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Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID)

Intermediate Care Facilities for Individuals with Intellectual Disabilities –(ICF/IID)– for children and adults are licensed by the DBHDS Office of Licensing, then a provider must be certified by the Virginia Department of Health, Office of Licensing and Certification, whose contact information may be found at the following link: http://www.vdh.virginia.gov/OLC/longtermcare/

Regulations Affecting State Training Centers

ICF/IID Forms for PCP

Following is a list of Virginia Person Centered Planning (PCP) Process forms for use by providers of care for persons who reside in Intermediate Care Facilities for Individuals with Intellectual Disabilities (ICF/IID).

  1. Important To-For Worksheet  (Word) (pdf)
  2. Essential Information Long form  (Word) (pdf)
  3. Essential Information - Chart Filing Order  (Word) (pdf)
  4. Part II Profile IV - VA ISP Blank  (Word) (pdf)
  5. Part V Plan for Supports  (Word) (pdf)
  6. Discussion Record Blank  (Word) (pdf)
  7. Communication Plan II  (Word) (pdf)
  8. Personal Schedule Blank  (Word) (pdf)
  9. Revised QMRP Review  (Word) (pdf)
  10. ISP Change Note  (Word) (pdf)
  11. ISP Checklist - data  (xls) (pdf)

Emergency and Respite Applications to Training Centers 

 

The SIS® Additional Support Needs Risk Assessment

Some of the links will go to forms that reside on the DMAS Web site.
DMAS forms 119, 121 and 121 A, please email Susan Elmore directly for instructions (Click on name to send email)

Level of Functioning Survey

I.         COMPLETE REFERRAL PACKAGE

Each application for admission to a state mental retardation facility must be prescreened by the appropriate community services board and have all the documentation necessary for the facility to determine the applicant’s eligibility for services. A complete referral package must contain the following items:

A.        Medical History and current status

B.         Psychological functioning level

C.         Social History and current status

D.        Educational needs and current Individualized Education Plan (for school-aged children) or vocational or training needs (for adults)

E.         Completed Application for Services Forms

  •         Identifying Information 
  •         Family Information 
  •         Current Medical Condition 
  •         Immunization History 
  •         Medication History 
  •         Service History 
  •         Services Requested 
  •         Skills and Behaviors Checklist 
  •         Level of Functioning Survey 
  •         Documentation of Recipient Choice 
  •         MR Prescreening Report 

F.      A completed Pre-discharge Plan outlining the services to be provided upon discharge and the anticipated date of discharge.

Following the receipt of the complete referral package, the facility must notify the community services board (CSB) of the determination of the applicant’s eligibility within thirty working days.

II.        GENERAL INSTRUCTIONS


All the above listed forms, assessments and reports are to be completed for each application for regular admission.

A request for either respite care or emergency admission does not require submission of service history, medication history or services request forms. For more information, please see the Regulations for Respite and Emergency Care Admissions to Mental Retardation Facilities.

Because of the specific services available at some training centers such as skilled nursing facilities, or limited medical services, additional information may be requested.  At the time of a regular admission, the field Reimbursement Office will request financial information from the applicant or the applicant’s family, guardian or legally authorized representative.  The financial information will not be shared with the facility staff.

III.      APPLICATION FOR SERVICES FORMS

A.           Identifying Information/Family Information

The case manager assisting in the admission process should complete these forms. The case manager may already have the information necessary to complete the forms in the case management records.

B.           Skills and Behaviors Check List

This booklet is used as a means of obtaining specific data regarding the applicant’s level of functioning. It is anticipated that a completed application may contain more than one booklet. For example, a child attending a public school program may behave much differently when at home. In that case it would be important to have the teacher and the parents provide data separately.

C.           Suggested Medical History Outline and Current Medical Condition

Many of the persons referred to state facilities for mental retardation require intensive medical monitoring and follow-up. It is therefore very important for the facility to receive as much medical informa­tion as possible. The medical sections of the application require a complete medical history, information from both past records as well as a description of the applicant’s current condition.

Occasionally, an applicant will have recently had a thorough evaluation by medical staff in a special diagnostic setting. In that case the medical history information may be available in the case manager’s files and it will not be necessary to rewrite it. The Current Medical Condition form  will still be required as an update to the existing history.

When there is no medical history readily available, the case manager must gather data from all possible sources to complete the medical history outline. This information may come from parents or other family members, other agency files or from the applicant’s primary physician. If the case manager cannot obtain all the necessary information due to a lack of records or the unavailability of family members, the case manager should send the facility all the historical data that is available and should complete the Current Medical Condition form.

D.          Service History and Medication History 

These forms should be self-explanatory. It should be noted that these forms are not necessary if the application is for a respite care or emergency admission.

E.           Services Requested

This section should be self-explanatory. It should be noted that this section is not necessary if the application is for a respite care or emergency admission.

F.           Suggested Social History Outline and Suggested Psychological Evaluation Outline (see attached)

This outline is provided to give the case manager examples of reports, which will fulfill the requirements for a completed referral package.

It is anticipated that the case manager will already have a social history and a psychological evaluation report in the case management record. If the existing reports are not as complete as the outline requests, the facility may require additional data. If no current reports are available, the case manager will be requested to obtain them.

G.  Immunization History 

           Facility staff should indicate whether this form should be sent with the other application
           forms or submitted the actual time of admission.

H.            ID Pre-Screening Report

This document is required for all admission requests and should be self-explanatory.

 

SUGGESTED MEDICAL HISTORY OUTLINE

To be used in conjunction with other reports during the application process for admission to a state mental retardation facility.

I.          Applicant Identification: Name, Date of Birth, Address, and Telephone Number, Name of Parent or Legally Authorized Representative

II.               Pre-Natal History: List any complications during the pregnancy and any significant medical factors, which may have a bearing on the applicant’s current condition. Did the mother take any medications or drink heavily during the pregnancy? Was the applicant’s birth early, on time or late? Did the mother experience high blood pressure, vaginal bleeding, German measles, or other unusual conditions? Was there an RH factor problem? Did the pregnancy progress normally?

III.       Birth and New Born History: Describe the applicant’s birth by indicating the type of delivery (vaginal, breech, Cesarean), length of labor, anesthesia used, birth weight, APGAR Scores, head size and any unusual conditions present during the birth process. Indicate whether the applicant was born in a hospital or at home. Give the name of the hospital and attending physician, if available. If the applicant’s diagnosis was made at this time, give all the relevant data.

IV.       Childhood: Describe any medical conditions the applicant experienced during applicant’s childhood especially those which may have some bearing on applicant’s current condition or need for future treatment. Describe the period in which the applicant was first suspected to have mental retardation and the procedure used to make this determination. Describe the onset of any behavioral, neurological, orthopedic, seizure, respiratory, cardiac, digestive, mobility, visual, speech or hearing disorder. If the applicant received a complete diagnostic evaluation at a major medical facility, attach the results of that evaluation. Indicate the general health of the applicant during childhood, including childhood diseases.

V.              Developmental History: Describe the applicant’s skill development. When did applicant learn to roll over, sit up, stand, walk, eat with a spoon, speak single words, use the toilet, dress, etc.? Was applicant shy or afraid of people? Did the applicant spend a great deal of time doing repetitive things like spinning toys, waving his hands or rocking? Did applicant seem to prefer those activities to contacts with other people? When did applicant begin to enjoy the company of other people and does he still get along with others?

VI.       Diagnosis: State the applicant’s past and current medical diagnoses for any medical or surgical conditions known to be present or part of the applicant’s history. Include all relevant conditions such as seizure disorder or physical impairment. State the level of the applicant’s mental retardation and the age at which this was first determined. Indicate who first made the diagnosis known to the applicant’s family. Has anyone else in the applicant’s family ever been given the same diagnosis?

VII.            Past Conditions: Using the attached chart as a reference, list all conditions, which the applicant has experienced and give additional information as appropriate. Concentrate especially on those conditions, which are of a recurring nature or those, which resulted in a permanent disability. Give the type and date of any surgical operations the applicant has had.

VIII.         Hospitalizations:  For each hospitalization list the name and address of the hospital, the name and address of the primary physician, the reason for and date of the hospitalization, and the course of treatment. Attach copies of all available discharge summaries.

IX.              Menstrual and Reproductive History: Describe the applicant’s birth control method (sterilization, medication or other). If the applicant is female describe her menstrual cycle. Are her periods regular? Does she have obvious mood swings related to her period? Does she experience cramps or unusual bleeding? Has she ever been pregnant? If so, give details.

Family Medical History: Using the following list for reference, note any conditions, which have been experienced by the applicant’s extended family. Include brothers, sisters, mother, father, grandparents, cousins, and aunts or uncles who are related by blood. Indicate the condition and the member(s) of the family experiencing it.

Diabetes

Tuberculosis

            Seizures

Mental Retardation

Cerebral Palsy

Mental Illness

Heart Disease

High Blood Pressure

Kidney Disease          

Cancer

Parkinson's

Alzheimer’s

 

X.                 Other Conditions: List any other current medical conditions that have not already been addressed.

XI.              Recommendations: List recommendations for the care of the applicant that have been made by health care professionals.

XII.            Sources of Information: List sources of information used to complete this Medical History Outline.

______________________________________                    ___________________________

Signature of Person Preparing History                                               Date

 

PAST CONDITIONS

To be used as a reference chart for the Suggested Medical History Outline, Section VII - Past Conditions.

Allergy

Food

Drug

Hay Fever

Asthma

Cardiovascular

Congenital Heart Defect

Heart Palpitations

Heart Murmur

Heart Attack

Pain/Pressure in Chest

High Blood Pressure

Low Blood Pressure

Varicose Veins

Edema

Stroke

Childhood Diseases

German Measles

Measles

Whooping Cough

Scarlet Fever

Rheumatic Fever

Chicken Pox

Mumps

Frequent Colds

Dental

Dilating Gum Overgrowth

Dentures

Gum Disease

Tooth Extraction

Numerous Cavities

Dermatology

Chronic Skin Condition

Deceits Ulcer

Excessively Dry or Oily Skin

Dandruff

Acne

Fungal Infection

Herpes Virus

Endocrinology

Thyroid Disorder

Diabetes (high blood sugar)

Hypoglycemia (low blood sugar)

Gastroenterology/Urology

Ulcer

Appendicitis

Hernia

Stomach or Intestinal Trouble

Hemorrhoids

Orthopedic

Back Problems

Trick Knee or Shoulder

Skeletal Deformity

Broken Bones

Osteoporosis (loss of bone mass)

Arthritis

Bursitis

Gout

Otolaryngology (ear, nose)

Ear Infection

Frequent Sore Throat

Strep Throat

Sinusitis

Frequent Colds

Hearing Difficulties

Tonsillitis

Cleft Lip, Palate Podiatry

Foot Deformity

Bunions

Plantar Warts

Fungal Infections

Ingrown Toenails

Chronic Constipation

Frequent Diarrhea

Parasites

Kidney/Bladder Infection

Frequent Urination

Venereal Disease

Gall Bladder Condition Gynecological

Irregular Menstrual Period

Excessive Menstrual Flow

Severe Cramps

Venereal Disease

Hematology

Anemia

Sickle Cell Anemia

Hepatitis

Injuries/Accidents

Poisoning

Broken Bones

Sprains

Head Injury

Severe Lacerations

Joint Injury

Cramps

Spasms

Weakness

Torn Muscles

Paralysis

Polio

Neurological

Seizure Disorder

Cerebral Palsy

Paralysis

Meningitis

Encephalitis

Brain Damage

Abnormal Head Size

Frequent Severe Headache

Oncology

Cancer

Premalignant Condition

Tumor

Cyst

Ophthalmology

Strabismus (crossed eyes)

Cataract

Glaucoma

Vision Difficulties

Psychiatric/Emotional

Frequent Anxiety

Frequent Depression

Worry or Nervousness

    Alcoholism

Substance Abuse

Psychosis

Neurosis

Insomnia

Eating Disorders

Pulmonary

Shortness of Breath

Pneumonia

Chronic Lung Disease

Emphysema

Chronic Cough

Bronchitis

Tuberculosis

Surgery

Appendectomy

Tonsillectomy

Tubal Ligation

Hysterectomy

Vasectomy

Colostomy

Other Surgical Procedures

 

SUGGESTED SOCIAL HISTORY OUTLINE

Name of Agency

Address

Date History Written:

Birth Date:

I.          Identifying Data:

Name:

Address:

Name of Parent or Legal Guardian:

Address:

Telephone #:

II.        Reason for Referral: When and how did the applicant become known to the referring agency? Why is residential care being requested? And why is it being requested now?

III.      Present Status:

A.        Skill Level: Describe the applicant’s current abilities in the areas of personal care and hygiene, survival skills, leisure time skills, time concepts, money management, etc. Be as specific as you can be in describing the amount of supervision or assistance needed.

B.        Socialization: Describe the applicant’s way of relating to family members, peers, and authority figures. How does the applicant respond in group situations? Does the applicant tend to be sociable or withdrawn? How does the applicant express or indicate moods of happiness, sadness and anger?

C.        Behavior: Does the applicant show hyperactivity, destructiveness, aggression or other behaviors, which are difficult to manage? If so, describe the intensity and frequency of the behavior. What seems to bring on this behavior and what helps to stop it? Please list any effective resources.

IV. Personal History:

A.        Developmental Milestones: Note the age of the applicant when he first learned to roll over, smile, sit up, stand, walk, talk, feed self and toilet unassisted.

B.        History of the Problem and Treatment: Relate information as to when, why and by whom the developmental delays were first noted. If the developmental delay has been attributed to an accident or trauma, describe the incident. Summarize all significant evaluations, hospitalizations and program enroll­ments.

C.        History of Care: If the applicant has lived in settings other than his/her family’s home, review those placements being sure to include information as to why the placement was arranged, the type of care provided and reasons why the placement was terminated. Information as to the applicant’s adjustment to new living situations would also be helpful.

D.        Vocational History: If the applicant has been employed, include information regarding the types of work involved and job performance.

E.         Marital History: If the applicant has been married, include name of spouse, date of marriage, date of separation or divorce, and current marital status.

F.         Financial Resources: Describe financial benefits the applicant receives; include all resources in addition to public assistance programs. If the applicant has a special burial fund, provide details.

V.        Family History:

A.        Father: Give name, age, educational level, and information regarding physical and emotional health. Indicate any special interests and abilities. Describe his attitude toward and relationship with the applicant.

B.        Mother: Give same information as for father.

C.        Siblings: List in order of birth from oldest to youngest, including same information as for parents.

D.        Others Living in the Home: Give name, relationship to family, age, and any relevant information regarding physical and emotional health. How long has he/she lived with the applicant’s family and how long will he/she remain there? Describe his/her attitude toward and manner of relating to the applicant.

E.         Living Situation: Describe the family’s socio-economic status, emotional climate and any relevant family issues of significance.

VI.       Diagnostic Impressions: What do you feel are the major issues for the applicant and his family at this time? What improvement do you feel can be made without removing the applicant from the current living situation. What services would be needed to accomplish this? What do you feel the applicant and family would gain from admission to a residential care setting?

VII.        Recommendations

 

VIII.                Sources of Information

 

 

__________________________________ ___________________________

Signature of Person Preparing History                                   Date

 

SUGGESTED PSYCHOLOGICAL EVALUATION OUTLINE

This outline is to be used in conjunction with other reports to determine eligibility for admission to a state mental retardation facility. It is to include a summarization of all previous psychological testing, when this information is available. In addition, the individual’s current (one year or less) levels of intellectual and adaptive functioning are to be given. It is not necessary to complete this outline if a current report is available which addresses ALL of the information requested.

I.          Identifying Data: Indicate the applicant’s name, date of birth, date of the evaluation, name of the examiner, and the agency providing the testing service.

II.        Reason for Referral:

III.       Standardized Psychological Testing Performed to Date: List the names of all tests used, forms of tests, date tests were administered, scores, and results including functional levels.

IV.       Current Intellectual Classification: Using the 1983 AAFID Classification in Mental Retardation manual and the standard deviation of the test administered, indicate the level of the applicant’s mental retardation (mild, moderate, severe or profound).

V.        Current Adaptive Behavior Level: Refer to the 1983 AAMD Classification in Mental Retardation manual for additional information. List the applicant’s level of adaptive behavior as determined by the AAMD ABS or other standardized assessment tool.

VI.       Test Behavior and/or Observations: Describe the applicant’s positive qualities and behaviors. Also describe maladaptive or inappropriate behaviors, being sure to include information regarding frequency and intensity. Include information regarding intervention programs implemented and results.

VII.            Summary and Recommendations:

_______________________________      __________________

Signature of Examiner                                          Date

 

Suggested tests to be used for assessment are as follows:


   

INTELLIGENCE (I.Q. 40 and above)

WAIS—R, WAIS, WISC—R, WISC

WPPSI, S-B, SIT, CIII

ADAPTIVE BEHAVIOR

A.A.M.D. ABS (refer to manual)

Behavior Observations Checklists

BELOW I.Q. OF 40

PPVT, ALPERN-BOLL DEVELOPMENTAL
PROFILE, SIT, CIIT, C.M.M.S

SPECIAL:  DEAF /or NON-VERBAL

L.I.P.S. Raven Progressive Matrices

SPECIAL:  BLIND

OHWAKI KOHS

Verbal subtests of Wechsler Scales

OTHERS (Which may be helpful for assessment

V.S.M.S.

Adaptive Behavior Developmental Profile

Fairview Scales

Denver

 

 

 

Regular (Judicial Certification) Admission Forms