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APPENDIX 100                                                                                                 LEVEL OF CARE

22.

List all diagnostic and treatment procedures the client is receiving.

23.

List all waivered services ordered by care coordination team.

NOTE:  Waivered services ordered by care coordination and approved by the physician/ nurse practitioner are considered physician’s orders for CCSP waivered services.

24.

Enter appropriate diet for client.  If "other" is checked (), please specify type.  Completion of this item is important as this information may serve as the service order for home delivered meals.  (Nutrition Screening Initiative (NSI), Appendix 100, is to be completed in conjunction with the LOC page, MDS-HC and CCP.)

25.

Enter number of hours out of bed per day if client is not bedfast.  Check () intake if client can take fluids orally.  Check () output if client’s bladder function is normal without catheter. Check () all appropriate boxes.

26.

Check () appropriate box to indicate client’s overall condition.

27.

Check () appropriate box to indicate client’s restorative potential.

28.

Check () all appropriate boxes to indicate client’s mental and behavioral status.  Document on additional sheet any behavior that indicates need for a psychological or psychiatric evaluation.

29.

Check () appropriate box to indicate if client has decubiti.  If “Yes” is checked and surgery did occur, indicate date of surgery.

30.

Check () appropriate box.

31.

Check () appropriate box.

32.

If applicable, enter number of treatment or therapy sessions per week that client receives or needs.

33.

Enter appropriate numbers in boxes provided to indicate level of impairment or assistance

needed.  

NOTE: Information on the MDS-HC should match the LOC form.  

34.

Care coordination team or the admitting/attending physician/ nurse practitioner indicates whether client’s  condition could or could not be managed by provision of Community Care or Home Health Services by checking () appropriate box.

MT 2010-1  8/09                                                                                          Appendix 100 page 77

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