8.00 Appendix 4 General Health Evaluation & Level of Care Recommendation Instructions
Home and Community Based Services Manual
8.00 Appendix 4 General Health Evaluation & Level of Care Recommendation Instructions
The Home and Community Based Services (HCBS) provider nurse shall complete the General Health Evaluation and Level of Care Recommendation (GHE) form for all agency model personal care participants during the semi-annual GHE nurse visits. The GHE form shall be uploaded to the participant’s electronic case record promptly after the date of completion, but no later than ten (10) working days after the nurse visit. The GHE form may also be completed for participants during their regular monthly nurse visits; however, uploading a copy to the participant’s electronic case record is unnecessary unless there has been a significant change in the participant’s condition.
The form shall be completed in its entirety for each semi-annual evaluation to best serve the participant's needs.
Instructions
A: Participant Information
The following information shall be entered in the appropriate fields:
- DATE: Enter the date the form is completed
- PARTICIPANT: Enter NAME, DCN, DATE OF BIRTH, ADDRESS, COUNTY, and PHONE NUMBER
B: Provider Nurse Information
The following information shall be entered in the appropriate fields:
- NAME OF PROVIDER NURSE: Enter the name of the nurse completing the evaluation
- PROVIDER: NAME and PHONE NUMBER
C: Reason for Nurse Visit
- Select all boxes that apply and explain when requested
Note: DSDS shall be notified via the online Person Centered Care Plan (PCCP) request form of any needed changes identified during the visit.
D: Health Care Information
The following information shall be entered in the appropriate fields.
- PRIMARY HEALTH CARE PROVIDERS: List all pertinent health providers currently treating the participant
- CURRENT DIAGNOSIS/CONCERNS
- RECENT HOSPITALIZATIONS, SURGERIES, OR PROCEDURES
- ANY ADDITIONAL HEALTH INFORMATION: List any upcoming surgeries, procedures, or additional health information relevant to the participant
E: Allergies and Vital Signs
The information shall be entered in the appropriate fields.
Note: A1C may not be available for all participants.
F: Cardiopulmonary Assessment
- Select the appropriate boxes and provide the additional information requested
G: Integumentary Assessment
- Select the appropriate box
- Concerns can be indicated on the available body diagram
H: Level of Care Determination
This section shall, at minimum, be completed during the semi-annual GHE and LOC Recommendation and at any time requested by DSDS staff or its designee.
- Evaluate and mark the box with the corresponding point value for each of the twelve (12) LOC categories
- Add a comment to each corresponding section for any additional information used to determine the point value assigned
I: Current Authorization Review
- Select the appropriate boxes and explain when requested
- Complete the Emergency Back-up Plan
- Select the appropriate risk box (see Policy 4.15 Risk Indicators section)
- Document directions to locate, safety concerns, or additional comments
J: Veteran History
- Select the appropriate boxes
Signatures
The form must be signed and dated by both the participant and the HCBS provider nurse. If an LPN completes the evaluation, the supervisory RN or physician must sign and date it in the appropriate fields.