Intake, Assessment, & Determination Summary
200.10 Purpose of the DDPAS-2
The purpose of the DDPAS-2 is to summarize and document the intake and assessment processes that occur for the PAS agency to determine whether the individual has a developmental disability and, if so, to determine whether the individual needs 24-hour nursing care and/or active treatment. These determinations enable the PAS agency to identify and link the individual to needed services. The DDPAS-2 also documents the final disposition of the PAS.
The following will describe the necessary procedures to:
- complete the intake (ID Screen) process;
- complete or obtain assessments from licensed, certified, or registered professionals;
- make a determination regarding the presence of a developmental disability;
- make determinations regarding whether the individual requires 24-hour nursing care and/or requires active treatment.
200.20 Intake (Part I of DDPAS-2)
The PAS agency must document the required information on Part I, ID Screen, of the DDPAS-2. This information includes:
- First name, last name, middle initial
- Social Security number
- Medicaid Recipient ID number
- Referral date
- Current diagnoses: Axis I through Axis V must be derived from an assessment that has been completed by a licensed physician within one year or licensed psychologist within the last five years
200.30 Assessment Process Summary (Part II of DDPAS-2)
The following describes the necessary fields in PART II, Assessment Process Summary, that must be completed by the PAS agency. The following also identifies the required assessments for each disability, the necessary components of each assessment, the professionals who must complete the assessments, and the time frames within which the assessments must be completed. Information derived from the assessments will enable the PAS agency to make accurate determinations.
- The PAS agency must document the individual's:
- Disability (e.g., developmental disabilities, dual diagnosis, or none - refer to 500.20 - Determination of Disability for additional information).
- Current Residential Setting (e.g., SODC, ICF/SNF, Sheltered Care, ICF/DD, Psychiatric Unit at a Hospital, General Hospital, Undomiciled, With Family Members, DHS-Funded Setting, Living Alone or With a Roommate, Other).
- Exceptional circumstances, if present (i.e., Chronic Obstructive Pulmonary Disease, dementia of all types, Huntington's Disease, Amyotrophic Lateral Sclerosis, Congestive Heart Failure, or Ventilator Dependency).
- When assessments have been completed, the PAS agency will document:
- Date each assessment is completed.
- Name and title of professional who completed each assessment.
- ICAP general maladaptive behavior index, adaptive behavior index, and service score and level.
- The PAS agency will also document whether or not the individual appears to be in need of a guardian, or whether the individual already has a legal guardian:
- If the individual has a guardian, the PAS agency will document his/her name.
- If the individual appears to need a guardian, the PAS agency will document the date that the individual is referred to OSG or the name of the person that has expressed an interest in pursuing legal guardian status, as determined in Chapter 800.
- The licensed or certified professional should use the time frames indicated below, in the description of assessment components (200.50), as a guide to determine if existing assessments accurately reflect the individual's current skills and service needs. If the professional involved believes that any assessment within these time frames may not accurately reflect the individual's current condition or level of functioning, the assessment must be repeated or updated, as deemed necessary by the professional.
- Once all of the above information has been documented, the PAS agency will record the final date of completion on the top right corner of Part II. Completed assessments must be included in referral packets resulting from the PAS and be a part of any resulting service plans.
- If the PAS agency should discover, at any point during the assessment process, that the individual being assessed does not have a developmental disability, the PAS agency should refer the individual to the appropriate screening entity (MH PAS, DRS, or Aging; see Chapter 100 for more information). An indication of "None" must be marked under "Disability."
200.40 Assessments Required By Disability
The PAS agency must ensure the following assessments are obtained. Guidance regarding necessary components of these assessments is provided in Section 200.50:
- Psychological (if MR)
- Medical review, consisting of:
- Medical history
- Medication review
- Physical examination
For persons with epilepsy and cerebral palsy, the physical examination and the medical history must address the reasons for these diagnoses.
For persons with autism who do not meet eligibility requirements as a person with mental retardation, the following assessments are also required:
- Psychiatric Evaluation (see Section 200.50)
- Psycho-Social Assessment (see Section 200.50)
200.50 Necessary Components of Each Required Assessment
Inventory For Client and Agency Planning (ICAP)
The Inventory for Client and Agency Planning (ICAP) must be administered by a Qualified Intellectual Disability Professional (QIDP), six months prior to the date on the DDPAS-2, Part II. The ICAP is not a substitute for the adaptive functioning assessment required in a psychological evaluation.
For individuals with mental retardation, the psychological evaluation must be completed by a licensed psychologist, within five years prior to the date recorded on the DDPAS-2, Part II. Psychological evaluations must include:
- Assessment of adaptive functioning: Licensed psychologists have the latitude to determine which tool should be used; however, the ICAP is not an adequate assessment of adaptive functioning. Suggested instruments are:
- American Association of Mental Retardation (AAMR) Adaptive Behavior Scales
- Vineland Adaptive Behavior Scale
- Adaptive Behavior Inventory for Children (ABIC) (English and Spanish)
- Scales of Independent Behavior
- Assessment of intellectual functioning - suggested instruments are:
- Stanford-Binet LM or 4th Edition
- Wechsler Pre-School Primary Scale of Intelligence (WPPSI)
- Wechsler Intelligence Scale for Children-Revised (WISC-R) or the WISC-III
- McCarthy Scales of Children's Abilities (MCSCA)
- Kaufman Assessment Battery for Children (K-ABC)
- Woodcock-Johnson Psycho-Educational Battery Part 1-Tests of Cognitive Ability (W-J, Part 1)
- The original Slossen
- Stanford-Binet LM or 4th Edition
- Wechsler Adult Intelligence Scale-Revised (WAIS-R) or the WAIS-III
- Woodcock-Johnson Psycho-Educational Battery Part 1-Test of Cognitive Ability
- Spanish Edition Wechsler Intelligence Scale for Children (WISC)
- Spanish Edition Wechsler Intelligence Scale for Children-Revised (WISC-R)
- Spanish Edition Wechsler Adult Intelligence Scale (WAIS)
- Woodcock Spanish Psycho-Educational Battery
- Non-Verbal, Impaired Verbal Skills/or Deaf, Impaired Hearing
- Wechsler Intelligence Scale for Children-Performance Scale
- Leiter International Performance Scales (Children and Adults)
- Wechsler Adult International Scales-Revised - Performance Scale
- Blind/Visually Impaired (Children or Adults)
- Wechsler Intelligence Scale for Children-Verbal Scale
- Wechsler Adult Intelligence Scale-Revised, Verbal Scales
- Haptic Intelligence Scale for Adult Blind
- The psychological evaluation must provide a clear and concise summary of the information derived from the functional assessment and the standardized intellectual functioning instrument. This evaluation must, at a minimum, include the following elements:
- Cognitive/intellectual functioning that includes the scores from the standardized intellectual functioning instrument and an interpretation of these data.
- Developmental history that clearly addresses the age of onset of the developmental disability. (Refer to 500.20.G).
- Educational background
- Adaptive skill level
- Multi-axial diagnosis that includes a primary diagnosis
- Recommendations for future service delivery (e.g., school services, day program, vocational, employment, senior citizens services).
In addition, if indicated for persons with mental illness, the following information will be included: Personality functioning and psychodynamics utilizing instruments suited to the functioning levels of persons receiving the evaluation, including but not limited to the Reiss Scales and Screen, the Psychological Inventory for Mentally Retarded Adults (PIMRA), the Diagnostic Assessment for the Severely Handicapped (DASH-II), or the Assessment of Dual Diagnosis (ADD).
- If substantial differences in test results (e.g., 10 - 15 points) are noted within the current battery of tests or between the current testing and that reported in years previous, the psychologist should attempt to identify and document the cause of the different test results and should refer the individual for additional assessments of various kinds, as appropriate. This may include confirmative retesting or assessments, such as:
- Neurological Consultation
- Neuropsychological Assessment
- Medical Consultation
- Any additional testing must be documented in the individual's record with the results coupled with a clear and concise clinical synthesis.
- When a psychologist selects a different test other than the test administered previously, he/she should provide, in the analysis of findings, the rationale for selecting a different test.
- Even though it is required that the psychological evaluation be current within five years, the clinical judgment and the service needs of the individual should dictate greater frequency and content of the psychological evaluation.
- Where functioning is stable and no additional concerns are raised by licensed professionals, repeated IQ testing may not be considered an essential component of the evaluation.
A medical history must be completed by a licensed physician, an Advanced Practice Nurse, a Physician Assistant, or a Registered Nurse (RN). If completed by an RN, the assessment must be co-signed by a licensed physician. This assessment must be current within 90 days prior to the date recorded on the DDPAS-2, Part II.
A medical history provides a chronological picture beginning with the time the individual was last well, or, in the case of a problem with an acute onset, the individual's condition just prior to the onset of the problem, and ending with a description of the individual's current condition.
If there is more than one important medical issue, each should be described in a separate, chronologically organized paragraph in the medical history of present illness. The medical history must include the following components:
- General health and strength (e.g., sleeping patterns, appetite, stability of weight, usual activities).
- Acute infectious diseases (e.g., measles, mumps, whooping cough, chickenpox, pneumonia, pleurisy, tuberculosis, scarlet fever, acute rheumatic fever, tonsilitis, hepatitis, polio, venereal disease, any other acute infectious problem the individual describes).
- Immunizations (e.g., polio, diphtheria, tetanus, influenza).
- Pertinent long-range medication history (over and above the separate Medication History, described in Chapter 300, that covers the 90-day period prior to the PAS determinations). The long-range medication history must address such issues as long-term use of psycho-active medications, including those administered to assist in regulating seizure activity. It must include effects of the medications, the amounts of each medication, the reason for which each medication was prescribed, the dates of administration of each medication, allergies to medication, and other medication information specific to the individual.
- Operations (document the indications, diagnosis, dates, hospital, surgeon, complications).
- Previous hospitalizations (document the doctor, hospital date/year, diagnosis, treatment).
- Injuries (types, resulting disabilities).
- Major illnesses (any prolonged illnesses not requiring hospitalization).
- Allergies (asthma, hay fever, hives, food allergies, drug reactions, previous treatment with penicillin and any reactions).
- Obstetrical history (pregnancies, miscarriages, abortions).
- Persons with epilepsy (seizure activity must be addressed including frequency, type, severity, medication history, and the date of the most recent seizure activity).
The physical examination must be completed by a licensed physician, an Advanced Practice Nurse, or a Physician Assistant. The assessment must also be current within 30 calendar days prior to the date recorded on the DDPAS-2, Part II. The physical examination must address the individual's current and past health issues.
The physical examination must include diagnoses of the individual's physical condition and include a review of the following components:
- Eyes and Vision
- Ears and Hearing
- Lymph Nodes
- Peripheral Circulation
- Male Genitalia and Hernias
- Female Genitalia
- Musculoskeletal System
- Neurological System
For persons with epilepsy and cerebral palsy, the physical examination must address the basis for the diagnoses.
The physical examination must include the professional's recommendations regarding the level of health support needs for the individual.
200.60 Other Assessments
In addition to the aforementioned required assessments, other assessments must be administered, if deemed necessary by the PAS agency. Such assessments are deemed necessary when:
- Observations or information received by the PAS agency indicate a potential service need that requires assessment before a service plan can be developed to address it.
- Recommended by a qualified professional.
- Indicated by a diagnostic category, such as mental illness, autism, or cerebral palsy or other motor impairment (see Section 200.40).
Unexplained changes in functioning often indicate the need for additional assessments.
These assessments may include, but are not limited to, the following assessments or areas:
- Communication Assessment
- Audiological Screening
- Behavior Therapy
- Physical Therapy
- Occupational Therapy
For persons for whom motor impairment is a significant factor, communication, physical therapy, and occupational therapy assessments are strongly recommended. The following represents the components that must be included in these assessments.
The communication assessment must be completed and signed by a licensed speech-language pathologist. The assessment must be current within six months prior to the date recorded on the DDPAS-2, Part II.
A communication assessment must include the following components:
- Background information that includes past and present test results and findings.
- Description of the individual's functional communication abilities (level of intelligibility and clarity of communication; ability to express needs and wants; ability to initiate, maintain, and respond in communication exchanges skill to communicate across a variety of settings such as work, home, and community; level of support needed to be successful in a variety of settings; language comprehension adequate for daily living activities)
- Receptive/expressive communication (skills relative to communication, based on person's adaptive level and discrepancy between comprehension and production of communication).
- Mode of communication (techniques used to express him/herself and effectiveness of the communication device).
- Appropriateness of communication (description of social and communication skills; relevant, coherent and fluent communication).
- Independence of communication (level of spontaneous communication, types of prompts needed to elicit communication; conditions that facilitate spontaneous communication)
- Treatment recommendations (types of therapy/training; purpose and focus of the therapy/training; devices and equipment to promote communication; referrals needed).
An audiological screening provides a means to determine the level of hearing ability for the individual. The assessment must be completed and signed by a certified audiologist, within six months prior to the date recorded on the DDPAS-2, Part II. This screening must include at least the following components:
- Previous and/or current history of the individual's ability or lack of ability to hear (documentation of medical referral/treatment for middle ear infections, impacted cerumen, or structural problems with the hearing system).
- Pure-tone audiometry (air conduction measurement, nerve conduction measurement, audiogram - conductive hearing loss, sensorineural hearing loss, mixed hearing loss).
- Speech audiometry (speech reception threshold, speech discrimination score, acoustic impedance evaluation).
- Treatment recommendations
Physical Therapy Assessment
The physical therapy assessment must be completed and signed by a registered physical therapist. This assessment must be completed within six months prior to the date recorded on the DDPAS-2, Part II. The physical therapy assessment must include the following components:
- History of past physical therapy services
- Range of motion
- Muscle strength (muscle groups or patterns of movements)
- Adaptive devices (wheelchair with back/seat cushion along with padded tray and seat belt)
- Gross motor functioning (sitting balance, bed mobility skills, gait, paralysis, transfer, endurance)
- Rehabilitation/habilitation potential
- Recommendations for treatment
Occupational Therapy Assessment
The occupational therapy assessment must be completed and signed by a certified occupational therapist. This assessment must be within six months prior to the date recorded on the DDPAS-2, Part II.
The occupational therapy assessment must include at least the following components:
- Previous and current occupational therapy services
- Muscle strength
- Adaptive devices, if applicable
- Gross motor functioning (sitting balance, bed mobility skills, gait, paralysis, transfer, endurance)
- Treatment recommendations
Behavior Therapy Assessment
The behavior therapy assessment must be completed and signed by a licensed psychologist or a certified behavior analyst. This assessment must be within six months prior to the date recorded on the DDPAS-2, PART II.
- The behavior therapy assessment must use at least one of the following functional assessments:
- Motivation Assessment Scale (MAS)
- Functional Analysis Screening Tool (FAST)
- Functional Analysis Interview (FAI)
- Questions About Behavioral Function (QABF)
- Behavioral Diagnostic Questionnaire
- A behavior therapy assessment must include at least the following components:
- A descriptive analysis which includes direct observations of the behaviors under natural conditions.
- Summary of the data that describes the individual's maladaptive behaviors, frequency of the behaviors, severity of the behaviors, and antecedents of the behaviors.
- Assessment of environmental events that are correlated with the occurrence of behavior problems.
- History of previously employed interventions and the results of these interventions.
- Treatment recommendations
- If the person is dually diagnosed or on medication, one or more of the following instruments, or an equivalent, may be used:
- Diagnostic Assessment for the Severely Handicapped (DASH II)
- Psychopathology Inventory for Mentally Retarded Adults (PIMRA)
- Reiss Screen for Dual Diagnosis
- Assessment of Dual Diagnosis (ADD)
The psychiatric evaluation is completed and signed by a licensed psychiatrist, within six months prior to the date recorded on the DDPAS-2, Part II. The psychiatric evaluation may be completed by a licensed psychologist, a master's degree psychiatric nurse, or a licensed clinical social worker, if a licensed psychiatrist co-signs the assessment.
Note: For children under the age of 16 whose primary disability appears to be a developmental disability, this assessment may be performed by a pediatrician with expertise in developmental or behavioral problems.
The psychiatric evaluation must include all of the following information:
- A psychiatric history with present and previous psychiatric symptoms.
- A comprehensive mental status examination, to include all of the following components:
- Description of intellectual functioning.
- Memory functioning (memory of remote events, recent past events, recent events, immediate memory and recall, abnormal memory or symptoms related to amnesia, anterograde amnesia, hysterical amnesia, hyperamnesia).
- Orientation to person, time and place.
- Affect (flat, blunt, elation, exultation, ecstasy, anxiety, fear, ambivalence, depersonalization, irritability, rage, depressed).
- Suicidal or homicidal ideation
- Response to reality testing
- Current attitudes: cooperative, outgoing, withdrawn, evasive, sarcastic, aggressive, perplexed, hostile, arrogant, dramatic, submissive, fearful, seductive, uncooperative, remote, resistant, unfeeling, apathetic.
- Motor behaviors: choreiform movements, hyperkinesis, compulsion, cataplexy, catalepsy, stereotype, psychomotor retardation, catatonic stupor or excitement, impulsiveness, tics and spasms.
- A Multi-axial diagnostic formulation: explaining how the diagnosis was derived using the mental status and psychiatric history and including information related to the individual's developmental status, physical status, environmental stressors, and global functioning.
- Judgement: Individual's ability to problem-solve and choose among alternatives based on reality.
- Thought processes and content: blocking, flight of ideas, word salad, perseveration, neologisms, circumstantiality, echolalia, condensation, delusion, phobia, obsession, hypochondriasis.
- A comprehensive medication history that includes the following information. (Psychiatric medication history must be consistent with DDPAS-3 Medication Review):
- Past and current medications, including psychotropic medications
- Effects (positive or negative) of those medications
- Amount of each medication, the reason and condition under which each medication was prescribed.
- Date of inception or discontinuation of each medication
- Other medication information specific to the individual
The psycho-social assessment must be signed by an MSW, a Qualified Mental Health Professional (QMHP), or an MA or MS in Psychology. The assessment may be completed by a Qualified Intellectual Disabilities Professional (QIDP), if co-signed by one of the aforesaid disciplines. The assessment must be current within six months prior to the date recorded on the DDPAS-2, Part II.
A psycho-social assessment must include all of the following components:
- Personal and family history including any history of mental illness in the family.
- History of mental health treatment.
- Legal status (guardianship, representative payee, trust beneficiary, pending court order).
- Level of education and/or specialized training.
- Previous employment and acquired vocational skills, activities and interests, if applicable.
- History of and/or current alcohol and/or chemical abuse or dependency.
- Resource availability (income entitlements, health care benefits, subsidized housing, social services).
- Current living arrangements.
- Existing natural support networks.
200.70 Determination Process (Part III of DDPAS-2)
The determination process requires the PAS agency to translate the assessment information into decisions regarding whether the individual does or does not require 24-hour nursing care and active treatment. Refer to Chapter 400 and Chapter 500 for procedures in making these determinations. The date of determination must match the signature date on the DDPAS-5.
Once the determinations have been made, the PAS agency will record the date that the assessments and determinations were shared with and interpreted to the individual, legal guardian, or others designated by the individual. Such sharing of information will facilitate their participation in decisions regarding the type and setting of services to be provided. The date for the interpretation of data will be entered on the DDPAS-2.
The date of the disposition represents the actual day the individual began receiving services. The name of the primary provider of service must be entered in Part III.
The disposition will be one of those in items a through h, or those mentioned in notes 1, 2, and 3 below:
- Nursing facility (record whether the individual does not require active treatment services or whether the individual will retire from active treatment).
- Home and Community-Based Services Waiver (services in such programs as Community Integrated Living Arrangements, Home-Based Support Services, day services, etc.).
- Convalescent Care (see Section 400.30 for guidance)
Note 1: Before the PAS assessment process has been completed, the individual may move out of the geographic area or withdraw from the process. Should this occur, record either Moved or Withdrawn, as applicable.
Note 2: During this process, the individual may be found to be Medicaid ineligible or may have died. If either circumstance occurs, mark the form accordingly.
Note 3: If the individual is found not to need a change in level of care, mark the form accordingly.
The signature represents that the PAS agency has personally reviewed the information and data sources referenced in this document and certifies that they are accurately described on this summary and that they are currently available in the individual's record.