparing a shopping list.

Applicant/member can shop if someone goes along to help.

Applicant/member may shop by telephone but needs assistance carrying or storing groceries.

Applicant/member can do most shopping, but needs extra items picked up between shopping trips.

Applicant/member may still decide what to buy, but seldom, if ever, goes to a store and needs shopping for all items and picking up medications.

Applicant/member may not be able to shop by telephone because of communication difficulties.

Applicant/member cannot regularly carry or store most of the purchases without help.

15.

Assistance with Medications

Applicant/member can self-direct* medications, but occasionally needs help with opening the containers.

Applicant/member may need to be reminded to take medications.
*Self-direct means the

Applicant/member can:

  • identify the proper medication by name or sight (color and/or shape);
  • identify the purpose of the medication (e.g. for my heart, for pain, for allergies);
  • determine the correct dosage is being taken (e.g. one pill); and
  • identify the time medication is needed (e.g. morning, lunchtime, etc.)

Applicant/member can self-direct* medications, but needs help opening containers and/or needs the medication brought to within reach.

Applicant/member can self-direct * medications, but has a visual impairment and may not be able to read labels.

Applicant/member can self-direct* medications, but must be reminded to ensure that medications are taken as prescribed.

This task may not be purchased if the functional score is “3.”

  • Total help indicates the applicant/member cannot self-direct medications and requires either skilled assistance or supervision from informal support; or
  • Total help indicates the applicant/member can self-direct medications, but due to a functional limitation is unable to self-administer medications.

16.

Trim Nails

Applicant/member can trim his own finger nails but may have difficulty doing his toe nails by himself.

Applicant/member trims finger nails only when no one is available to help.

Applicant/member is unable to reach and trim toe nails and has difficulty using scissors or clippers.

 

 

A diagnosis of diabetes does not automatically indicate a score of “3”; many people with diabetes can trim their nails. If a medical practitioner has instructed an applicant/member with diabetes not to trim the nails, score the task “3.”

17.

Balance

Applicant/member occasionally gets dizzy and/or needs to steady himself by holding onto furniture or a person and may need to hold someone's arm to go up and down stairs.

Applicant/member may have experienced an occasional fall because of imbalance or the applicant's/member's movement is restricted because of fear of falling.

Applicant/member usually experiences some imbalance and needs to hold onto a support when he first stands up to steady himself.

Applicant/member suffers from dizziness that affects his balance and would likely fall if assistance was not available.

18.

Open Jars, Containers

Applicant/member can open some containers but may have difficulty with very large jars, special medicine caps or containers that require special opening instructions or procedures.

Applicant/member may use an assistive device.

Applicant/member cannot open large jars or new bottles/jars without help or an assistive device.

Applicant/member may be able to open small jars and bottles that have been previously opened.

19.

Telephone

Applicant/member can use telephone but may have difficulty hearing or getting to the telephone quickly when it rings.

Applicant/member may need to go out of the home to use telephone but can do so without much difficulty.

Applicant/member may be able to answer and/or talk on the telephone but may not be able to dial the correct number.

Applicant/member is sometimes not able to get to a telephone when necessary.

On Items 20 and 21, the service coordinator can use information other than the applicant/member perception of himself only if:

  • the applicant/member provides inaccurate information because of his physical or mental impairment;
  • there are inconsistencies between the information the applicant/member is providing and the service coordinator's observation of the applicant/member; or
  • there is conflicting information provided by a family member present during the interview.

To properly score these questions, if the service coordinator is unsure of the information provided by the applicant/member, he will:

  • get as much information as possible from the applicant/member; and
  • contact a third party (family member, friend, etc.) who is aware of the applicant's/member's cognitive abilities; or
  • use his judgment to score the question if no one is available who knows the applicant's/member's cognitive abilities.

20. — Initial scoring: These questions are based on the applicant's/member's perception of himself.

0 – If the answer to both questions is no, stop here.
Final scoring:
1 – If the answer to all four questions is no.
2 – If the answer to any one of these four questions is yes.
3 – If the answer to at least two of these four question is yes.

21. — Scoring instructions: This question is based on the applicant's/member's perception of himself. Does the applicant/member indicate he has trouble concentrating and has memory lapses? Does the applicant/member indicate he needs help making decisions?

0 – If the answer to the question is not at all.
1 – If the answer to the question is occasionally or a couple times.
2 – If the answer to the question is frequently, more than a couple times, but not every day.
3 – If the answer to the question is every day.

22. — Scoring instructions: This question is based on someone's observation of the applicant/member. This may be a family member, caregiver or the person who called in the intake. Information from home health attendants or service coordinator observation can be used to score this question, but only as a last resort. The service coordinator must make every effort to contact a third party to provide the information. There should be documented attempts in the case record to contact other resources. If no other source is available, and the service coordinator feels the information provided by the attendant is accurate, he can score the information based on the attendant’s knowledge and observation of the applicant/member.

0 = The answer to the question is the applicant/member makes consistent and reasonable decisions independently (for example, pays bills and makes financial decisions, keeps own medical appointments, maintains own household).
1 = The answer to the question is the applicant/member makes simple decisions without assistance (for example, what to wear, what to buy at the grocery store, when to do housekeeping chores).
2 = The answer to the question is the applicant/member makes poor decisions and needs cues/supervision for most decisions.
3 = The answer to the question is the applicant/member is severely impaired and rarely makes his own decisions.

23. — Scoring instructions: This question is based on someone's observation of the applicant/member. This may be a family member, caregiver or the person who called in the intake. Information from home health attendants or service coordinator observation can be used to score this question, but only as a last resort. The service coordinator must make every effort to contact a third party to provide the information. There must be documented attempts in the case record to contact other resources. If no other source is available, and the service coordinator feels the information provided by the attendant is accurate, he can score the information based on the attendant's knowledge and observation of the applicant/member.

0 = The answer to the question is no.
1 = The answer to the question is the applicant/member has some short-term memory problems and can perform tasks for self with occasional reminders.
2 = The answer to the question is the applicant/member has memory lapses resulting in frequently not performing tasks even with reminders.
3 = The answer to the question is the applicant/member has memory lapses resulting in inability to perform routine tasks on a daily basis.

24. Total Score — Enter the total score of Items 1-2, 5-12 and 14-23. The applicant/member must receive a minimum score of 24 to be eligible to receive PAS for the STAR+PLUS Program. This item is not applicable for STAR+PLUS HCBS program PAS as a score is not required.

The Service Arrangement column will be coded according to the program.

Service Arrangement — Enter the following codes to indicate the service provider.

S =

Self. Use “S” if the Applicant/Member performs the task without any assistance.

C =

Caregiver. Use “C” when all of the task is being performed by a relative, neighbor or friend on a regular basis.

P =

Purchased. Use “P” if any part of the task is to be purchased all of the time or at times when another service arrangement type is not available to assist.

For Home-Delivered Meals (HDM) only cases with no PAS purchased, the Service Arrangement column for meal preparation is the only task marked “P” with no allocation of time if lunch is purchased through HDM. The other tasks are not coded for HDM. Check the block HDM in Item 12 to designate that the meal is provided through HDM.

For HDM with other PAS purchased, no time is allocated if HDM is the only meal indicated as being purchased in Item 12. In Item 12, use Breakfast, Lunch and Supper to designate the meals purchased through PAS. If lunch is purchased through PAS on the days HDM is not authorized, documentation should support the authorization of lunch through PAS on some days and HDM on others.

A service arrangement code of “P” should never appear under Item 15, Assistance with Medications, if the functional score is “3.” Since “3” indicates total inability to perform any aspect of the task, only a licensed nurse or designated informal support/caregiver may fulfill this need.

P/C =

Purchased/Caregiver. Use “P/C” when the caregiver is assisting with or performing a purchased task during the time the attendant is present. Document in the Comments section the part of the task the caregiver performs.

Example 1: The caregiver assists with bathing by laying out supplies, but needs the attendant to assist with the bath.

Example 2: The applicant/member requests a five-day plan and the daughter, who is the caregiver, works Monday, Wednesday and Friday. The daughter assists the applicant/member with bathing on Tuesday and Thursday during the time the attendant is present performing other tasks.

When the caregiver is not available during the time purchased tasks are delivered and helps only in the evenings and/or on weekends, a general comment may be entered in the Comments section. The tasks are not coded as “P/C,” but “P” only for purchased tasks.

Example 3: The applicant/member requests a five-day plan and the caregiver works full time. The caregiver will assist in the evenings and on the weekend, but does not assist with tasks during the time the attendant is present. A comment, "Caregiver (use name and relationship) assists in the evenings and on weekends" in the Comments section is adequate documentation. Code the task as “P.”

A =

Other agency. Use “A” when a non-contracted agency is performing the task.

P/A =

Purchased/Agency. Use “P/A” when another agency is available to perform the task on some days, but not other days. Document in the Comments section the part of the task the other agency performs.

N/A =

Not Applicable or None Available. Not Applicable: The only tasks that can be not applicable are Walking and Assistance with Medications. Use “N/A” when the applicant/member is unable to perform any part of the walking task, exercise task or assistance with medications task, and there is no caregiver or other agency totally performing the task. For example, an applicant/member is a double amputee and is unable to walk or use wheelchair ambulation. No time will be allotted for the task. Explain in the Comments section the task is not applicable.

Service Arrangement (STAR+PLUS HCBS program services) — Record the most significant service arrangement code for each task. Use additional codes and comments to document the use of other service arrangements.

S =

Self. Use “S” if the applicant/member performs the task without any assistance.

C =

Caretaker. Use “C” when all of the task is being performed by a relative, neighbor or friend on a regular basis.

P =

Purchased. Use “P” if any part of the task is to be purchased all of the time or at times when another service arrangement type is not available to assist.

For HDM-only cases with no PAS purchased, the Service Arrangement column for meal preparation is the only task marked “P” with no allocation of time if lunch is purchased through HDM. The other tasks are not coded for HDM. Check the block HDM in Item 12 to designate that the lunch meal is provided through HDM.

For HDM with other PAS purchased, no time is allocated if HDM is the only meal indicated as being purchased in Item 12. In Item 12, use Breakfast, Lunch and Supper to designate the meals purchased through PAS. If lunch is purchased through PAS on the days HDM is not authorized, documentation should support the authorization of lunch through PAS on some days and HDM on others.

A service arrangement code of “P” should never appear under Item 15, Assistance with Medications, if the functional score is “3,” since “3” indicates total inability to perform any aspect of the task and requires either skilled assistance or assistance from informal support.

P/S =

Purchased/Self. Use “P/S” if the applicant/member requires some assistance with the task, but is able to manage the task to meet his needs during the times when the PAS attendant is not present.

P/C =

Purchased/Caregiver. Use “P/C” when part of a task is purchased and part of the task is performed by a caregiver. “C” is used in conjunction with “P” when a caregiver assists with the task, regardless of whether or not the task is performed in conjunction with the services provided by the PAS attendant or when the PAS attendant or other service arrangement type is not available. Document in the Comments section the part of the task the caregiver performs. Document if the applicant/member can perform any part of the task when the PAS attendant or caregiver is unable to assist.

A =

Other Agency. Use “A” when a non-contracted agency is performing the task.

P/A =

Purchased/Agency. Use “P/A” when another agency is available to perform the task on some days, but not other days. Document in the Comments section the part of the task the other agency performs.

N/A =

Not Applicable or None Available. Not Applicable: The only tasks that can be not applicable are Walking and Assistance with Medications.  Use “N/A” when the applicant/member is unable to perform any part of the walking task or assistance with medications task, and there is no caregiver or other agency totally performing the task. For example, an applicant/member is a double amputee and is unable to walk or use wheelchair ambulation. No time will be allotted for the task. Explain in the Comments section the task is not applicable.

Do not give time for the task denoted as a nursing/delegated nursing task because time will be allotted on Form H2060-A, Addendum to Form H2060, for PAS under delegated tasks. Explain in the Comments section this task is a nursing/delegated nursing task.

 

Support Score Column

Support Score — If the applicant/member has a functional score of “3” for a purchased priority task (feeding, toileting, transfer, meal preparation), determine the likelihood of that task being done if the attendant does not show up during a normally scheduled service shift. Use the following scale and enter the score in the Support Score column by the appropriate item.

1 = It is very likely that the task would be done even if the attendant does not show up.
2 = The task will probably be done if the attendant does not show up.
3 = The task will probably not be done if the attendant does not show up.
4 = It is very unlikely the task will be done if the attendant does not show up.

In determining this support score, do not consider caregivers as available if they would be at work or school, even if they could come to the applicant's/member's home if the attendant was not there. Do not enter a support score for an item if either that task is not purchased or the score for that item is not “3.”

Note: Support scores are not applicable to STAR+PLUS HCBS program services; therefore, this field is not required for STAR+PLUS HCBS program cases.

 

Part B — Task/Hour Guide Column

Complete Part B.

Minutes Per Day — Refer to Pages 3 and 4 for the minimum and maximum times for each task by impairment score. For each task to be authorized, enter the daily number of minutes needed to conduct that task based on the impairment score and the minute range for that task. Times must be shown in five-minute increments and, if needed, rounded up to the next five-minute increment.

The subtasks must be checked to indicate specifically what the applicant/member needs. An applicant/member scoring “2” or “3” may need all subtasks under the impairment score for “1” and additional subtasks under the impairment score of “2.”

The time allotted must be within the range for the impairment score and cannot be higher or lower, except in the following situations:

  • If an applicant/member has a compelling reason for not wanting any of the subtasks under the appropriate impairment score, but only wants subtasks listed in a lower impairment score, the service coordinator must document the applicant's/member's request and allocate minutes in the minute range for the subtasks selected. The service coordinator must document the reason, and no supervisory approval is required.

Example: The applicant/member scores “2” on bathing. She needs assistance with drying. However, when discussing subtasks, she states she would like standby assistance for safety and drawing of water, all under the impairment score of “1.” She states her skin is very sensitive and she would not allow help with drying as she is afraid it would hurt her. The subtasks checked are all under the impairment score of “1,” so ten minutes is allowed. Documentation is required to explain the variance. No supervisory approval is required.

  • If an applicant/member has a caregiver or other agency performing part of a task and only subtasks in a lower impairment score are needed, the service coordinator must document the applicant's/member's request and allocate minutes in the minute range for the subtasks selected. The service coordinator must document the reason, and no supervisory approval is required.

Example: The applicant/member scores “2” for bathing, but only wants assistance with laying out supplies and drawing water because her daughter provides all hands-on assistance with the bathing task. The task is marked “P/C.” The subtasks under the impairment score of “1” are checked and ten minutes is allowed for the subtasks to be purchased. Documentation is required to explain the variance. No supervisory approval is required.

A task may be purchased if it is performed at least once a month by the provider. Time allotted for the task must be prorated into a weekly amount. Example: Escort 1/mo. × 120 mins. ÷ 4.33 = 28 mins./week (round up to the next five-minute increment) = 30 min./week.

Escort may be shown as PRN (as needed), if it occurs less than once a month no time is allocated.

Note: If the applicant/member has extenuating circumstances (other than the exceptions listed above) and requires time outside the range (either more or less) for the subtasks within the appropriate impairment score, the service coordinator must obtain supervisory approval. Do not change the impairment score to adjust the minutes, or for the convenience of a provider or attendant. For supervisory approval, the service coordinator must document the applicant's/member's extenuating circumstances and justify the need for minutes outside the range. The request must be in writing (written or email) and the supervisor's approval or disapproval must be in writing. Documentation of the request and the approval/disapproval must be filed in the case record. Supervisory approval is required for adjustment of time outside the ranges to specific tasks and to combinations of tasks that have ranges.

Companion Cases — For general household tasks, including cleaning, shopping and meal preparation, use the companion minute range rather than the applicant/member range. Time is assigned per applicant/member based on the applicant's/member's impairment score. Check the box(es) in the Total Minutes Per Week column for cleaning, meal preparation and/or shopping to indicate that time is authorized for these tasks to the companion case. In situations where there are more than two companions in the household, assign time based on the applicant's/member's impairment score using the companion minute ranges.

Example 1: On cleaning, Mr. Jones scores “3” and Mrs. Jones scores “1.” Mrs. Jones can do some light housekeeping, but due to her husband's incapacity, he needs all cleaning tasks performed in his area. Mrs. Jones is allowed the maximum of 45 minutes under impairment score “1” in the companion range. Mr. Jones is allowed the maximum of 180 minutes under impairment score “3” in the companion range.

Example 2: On meal preparation, Mr. and Mrs. Smith both score “2.” However, they have different schedules and need some meals shared and others on an applicant/member basis. Calculate each applicant's/member's time based on the meals needed within the impairment range. Use the time in the companion minute range for shared meals and time in the applicant/member range for non-shared meals. Use the Optional Meal Preparation Chart as a tool for calculating time.

Optional Meal Preparation Chart (for a Varied Meal Schedule)
This is an optional chart to assist in calculating time for meals for applicants/members who have a varied schedule. There is no requirement for this chart to be completed as it is a tool only to assist in calculating times. Enter the time for each meal by the number of days the meal is needed for the total minutes for each type of meal. Use the applicant/member or companion range, as appropriate, and check the box. Total the minutes for the Total Minutes per Week.

Divide the total by the number of days per week meals will be authorized for the Average Daily Minutes. If needed, round this amount up to the next five-minute increment. Enter this amount on Page 1, Minutes Per Days for Meals. In Days Per

Week, enter the highest number of days meals are prepared, even if not all meals are prepared daily.

Days Per Week — For each task to be authorized, enter the number of days per week the attendant will conduct that task. Enter in the Comments section if the task is performed less than once a week. (For the task of Feeding, enter the total number of meals per week.)

Total Minutes — Multiply the minutes per day by the days per week to obtain the weekly Total Minutes Per Week for each task.

Grand Total Minutes — Add the total minutes for each task to obtain the Grand Total Minutes for all tasks. For STAR+PLUS HCBS program, transfer this amount to Form H2060-A, Addendum to Form H2060, Section IV, Box 1.

Hours Needed — Divide the Grand Total Minutes by 60 to determine the weekly total in hours. Round the weekly number of hours to the next highest half hour to determine the total hours to authorize. Example: If an applicant/member needs 7 hours and 10 minutes of service each week, enter 7.5 in Hours Needed. This field is “N/A” STAR+PLUS HCBS program.

Less Total A&A Hours — If the applicant/member receives Aid and Attendance (A&A) Benefits from Veterans Affairs, reduce the Hours Needed by applying the formula shown on Page 2.

Total Authorization — Enter the total weekly hours that can be authorized. Round the time up to the next highest half hour. The authorized hours cannot exceed 50 for all STAR+PLUS Program applicants/members. If fewer than six hours are authorized, explain in the Comments section.

Priority Status — Check the box Yes if there is at least one purchased priority task (feeding, toileting, transfer, meal preparation) and:

  • the applicant's/member's functional score for that task is “3,” and the support score for that task is “4”; and
  • it is determined that there is a high likelihood the applicant's/member's health, safety or well-being would be jeopardized if PAS were not provided on a single given shift.

Do not assign priority status or a support score of “4” if the applicant/member is not in jeopardy.
If the applicant/member does not meet priority status, check the No box.

Note: Check the Yes box for STAR+PLUS HCBS program applicants/members. By program requirements, all waiver applicants/members have priority status.

 
Aid and Attendance (A&A) Calculations

Monthly Amount of A&A — Enter the total amount of A&A or housebound benefits received by the applicant/member. (For STAR+PLUS HCBS program, enter only the “Monthly Amount of A&A,” and complete the calculations on Form H2060-A, Addendum to Form H2060.)

Conversion to Weekly Amount — Divide the monthly amount by 4.33 to arrive at the weekly amount.

Conversion to Hours/Total A&A Hours — Divide the weekly amount by the maximum non-priority attendant care rate without regard to service authorized. If the person meets the priority status criteria, use the maximum priority status attendant care rate.

This is the number of hours that can be purchased with the A&A benefits. Enter this amount on Page 1 in “Less Total A&A Hours” and subtract to arrive at the total hours that can be authorized.

 
Approvals

Signature – Service Coordinator — Sign Form H2060/H2060-S after completing the form, but before asking for a variance (if needed).

Signature – Supervisor: Variance — Request the supervisor's approval if the applicant/member requires minutes outside the mandated minute range. The service coordinator must document the reason for the variance and submit the documentation to the supervisor. The supervisor will indicate approval by signing this form or if not approved, will not sign the form. If approval is via email, check the “Email OK” box, print the supervisor's name and enter the date approval was obtained. A copy of the documentation and the email must be filed in the case record.

Comments — Use this space, as needed, to explain tasks and hours authorized.

 

Part CTask/Minute and Subtask Guide

The Task/Minute and Subtask Guide beginning on Page 3 provides mandatory guidelines for the minutes that may be allowed per task per impairment score. It also contains the subtasks involved in performing the task. Carefully consider whether the applicant/member needs total assistance or assistance with only one or more of the subtasks when calculating time in Part B. See exceptions under the Minutes Per Day section.

It is mandatory to check the appropriate subtasks to justify time calculations for the overall task. If the applicant/member scores “2” on a task, check all applicable subtasks under “Impairment Score 2.” Additionally, all the appropriate subtasks under “Impairment Score 1” may be checked. For a score of “3,” the check box “Total Help” under “Impairment Score 3” is marked, but subtasks under “Impairment Score 1 and 2” are checked to identify the specific needs of the applicant/member. Any exceptions as described in the Minutes Per Day section must be documented. This information can be referenced at reassessments and service plan changes.