No. | Question | Scoring |
Response | Score | Response | Score | Response | Score | Response | Score |
1 | Do you need help to do the following? Bathing Bed mobility Medication management Transferring Ambulating Eating Toileting Dressing Personal hygiene | Zero to two selected | Zero | Three or more selected | Two | | | | |
2 | Do you need help turning and repositioning? | No | Zero | Yes | Two | | | | |
3 | Who helps you with daily activities? | No one | One | Family/friend/other/paid help | Zero | | | | |
4 | During the last six months, have you had a fall that caused injuries? | No | Zero | Yes | Two | | | | |
5 | Have you had a hospitalization, or been admitted to a nursing facility, or both, in the past six months? | No | Zero | Yes | Two | | | | |
6 | Have you received rehabilitation in the past six months? | No | Zero | Yes | Two | | | | |
7 | Have you been treated in an emergency room, called 911 in the past six months, or both? | No | Zero | Yes, one to two times | One | Yes, three or more times | Two | | |
8 | Do you live alone? | No | Zero | Yes | Two | | | | |
| If yes, do you feel safe living alone? | No | One | Yes | Zero | | | | |
9 | Do you plan on moving to other housing in the near future? | No | Zero | Yes | Two | | | | |
10 | Do you or your family have concerns about your memory, thinking, ability to make decisions, or remembering to pay your bills? | No, not concerned | Zero | Yes, somewhat concerned | One | Yes, very concerned | Two | | |
11 | Are you content with your social life? | No | Two | Somewhat | One | Yes | Zero | | |
12 | Over the last two weeks, have you been bothered by, or have little interest in doing things? | Not at all | Zero | Several days | One | More than half the days | Two | Nearly every day | Three |
13 | Over the last two weeks, have you been bothered by feeling down, depressed, or hopeless? | Not at all | Zero | Several days | One | More than half the days | Two | Nearly every day | Three |
(2) The risk level is calculated by totaling the points assigned to each question as determined by responses to the screening questions in subsection (1) of this section and matching the total points to the risk level in the following table:
Risk level | Point totals |
No risk | 0 |
Low risk | 1- 8 |
Moderate risk | 9-16 |
High risk | 17 and up |
[Statutory Authority: RCW
74.08.090 and
74.39A.030. WSR 19-09-003, § 388-106-1933, filed 4/4/19, effective 5/5/19. Statutory Authority: RCW
74.08.090. WSR 18-08-033, § 388-106-1933, filed 3/27/18, effective 4/27/18.]