Original Notice.

     Preproposal statement of inquiry was filed as WSR 05-23-133.

     Title of Rule and Other Identifying Information: Adopting chapter 388-828 WAC, The division of developmental disabilities (DDD) assessment.

     Hearing Location(s): Blake Office Park East, Rose Room, 4500 10th Avenue S.E., Lacey, WA 98503 (one block north of the intersection of Pacific Avenue S.E. and Alhadeff Lane. A map or directions are available at http://www1.dshs.wa.gov/msa/rpau/docket.html or by calling (360) 664-6097), on March 27, 2007, at 10:00 a.m.

     Date of Intended Adoption: Not earlier than March 28, 2007.

     Submit Written Comments to: DSHS Rules Coordinator, P.O. Box 45850, Olympia, WA 98504, delivery 4500 10th Avenue S.E., Lacey, WA 98503, e-mail fernaax@dshs.wa.gov, fax (360) 664-6185, by 5:00 p.m. on March 27, 2007.

     Assistance for Persons with Disabilities: Contact Stephanie Schiller, DSHS Rules Consultant, by March 23, 2007, TTY (360) 664-6178 or (360) 664-6097 or by e-mail at schilse@dshs.wa.gov.

     Purpose of the Proposal and Its Anticipated Effects, Including Any Changes in Existing Rules: The purpose of these rules is to govern and support the administration of the division's newly developed, computer-based assessment tool that is designed to measure the support needs of clients for service determination. The DDD assessment will replace existing paper-based methods resulting in a universal assessment and support planning process. The purpose of the DDD assessment is to provide a comprehensive assessment process that: (1) Collects a common set of assessment information for reporting purposes to the legislature and the department; (2) promotes consistency and accuracy in evaluating client support needs for purposes of planning, budgeting, and resource management; (3) identifies a level of service and/or number of care hours that is used to support the assessed needs of clients who have been authorized to receive Medicaid/waiver personal care, waiver respite care, and/or voluntary placement program services; (4) records clients' service requests.

     Reasons Supporting Proposal: In 2003, the Joint Legislative Audit and Review Committee (JLARC) issued its performance audit of the division and recommended that DSHS develop a standardized assessment process for developmentally disabled clients that is designed to be consistently applied to all clients in all parts of the state. The legislature appropriated funds for the development and implementation of the DDD assessment per section 205(3), chapter 518, Laws of 2005.

     Statutory Authority for Adoption: RCW 71A.12.030.

     Statute Being Implemented: Title 71A RCW and chapter 518, Laws of 2005.

     Rule is not necessitated by federal law, federal or state court decision.

     Name of Proponent: Department of social and health services, governmental.

     Name of Agency Personnel Responsible for Drafting: Mark Eliason, 640 Woodland Square Loop S.E., Lacey, WA 98504, (360) 725-2517; Implementation and Enforcement: Don Clintsman, 640 Woodland Square Loop S.E., Lacey, WA 98504, (360) 725-3426.

     No small business economic impact statement has been prepared under chapter 19.85 RCW. DDD has identified that there are approximately forty-five supported living (SL), twenty-three group home (GH), and four hundred twenty-five adult family home (AFH) providers who provide services to DDD clients and meet the definition of a small business as defined above. DDD conducted a survey of these providers regarding their reported costs to participate in a client's annual assessment and concluded that overall costs to them will be minor, if there are any costs at all. In addition, DDD is not able to determine if there is a disproportionate impact to AFHs since all are considered small businesses. Based on this information, DDD has concluded that preparation of a small business economic impact statement is not required.

     A cost-benefit analysis is required under RCW 34.05.328. A preliminary cost-benefit analysis may be obtained by contacting Mark Eliason, 640 Woodland Square Loop S.E., Lacey, WA 98504, phone (360) 725-2517, fax (360) 407-0954, e-mail eliasmr2@dshs.wa.gov.

January 19, 2007

Jim Schnellman, Chief

Office of Administrative Resources

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     "AAIDD" means the American Association on Intellectual and Developmental Disabilities.

     "Acuity Scale" refers to an assessment tool that is intended to provide a framework for documenting important assessment elements and for standardizing the key questions that should be asked as part of a professional assessment. The design helps provide consistency from client to client by minimizing subjective bias and assists in promoting objective assessment of a person's support needs.

     "ADSA" means the aging and disability services administration (ADSA), an administration within the department of social and health services, which includes the following divisions: home and community services, residential care services, management services and division of developmental disabilities.

     "ADSA contracted provider" means an individual or agency who is licensed, certified, and/or contracted by ADSA to provide services to DDD clients.

     "Adult Family Home" or "AFH" means a residential home in which a person or persons provide personal care, special care, room and board to more than one but not more than six adults who are not related by blood or marriage to the person or persons providing the services (see RCW 70.12.010).

     "Agency provider" means a licensed and/or ADSA certified business who is contracted with ADSA or a county to provide DDD services (e.g., personal care, respite care, residential services, therapy, nursing, employment, etc.).

     "Algorithm" means a numerical formula used by the DDD Assessment for one or more of the following:

     (1) Calculation of assessed information to identify a client's relative level of need;

     (2) Determination regarding which assessment modules a client receives as part of his/her DDD assessment; and

     (3) Assignment of a service level to support a client's assessed need.

     "Authorization" means DDD approval of funding for a service as identified in the Individual Support Plan or evidence of payment for a service.

     "CARE" refers to the Comprehensive Assessment Reporting Evaluation assessment per chapter 388-106 WAC.

     "Client" means a person who has a developmental disability as defined in RCW 71A.10.020(3) who also has been determined eligible to receive services by the division under chapter 71A.16 RCW.

     "Collateral contact" means a person or agency that is involved in the client's life (e.g., legal guardian, family member, care provider, friend, etc.).

     "Companion home" is a DDD contracted residential service that provides twenty-four hour training, support, and supervision, to one adult living with a paid provider.

     "DDD" means the division of developmental disabilities, a division with the aging and disability services administration (ADSA), department of social and health services (DSHS).

     "Department" means the department of social and health services (DSHS).

     "Group home" or "GH" means a ADSA licensed adult family home or boarding home contracted and certified by ADSA to provide residential services and support to adults with developmental disabilities.

     "ICF/MR" means a facility certified as an intermediate care facility for the mentally retarded to provide habilitation services to DDD clients.

     "ICF/MR Level of Care" is a standardized assessment of a client's need for ICF/MR Level of Care per 42 CFR 440 and 42 CFR 483. In addition, ICF/MR Level of Care refers to one of the standards used by DDD to determine whether a client meets minimum eligibility criteria for one of the DDD HCBS waivers.

     "Individual Support Plan" or "ISP" is a document that authorizes and identifies the DDD paid services to meet a client's assessed needs.

     "Legal Guardian" means a person/agency, appointed by a court, who is authorized to make some or all decisions for a person determined by the court to be incapacitated. In the absence of court intervention, parents remain the legal guardians for their child until the child reaches the age of eighteen.

     "LOC score" means a score for answers to questions in the Support Needs Assessment for Children that are used in determining if a client meets eligibility requirements for ICF/MR Level of Care.

     "Modules" refers to three sections of the DDD Assessment. They are: the Support Assessment, the Service Level Assessment, and the Individual Support Plan (ISP).

     "Panel" refers to the visual user-interface in the DDD Assessment computer application where assessment questions are typically organized by topic and you and your respondents' answers are recorded.

     "Plan of Care" or "POC" refers to the paper-based assessment and service plan for clients receiving services on one of the DDD HCBS waivers prior to June 1, 2007.

     "Raw Score" means the numerical value when adding a person's "Frequency of Support," "Daily Support Time," and "Type of Support" scores for each activity in the support needs and supplemental protection and advocacy scales of the Supports Intensity Scale (SIS) Assessment.

     "Residential Habilitation Center" or "RHC" is a state-operated facility certified to provide ICF/MR and/or nursing facility level of care for persons with developmental disabilities per chapter 71A.20 RCW.

     "Respondent" means the adult client and/or another person familiar with the client who participates in the client's DDD Assessment by answering questions and providing information. Respondents may include ADSA contracted providers.

     "SIS" means the Supports Intensity Scale developed by the American Association of Intellectual and Developmental Disabilities (AAIDD). The SIS is in the Support Assessment module of the DDD Assessment.

     "Service Provider" refers to an ADSA contracted agency or person who provides services to DDD clients. Also refers to state operated living alternative programs (SOLA).

     "SOLA" means a state operated living alternative program for adults that is operated by DDD.

     "State supplementary payment" or "SSP" is the state paid cash assistance program for certain DDD eligible Social Security Income clients per chapter 388-827 WAC.

     "Supported living" or "SL" refers to residential services provided by ADSA certified residential agencies to clients living in homes that are owned, rented, or leased by the clients or their legal representatives.

     "Waiver personal care" means physical or verbal assistance with activities of daily living (ADL) and instrumental activities of daily living (IADL) due to your functional limitations per chapter 388-106 WAC to individuals who are authorized to receive services available in the Basic, Basic Plus, and Core waivers per chapter 388-845 WAC.

     "Waiver respite care" means short-term intermittent relief for persons normally providing care to individuals who are authorized to receive services available in the Basic, Basic Plus, and Core waivers per chapter 388-845 WAC.

     "You/Your" means the client.

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     (2) The DDD Assessment has three modules:

     (a) The Support Assessment (see WAC 388-828-2000 to WAC 388-828-6020);

     (b) The Service Level Assessment (see WAC 388-828-7000 to WAC 388-828-7080); and

     (c) The Individual Support Plan (ISP) (see WAC 388-828-8000 to 388-828-8060).

     (3) The DDD Assessment is part of the Aging and Disability Services Administration's (ADSA) Comprehensive Assessment Reporting Evaluation system (CARE).

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     (1) Collects a common set of assessment information for reporting purposes to the legislature and the department.

     (2) Promotes consistency in evaluating client support needs for purposes of planning, budgeting, and resource management.

     (3) Identifies a level of service and/or number of hours that is used to support the assessed needs of clients who have been authorized by DDD to receive:

     (a) Medicaid personal care services or DDD HCBS Waiver Personal Care per chapter 388-106 WAC;

     (b) Waiver respite care services per chapter 388-845 WAC;

     (c) Services in the Voluntary Placement Program (VPP) per chapter 388-826 WAC.

     (4) Records your service requests.

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     (1) You are currently approved by DDD to receive a DDD paid service evidenced by meeting one of the conditions in WAC 388-828-1440;

     (2) You request enrollment in one of the DDD HCBS waivers per chapter 388-845 WAC;

     (3) You are age three or older and request a DDD Assessment;

     (4) You have been determined eligible for categorically needy medical coverage per WAC 388-475-0100 and requested one of the following Medicaid state plan services:

     (a) You have requested an assessment for Medicaid personal care services per chapter 388-106 WAC; or

     (b) You have been approved to receive Private Duty Nursing services for clients seventeen years of age and younger per WAC 388-551-3000.

     (5) You are receiving SSP in lieu of a DDD paid service per chapter 388-827 WAC;

     (6) You request admission to a RHC per title 42 CFR 440, title 42 CFR 483, and title 71A RCW;

     (7) You reside in a RHC or community ICF/MR and you are involved in discharge planning for community placement;

     (8) You do not meet any of the conditions listed in WAC 388-828-1120.

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     (1) You have not identified a person willing to receive notice on your behalf regarding specific DDD decisions as required per RCW 71A.10.060 and DDD does not believe you are capable of understanding department decisions that may affect your care; or

     (2) A respondent cannot be identified to participate in your DDD Assessment;

     (3) You reside in a RHC and are not currently involved in discharge planning for community placement;

     (4) You reside in a community ICF/MR and are not authorized by DDD to receive employment/community services paid through the counties; or

     (5) You are under the age of three and do not meet any of the conditions in WAC 388-828-1100.

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     (1) Consult with the Assistant Attorney General to determine if:

     (a) You are able to represent yourself; or

     (b) You require a legal representative/guardian.

     (2) Continue current services until the issue is resolved per section (1) above.

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     (2) Only clients receiving a DDD paid service, SSP in lieu of a DDD paid service, or who are approved for a DDD paid service will receive the Service Level Assessment and Individual Support Plan modules since these modules are required:

     (a) Prior to the authorization/reauthorization of a DDD paid service or SSP; and

     (b) To determine a service level and/or number of hours for a service; and

     (c) To authorize the DDD approved paid service(s) per WAC 388-828-8000.

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     (1) Provide information and referral for Non-DDD community-based supports; and

     (2) Add your name to the waiver data base, if you have requested enrollment in a DDD HCBS waiver per chapter 388-845 WAC; and

     (3) Authorize short-term emergency services as an exception-to-rule (ETR) per WAC 388-440-0001.

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     (1) You are age seventeen or younger; and

     (2) Your family has not made a request for your admission to a Residential Habilitation Center (RHC).

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     (1) Ask if you would like referral information for ICF/MR services; and

     (2) Continue to administer your DDD Assessment; and

     (3) Continue to authorize the DDD paid services or SSP you are receiving at the time of your DDD Assessment if you continue to meet the eligibility requirements for those services.

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     (1) Explain what happens if you refuse to allow DDD to administer the DDD Assessment to you, your respondents, and the person you have identified to receive notice on your behalf per RCW 71A.10.060.

     (2) Consult with the Assistant Attorney General when you have not identified a person to receive notice on your behalf per RCW 71A.10.060 to determine if:

     (a) You are able to represent yourself; or

     (b) You require a legal representative/guardian.

     (3) Terminate existing DDD paid services when they reach their authorized end date.

     (4) Provide you notice and appeal rights for denied and/or terminated service(s) per WAC 388-825-100 and WAC 388-825-120.

     (5) Provide you with information on how to contact DDD in case you later decide you want a DDD Assessment administered.

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     (2) DDD will complete your DDD Assessment no later than thirty days from the date it was created in CARE.

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     (1) You are approved to receive a DDD paid service; and

     (2) You have not identified an ADSA contracted provider.

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     Reviser's note: The above new section was filed by the agency as WAC 388-825-1400. This section is placed among sections forming new chapter 388-828 WAC, and therefore should be numbered WAC 388-828-1400. Pursuant to the requirements of RCW 34.08.040, the section is published in the same form as filed by the agency.
NEW SECTION
WAC 388-828-1420   What is your responsibility when selecting an ADSA contracted agency provider?   You or your legal representative/guardian has the responsibility of choosing an agency provider. DDD or the county will provide you information on contracted and qualified agency providers.

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     (1) An open social service payment system (SSPS) authorization within the past ninety days used for payment of a service or SSP; or

     (2) A current county service authorization for one of the following services:

     (a) Person to Person; or

     (b) Individual Employment; or

     (c) Group Supported Employment; or

     (d) Pre-vocational/Specialized Industries; or

     (e) Community Access; or

     (f) Individual and Family Assistance.

     (3) A current waiver POC or waiver ISP; or

     (4) Residence in a State Operated Living Alternative (SOLA) program; or

     (5) Authorization of Family Support services within the last twelve months per chapter 388-825 WAC; or

     (6) Documentation of DDD approval of your absence from DDD paid services for more than ninety days with available funding for your planned return to services; or

     (7) Evidence of approval for funding of a DDD service or enrollment in a DDD HCBS waiver; or

     (8) Payment of services using Form A-19 State of Washington Invoice Voucher for receipt of:

     (a) Dangerous Mentally Ill Offender funds

     (b) Crisis stabilization services;

     (c) Specialized psychiatric services; or

     (d) Diversion bed services.

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     (1) You are receiving a DDD paid service and your annual reassessment is due for continuation of the DDD paid service; or

     (2) You are receiving a DDD paid service and a reassessment is needed due to a significant change that may affect your support needs; or

     (3) You are receiving SSP in lieu of a DDD paid service and your eligibility for SSP needs to be re-determined per WAC 388-827-0120;

     (4) You are not receiving a paid service and you are approved for funding of a DDD paid service and an assessment must be performed prior to the authorization of services; or

     (5) You make a request to have a DDD Assessment administered and meet the criteria in WAC 388-828-1100; or

     (6) You are contacted by DDD and offered an opportunity to have a DDD Assessment.

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     (1) Funding from the legislature that provides resources for services to be available by a certain date;

     (2) The annual reallocation of dollars for Traditional Family Support in June 2007; or

     (3) Emergency services as determined by DDD as critical to the client's health and safety.

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     (1) On an annual basis if you are receiving a paid service or SSP; or

     (2) When a significant change is reported that may affect your need for support. (e.g. changes in your medical condition, caregiver status, behavior, living situation, employment status).

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     (2) DDD requires that at a minimum: you, one of your respondents, and your DDD case resource manager/social worker participate in your DDD Assessment interview. In addition:

     (a) If you are under the age of eighteen, your parent(s) or legal guardian(s) must participate in your DDD Assessment interview.

     (b) If you are age eighteen or older, your court appointed legal representative/guardian must be consulted if he/she does not attend your DDD Assessment interview.

     (c) If you are age eighteen and older and have no legal representative/guardian, DDD will assist you to identify a respondent.

     (d) DDD may require additional respondents to participate in your DDD Assessment interview, if needed, to obtain complete and accurate information.

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     (1) The legislature has directed DDD to assess all eligible clients with a common, standardized assessment process that measures the support needs of individuals with developmental disabilities.

     (2) The DDD Assessment algorithms in the Support Assessment module are designed to:

     (a) Determine acuity scores and acuity levels for a variety client needs; and

     (b) Provide a valid measure of each client's support needs relative to the support needs of other clients who have received the DDD Assessment.

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     (1) Explain what happens if you refuse to answer a question on a mandatory panel to you, your respondents, and the person you have identified to receive notice on your behalf per RCW 71A.10.060.

     (2) Consult with the Assistant Attorney General when you have not identified a person to receive notice on your behalf per RCW 71A.10.060 to determine if:

     (a) You are able to represent yourself; or

     (b) You require a legal representative/guardian.

     (3) Terminate existing DDD paid services when they reach their authorized end date;

     (4) Provide you notice and appeal rights for denied and/or terminated service(s) per WAC 388-825-100 and WAC 388-825-120; and

     (5) Provide you with information on how to contact DDD in case you later decide you want a DDD Assessment administered.

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If you are approved by DDD to receive:	Your client group is:
(1) DDD DCBS Waiver services per chapter 388-845 WAC; or (2) State-only residential services per chapter 388-825 WAC; or (3) ICF/MR services per 42 CFR 440 and 42 CFR 483.	Waiver and State-Only Residential
(4) Medicaid personal care (MPC) per chapter 388-106 WAC; or (5) DDD HCBS Basic, Basic Plus, or Core Waiver services per chapter 388-845 WAC and Personal Care services per chapter 388-106 WAC; or (6) Medically Intensive Health Care Program services per chapter 388-551 WAC; or (7) Adult Day Health services per chapter 388-106 WAC; or (8) Private Duty Nursing services per chapter 388-551 WAC; or (9) Community Options Program Entry System (COPES) services per chapter 388-106 WAC; or (10) Medically Needy Residential waiver services per chapter 388-106 WAC; or (11) Medicaid Nursing Facility Care services per chapter 388-106 WAC.	Other Medicaid Paid Services
(12) County Employment services per chapter 388-850 WAC. (13) Other DDD paid services per chapter 388-825 WAC, such as: (a) Family support services; or (b) Professional services. (14) Non-waiver voluntary placement program services per chapter 388-826 WAC; (15) SSP only per chapter 388-827 WAC;	State-Only Paid Services
(16) You are not approved to receive any DDD paid services.	No Paid Services

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     (1) DDD "Assessment Main" and Client Details Information

	Client Group
DDD Assessment Panel Name	No Paid Services	Waiver and State Only Residential	Other Medicaid Paid Services	State Only Paid Services
Assessment Main	X	X	X	X
Demographics	X	X	X	X
Overview	X	X	X	X
Addresses	X	X	X	X
Collateral Contacts	X	X	X	X
Financials	X	X	X	X

     (2) Supports Intensity Scale Assessment

	Client Group
DDD Assessment Panel Name	No Paid Services	Waiver and State Only Residential	Other Medicaid Paid Services	State-Only Paid Services
Home Living	X	X	X	X
Community Living	X	X	X	X
Lifelong Learning	X	X	X	X
Employment	X	X	X	X
Health & Safety	X	X	X	X
Social Activities	X	X	X	X
Protection & Advocacy	X	X	X	X

     (3) Support Assessment for Children

	Client Group
DDD Assessment Panel Name	No Paid Services	Waiver and State Only Residential	Other Medicaid Paid Services	State-Only Paid Services
Activities of Daily Living	X	X	X	X
IADLs (Instrumental Activities of Daily Living)	X	X	X	X
Family Supports	X	X	X	X
Peer Relationships	X	X	X	X
Safety & Interactions	X	X	X	X

     (4) Common Support Assessment Panels

DDD Assessment Panel Name	No Paid Services	Waiver and State Only Residential	Other Medicaid Paid Services	State-Only Paid Services
Medical Supports	X	X	X	X
Behavioral Supports	X	X	X	X
Protective Supervision	X	X	X	X
DDD Caregiver Status*	X	X	X	X
Programs and Services	X	X	X	X
*Information on the DDD Caregiver Status panel is not mandatory for clients receiving paid services in an AFH, SL, GH, SOLA, or RHC.

     (5) Service Level Assessment Panels

DDD Assessment Panel Name	No Paid Services	Waiver and State Only Residential	Other Medicaid Paid Services	State-Only Paid Services
Environment		X	X	O
Medical Main		O	X	O
Medications		X	X	X
Diagnosis		X	X	X
Seizures		X	X	X
Medication Management		X	X	X
Treatments/programs		X	X	X
ADH (Adult Day Health)		O	O	O
Pain		X	X	X
Indicators-Main		O	X	O
Allergies		X	X	X
Indicators/Hospital		X	X	X
Foot		X	X	O
Skin		X	X	O
Skin Observation		O	O	O
Vitals/Preventative		X	X	O
Comments		O	O	O
Communication-Main		O	X	O
Speech/Hearing		O	X	O
Psych/Social		O	X	O
MMSE (Mini-Mental Status Exam)		O	X	O
Memory		O	X	O
Behavior		O	X	O
Depression		O	X	O
Suicide		O	O	O
Sleep		O	O	O
Relationships & Interests		O	O	O
Decision Making		O	X	O
Goals		X	O	O
Legal Issues		O	O	O
Alcohol		O	O	O
Substance Abuse		O	O	O
Tobacco		O	X	O
Mobility Main		O	X	O
Locomotion In Room		O	X	O
Locomotion Outside Room		O	X	O
Walk in Room		O	X	O
Bed Mobility		O	X	O
Transfers		O	X	O
Falls		O	O	O
Toileting-Main		O	X	O
Bladder/Bowel		O	X	O
Toilet Use		O	X	O
Eating-Main		O	X	O
Nutritional/Oral		O	X	O
Eating		O	X	O
Meal Preparation		O	X	O
Hygiene-Main		O	X	O
Bathing		O	X	O
Dressing		O	X	O
Personal Hygiene		O	X	O
Household Tasks		O	X	O
Transportation		O	X	O
Essential Shopping		O	X	O
Wood Supply		O	X	O
Housework		O	X	O
Finances		O	O	O
Pet Care		O	O	O
Functional Status		O	O	O
Employment Support*		X*	X*	X*
Mental Health		X	X	X
DDD Sleep*		X*	O	O
*Indicates that:      (a) The "Employment Support" panel is mandatory only for clients age twenty-one and older who are on or being considered for one of the county services listed in WAC 388-828-1440(2).      (b) The "DDD Sleep" panel is mandatory only for clients who are age eighteen or older and who are receiving:      (i) DDD HCBS Core or Community Protection waiver services; or      (ii) State-Only residential services.

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     (1) Collect a common set of assessment information that is scored for all persons who are eligible to receive a DDD Assessment per WAC 388-828-1100;

     (2) Promote a consistent process to evaluate client support needs;

     (3) Determine whether a person meets the ICF/MR level of care standard for potential waiver eligibility; and

     (4) Identify the persons receiving, or approved for, DDD paid services or SSP who will need the additional two assessment modules:

     (a) The Service Level Assessment module; and

     (b) The Individual Support Plan module.

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     (1) The Support Assessment for Children;

     (2) The Supports Intensity Scale (SIS)Assessment;

     (3) DDD Protective Supervision Acuity Scale;

     (4) DDD Caregiver Status Acuity Scale;

     (5) DDD Activities of Daily Living (ADL) Acuity Scale;

     (6) DDD Behavioral Acuity Scale;

     (7) DDD Medical Acuity Scale;

     (8) DDD Interpersonal Support Acuity Scale;

     (9) DDD Mobility Acuity Scale;

     (10) DDD Respite Assessment; and

     (11) Programs and Services component.

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Components contained in the Support Assessment module	Age (0-15)	Age (16+)
The Support Assessment for Children	Yes	No
SIS Support Needs and Supplemental Protection and Advocacy Scales	No	Yes
SIS Exceptional Medical and Behavior Support Needs Scales	Yes	Yes
DDD Protective Supervision Acuity Scale	Yes	Yes
DDD Caregiver Status Acuity Scale	Yes	Yes
DDD Activities of Daily Living Acuity Scale	Yes	Yes
DDD Behavioral Acuity Scale	Yes	Yes
DDD Medical Acuity Scale	Yes	Yes
DDD Interpersonal Support Acuity Scale	Yes	Yes
DDD Mobility Scale	Yes	Yes
Current Programs and Services component	Yes	Yes

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     (1) Your ICF/MR Level of Care score for DDD HCBS waiver eligibility;

     (2) The health and welfare needs that must be addressed in your individual support plan if you are enrolled in a DDD HCBS waiver; and

     (3) Your support need levels for:

     (a) The DDD Activities of Daily Living Acuity Scale;

     (b) The DDD Interpersonal Support Acuity Scale; and

     (c) The DDD Mobility Acuity Scale.

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     (1) Dress and groom self: What support does the child need to dress and groom self as expected of others of same age?

Answers	Definitions	LOC Score	Acuity Score
Physical Assistance	Needs major support in the form of total physical assistance, intensive training and/or therapy for dressing and grooming.	1	4
Training	Needs moderate support in the form of some physical assistance and/or training and/or therapies to dress and groom self.	0	3
Reminders/Prompts	Needs reminders or prompts to dress and groom self appropriately.	0	2
No support needed or at age level	At age level (may have physical supports) in dressing and grooming.	0	0

     (2) Toilet self: What support does the child need to toilet self as expected of others in his/her age group?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Needs major support in the form of total physical support. Intensive training intervention and/or daily therapy to toilet self.	1	4
Partial physical assistance, training	Needs moderate support in the form of some physical assistance, standard training and/or regular therapy.	0	3
Reminders/prompts	Needs reminders or prompts.	0	2
No support needed or at age level	Toilets self or has physical support in place to toilet self.	0	0

     (3) Eat at age level: What support does the child need to eat at age level?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Needs major support in the form of total physical assistance, intensive training and/or daily therapy.	1	4
Partial physical assistance, training	Needs moderate support in the form of some physical assistance, standard training, and/or regular therapy.	1	3
Reminders/prompts	Needs help with manners and appearance when eating, in the form of reminders and prompts.	0	2
No support needed or at age level	At age level (may have physical supports) in eating.	0	0

     (4) Move Around: What support does the child need to move around in the same ways as other children of same age?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Needs major intervention in the form of total physical support to move around, intensive training and/or daily therapy.	1	4
Partial physical assistance, training	Needs moderate support such as someone's help to move around or may use or learn to use adaptive device or may require standard training.	1	3
Reminders/prompts	Needs mild intervention in the form of training and physical prompting for scooting/crawling/walking behaviors.	0	2
No support needed or at age level	No supports needed - child is scooting/crawling/walking at age level	0	0

     (5) Communicate: What support does the child need to communicate as others of same age?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Currently someone else must always determine and communicate child's needs.	1	4
Training/therapy	With intensive training or therapy support, child may learn sufficient verbal and/or signing skills to make self easily understandable to others. May include partial physical support.	1	3
Adaptive device/interpreter	With physical support (adaptive device, interpreter), child is always able to communicate.	0	2
No support needed or at age level	No supports needed and/or at age level.	0	0

     (6) Learn about and use money: What support does the child need to learn about and use money?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Child is not old enough to know about money.	0	4
Partial physical assistance, training	Family must devise special opportunities for child to earn/or spend money.	0	3
Create opportunities, reminders/prompts	Needs to learn about earning and/or spending money in typical age-level ways.	0	2
No support needed or at age level	Needs no support. Independently uses opportunities typical to his/her age group to earn and/or spend money.	0	0

     (7) Make choices and take responsibility: What support does the child need to make choices and take responsibility?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Needs major support in the form of special and/or technical help to and from family/teachers to create opportunities for making choices and taking responsibility.	1	4
Partial physical assistance, training	Needs moderate support in the form of family/teachers creating and explaining a variety of opportunities for making choices and taking responsibility.	1	3
Create opportunities, reminders/prompts	Needs some support in the form of explanation of available options for making choices and taking responsibility.	1	2
No support needed or at age level	Needs no support. Readily uses a variety of opportunities to indicate choices (activity, food, etc.) and take responsibility for tasks, self, etc.	0	0

     (8) Explore environment: What support does the child need to explore environment?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Needs major support in the form of specialized technical help to and from family/teachers to create ways which support/encourage child to explore and reach out.	1	4
Partial physical assistance, training	Needs moderate support in the form of some training/physical help to and from family and teachers to create ways and opportunities for child to explore environment and reach out.	1	3
Reminders/prompts	Needs some support in the form of verbal encouragement or presence of someone child trusts to explore environment and reach out.	0	2
No support needed or at age level	Needs no support and/or is at age level. Readily explores environment (may have adaptive device) and reaches out in ways typical to child's age group.	0	0

     (9) Meet therapy health needs: What supports are necessary to get child's therapy health needs met?

Answers	Definitions	LOC Score	Acuity Score
Daily intervention by professionals	Child requires medical/health intervention or monitoring by professionals at least daily.	1	4
Monitoring by health professionals	Child needs regular (weekly, monthly) monitoring by health professionals.	1	3
Monitoring by trained others	Child needs daily support and/or monitoring by training others.	1	2
Community health system	Needs regular on-going therapy and/or monitoring of health needs through typical community health systems.	0	1
No support needed or at age level	No specialized supports or ongoing therapies necessary.	0	0

     (10) Help family continue to meet child's needs: What support services should the system provide to help family continue to meet child's needs?

Answers	Definitions	LOC Score	Acuity Score
Urgent extensive support	Substantial significant supports to child and parents needed. Child in, or at risk of, out-of-home placement at this time.	1	4
Substantial support/referrals needed	Substantial support needed/requested; (e.g., requests for more than two days per month respite, referral to homemakers, homebuilders; request for long term behavior management training, need extensive and/or expensive environmental modification or equipment; request frequent contact with case manager.)	1	3
Moderate support	Moderate external support needed/requested; (e.g., requests for regular respite, intensive but short-term behavior management, referral for parent training help, referral to day care services; and/or request for regular contact with case manager.)	0	2
Minimal support	Minimal external support needed/requested; (e.g., requests for occasional respite, referrals to parent support group, and/or case manager helps obtain adaptive equipment.)	0	1
No support needed or at age level	No external supports are necessary. Family has obtained any necessary adaptive equipment.	0	0

     (11) Have relationships with family members: What support does the child need to make the kind of relationships with family members expected of non-disabled children of the same age?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Opportunities for contributing to family life totally dependent on others to maintain, interpret child's role to other family members.	0	4
Partial physical assistance, training	Requires major support in the form of daily/weekly creation of opportunities to be seen as a contributing member and assume typical family responsibilities.	0	3
Reminders/prompts	Requires moderate support in the form of adaptive device, training and/or reminders to be seen as contributing member and assume typical family responsibilities.	0	2
No support needed or at age level	Needs no support to form positive family relationship.	0	0

     (12) Explore and use typical community resources: What support does the child need to explore and use typical community resources such as stores, parks, and playgrounds?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Family needs major support (perhaps respite) to continue to provide child total physical support to use typical resources.	0	4
Partial physical assistance, training	Moderate support is needed - family must create ways for child to use these resources in ways typical to child's age group.	0	3
Reminders/prompts	Minimal support needed - family may wish suggestions or some support on ways to enable child's regular use of typical resources.	0	2
No support needed or at age level	Needs no support and/or at age level. Uses these resources regularly.	0	0

     (13) Play with others: What supports are needed for the child to develop age-level skills in playing with others?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Major support needed by others to help child play. Parents may request special adaptive equipment and training to foster child's playing skills.	0	4
Partial physical assistance training	Moderate support needed in the form of a verbal and/or some physical intervention to help child play. Parents may be requesting suggestions instruction in ways to help child develop playing skills.	0	3
Reminders/prompts	Minimal support needed.	0	2
No support needed or at age level	No supports needed and/or at age level. Child's playing skills developing at age level.	0	0

     (14) Have opportunities to play with typically developing children: What supports does the child need to have opportunities to play with typically developing children?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Substantial system support (e.g., system must set up "programs" that allow for interaction with typically developing children and the "programs".)	0	4
Partial physical assistance, training	Moderate supports (e.g., parents have to create opportunities for contacts). Parents may ask for instruction in how to facilitate such contacts. System may need to provide structural supports (e.g., transportation, barrier-free public play environments, etc).	0	3
Reminders/prompts	Minimal support (e.g., some monitoring). Parents may request help on how to broaden child's range of contacts or to increase the age appropriateness of contacts.	0	2
No support needed or at age level	No support needed.	0	0

     (15) Identify and respond safely to emergencies: What support does the child need to identify and respond safely to emergencies?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Needs total physical support to respond to emergencies.	1	4
Always needs help to identify and respond	Needs help all of the time to identify emergencies and to respond.	1	3
Sometimes needs help to identify and respond	Needs help some of the time to identify emergencies and to respond.	1	2
Can identify, needs help to respond	Independently identifies emergencies; needs help from others to respond.	1	1
No help needed or at age level	Needs no help from others in emergencies.	0	0

     (16) Practice age-level safety measures: What support does the child need to practice age-level safety measures?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Needs total physical support for safety measures in daily activities and routines.	1	4
Partial physical assistance, training	Does not recognize own safety needs and requires help in most safety areas.	1	3
Reminders/prompts	Knows importance of safety measures. Needs training and/or physical support in many areas.	1	2
No support needed or at age level	Needs no support in providing for own safety.	0	0

     (17) Effectively relate to other students/peers: What support does the child need to most effectively relate to fellow students and/or peers?

Answers	Definitions	LOC Score	Acuity Score
Total physical support	Needs physical support by others in the form of interpretation of self to others to interact with peers.	1	4
Partial physical assistance, training	Needs physical intervention in the form of modeling to enable child to reach out to peers to give and take support.	1	3
Reminders/prompts	Needs much encouragement, supervision and guidance in how to give and ask for support and interact with peers.	0	2
No support needed or at age level	Without support, child relates to others as a valued member of work/learning unit.	0	0

     (18) Have behaviors which promote being included: What support is needed for this child to have behaviors which promote being included?

Answers	Definitions	LOC Score	Acuity Score
Continuous behavioral interventions	Needs major tolerance and control. Could include being dangerous to self and/or others.	1	4
Major behavior modifications	Needs major behavior modifications to be perceived as typical. Child's behaviors are extremely disagreeable to others.	1	3
Modeling, reminders, prompts	Needs participation in typical settings with typically developing others to model desirable behaviors. Child's behaviors cause him/her to be easily recognized as different from others.	0	2
Minor support	Needs interactions with typically developing others. Child's behaviors are different from others in minor ways and the child may not immediately be perceived as different.	0	1
No support needed or at age level	Needs no support. Behaviors are similar to others in general community of same age and culture.	0	0

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     (1) You are age birth through five years old and the total of your LOC scores is five or more; or

     (2) You are age six through fifteen years old and the total of your LOC scores is seven or more.

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     (1) Your ICF/MR Level of Care score for DDD HCBS waiver eligibility;

     (2) The health and welfare needs that must be addressed in your individual support plan if you are enrolled in a DDD HCBS waiver;

     (3) Your DDD behavioral and medical acuity levels regardless of your age; and

     (4) Your support need acuity levels specific to the:

     (a) DDD Activities of Daily Living Acuity Scale;

     (b) DDD Interpersonal Support Acuity Scale; and

     (c) DDD Mobility Acuity Scale.

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     (1) The Support Needs scale;

     (2) The Supplemental Protection and Advocacy scale;

     (3) Exceptional Medical Support Needs scale; and

     (4) Exceptional Behavioral Support Needs scale.

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     (1) Home living activities;

     (2) Community living activities;

     (3) Lifelong learning activities;

     (4) Employment activities;

     (5) Health and safety activities; and

     (6) Social activities.

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     (1) Type of support;

     (2) Frequency of support; and

     (3) Daily support time.

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Type of Support: What kind of support is needed for the assessed activity?
Answer	Score
None	0
Monitoring	1
Verbal/gestural prompting	2
Partial physical assistance	3
Full physical assistance	4

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Frequency: How frequently is support needed for the assessed activity?
Answer	Score
None or less than monthly	0
At least once a month, but not once a week	1
At least once a week, but not once a day	2
At least once a day, but not once an hour	3
Hourly or more frequently	4

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Daily Support Time: On a typical day when support in this area is needed, how much time should be devoted?
Answer	Score
None	0
Less than 30 minutes	1
30 minutes to less than 2 hours	2
2 hours to less than 4 hours	3
4 hours or more	4

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#	Home Living Activities	Type of Support					Frequency of Support					Daily Support Time					Raw Score
A1	Using the toilet	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
A2	Taking care of clothes (includes laundering)	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
A3	Preparing food	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
A4	Eating food	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
A5	Housekeeping and cleaning	0	1	2	3	4	0	1	2	3	4	0	1	2	*	*
A6	Dressing	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
A7	Bathing and taking care of personal hygiene and grooming needs	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
A8	Operating home appliances	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
A9	Using currently prescribed equipment or treatment	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
Total Raw Score for Home Living Activities:
* = Score is not an option per AAIDD. Note: Question A9 is a question added by DDD. It is for information purposes only and is not used to calculate scores or levels for service determination.

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#	Community Living Activities	Type of Support					Frequency of Support					Daily Support Time					Raw Score
B1	Getting from place to place throughout the community (transportation)	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
B2	Participating in recreation/leisure activities in community settings	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
B3	Using public services in the community	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
B4	Going to visit friends and family	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
B5	Participating in preferred community activities (church, volunteer, etc.)	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
B6	Shopping and purchasing goods and services	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
B7	Interacting with community members	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
B8	Accessing public buildings and settings	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
Total Raw Score for Community Living Activities:
* = Score is not an option per AAIDD.

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#	Lifelong Learning Activities	Type of Support					Frequency of Support					Daily Support Time					Raw Score
C1	Interacting with others in learning activities	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
C2	Participating in training/educational decisions	0	1	2	3	4	0	1	2	3	*	0	1	2	3	*
C3	Learning and using problem-solving strategies	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
C4	Using technology for learning	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
C5	Accessing training/educational settings	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
C6	Learning functional academics (reading signs, counting change, etc.)	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
C7	Learning health and physical education skills	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
C8	Learning self-determination skills	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
C9	Learning self-management strategies	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
Total Raw Score for Lifelong Learning Activities:
*= Score is not an option per AAIDD.

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#	Employment Activities	Type of Support					Frequency of Support					Daily Support Time					Raw Score
D1	Accessing/receiving/job/tasks accommodations	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
D2	Learning and using specific job skills	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
D3	Interacting with co-workers	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
D4	Interacting with supervisors and/or coaches	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
D5	Completing work-related tasks with acceptable speed	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
D6	Completing work-related tasks with acceptable quality	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
D7	Changing job assignments	0	1	2	3	4	0	1	2	*	*	0	1	2	3	4
D8	Seeking information and assistance from an employer	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
Total Raw Score for Employment Activities:
* = Score is not an option per AAIDD.

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#	Health and Safety Activities	Type of Support					Frequency of Support					Daily Support Time					Raw Score
E1	Taking medications	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
E2	Avoiding health and safety hazards	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
E3	Obtaining health care services	0	1	2	3	4	0	1	2	3	4	0	1	2	*	*
E4	Ambulating and moving about	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
E5	Learning how to access emergency services	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
E6	Maintaining a nutritious diet	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
E7	Maintaining physical health and fitness	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
E8	Maintaining emotional well-being	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
Total Raw Score for Health and Safety Activities:
* = Score is not an option per AAIDD.

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#	Social Activities	Type of Support					Frequency of Support					Daily Support Time					Raw Score
F1	Socializing within the household	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
F2	Participating in recreation and/or leisure activities with others	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
F3	Socializing outside the household	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
F4	Making and keeping friends	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
F5	Communicating with others about personal needs	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
F6	Using appropriate social skills	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
F7	Engaging in loving and intimate relationships	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
F8	Engaging in volunteer work	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
Total Raw Score for Social Activities:
* = Score is not an option per AAIDD.

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#	Protection and Advocacy Activities	Type of Support					Frequency of Support					Daily Support Time					Raw Score
G1	Advocating for self	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
G2	Managing money and personal finances	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
G3	Protecting self from exploitation	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
G4	Exercising legal responsibilities	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
G5	Belonging to and participating in self-advocacy/support organizations	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
G6	Obtaining legal services	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
G7	Making choices and decisions	0	1	2	3	4	0	1	2	3	4	0	1	2	3	4
G8	Advocating for others	0	1	2	3	4	0	1	2	3	*	0	1	2	3	4
Total Raw Score for Protection and Advocacy Activities:
* = Score is not an option for AAIDD.

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Answer	Score
No support needed	0
Some support needed	1
Extensive support needed	2

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#	Medical Supports Needed	No Support Needed	Some Support Needed	Extensive Support Needed
1.	Inhalation or oxygen therapy	0	1	2
2.	Postural drainage	0	1	2
3.	Chest PT	0	1	2
4.	Suctioning	0	1	2
5.	Oral stimulation or jaw positioning	0	1	2
6.	Tube feeding (e.g., nasogastric)	0	1	2
7.	Parenteral feeding (e.g., IV)	0	1	2
8.	Turning or positioning	0	1	2
9.	Dressing of open wound(s)	0	1	2
10.	Protection from infectious diseases due to immune system impairment	0	1	2
11.	Seizure management	0	1	2
12.	Dialysis	0	1	2
13.	Ostomy care	0	1	2
14.	Lifting and/or transferring	0	1	2
15.	Therapy services	0	1	2
16.	Diabetes Management*	0	1	2
17.	Other(s) - Specify:	0	1	2
Sub-total Scores of 1s and 2s:
Add Sub-totals scores for 1's and 2's for total exceptional Medical Support Needs Score:
* #16 is a question added by DDD. It is used as part of the DDD Medical Acuity Scale and is not used to calculate SIS percentiles.

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#	Behavioral Supports Needed	No Support Needed	Some Support Needed	Extensive Support Needed
1.	Prevention of assaults or injuries to others	0	1	2
2.	Prevention of property destruction (e.g., fire setting, breaking furniture)	0	1	2
3.	Prevention of stealing	0	1	2
4.	Prevention of self-injury	0	1	2
5.	Prevention of PICA (ingestion of inedible substances)	0	1	2
6.	Prevention of suicide attempts	0	1	2
7.	Prevention of sexual aggression	0	1	2
8.	Prevention of non-aggressive but inappropriate behavior (e.g., exposes self in public, exhibitionism, inappropriate touching or gesturing)	0	1	2
9.	Prevention of tantrums or emotional outbursts	0	1	2
10.	Prevention of wandering	0	1	2
11.	Prevention of substance abuse	0	1	2
12.	Maintenance of mental health treatments	0	1	2
13.	Managing attention-seeking behavior*	0	1	2
14.	Managing uncooperative behavior*	0	1	2
15.	Managing agitated/over reactive behavior*	0	1	2
16.	Managing obsessive/repetitive behavior*	0	1	2
17.	Prevention of other serious behavior problem(s) - Specify:	0	1	2
Sub-total Scores of 1s and 2s:
Add sub-totals scores for 1s and 2s for total exceptional Behavioral Support Needs Scores:
*#13-16 are questions added by DDD. They are used as part of the DDD Behavior Acuity Scale and are not used to calculate SIS percentiles.

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     (1) You have a percentile rank that is over nine percent for three or more of the six subscales in the SIS Support Needs Scale;

     (2) You have a percentile rank that is over twenty-five percent for two or more of the six subscales in the SIS Support Needs Scale;

     (3) You have a percentile rank that is over fifty percent in at least one of the six subscales in the SIS Support Needs Scale;

     (4) You have a support score of one or two for any of the questions listed in the SIS Exceptional Medical Support Needs Scale;

     (5) You have a support score of one or two for at least one of the following items in the SIS Exceptional Behavior Support Needs Scale:

     (a) Prevention of assaults or injuries to others;

     (b) Prevention of property destruction (e.g., fire setting, breaking furniture);

     (c) Prevention of self-injury;

     (d) Prevention of PICA (ingestion of inedible substances);

     (e) Prevention of suicide attempts;

     (f) Prevention of sexual aggression; or

     (g) Prevention of wandering.

     (6) You have a support score of two for any of the questions listed in the SIS Exceptional Behavior Support Needs Scale; or

     (7) You meet or exceed any of the qualifying scores for one or more of the following SIS questions:

Question # of SIS Support Needs Scale	Text of Question	Your score for "Type of Support" is:	And your score for "Frequency of Support" is:
A1	Using the toilet	2 or more	4
		3 or more	2
A2	Taking care of clothes	2 or more	2 or more
		3 or more	1
A3	Preparing food	2 or more	4
		3 or more	2
A4	Eating food	2 or more	4
		3 or more	2
A5	Housekeeping and cleaning	2 or more	2 or more
		3 or more	1
A6	Dressing	2 or more	4
		3 or more	2
A7	Bathing and taking care of personal hygiene and grooming needs	2 or more	4
		3 or more	2
C3	Learning and using problem-solving strategies	2 or more	3 or more
		3 or more	2
C9	Learning self-management strategies	2 or more	3 or more
		3 or more	2
B6	Shopping and purchasing goods and services	2 or more	2 or more
		3 or more	1
E1	Taking medication	2 or more	4
		3 or more	2
E2	Avoiding health and safety hazards	2 or more	3 or more
		3 or more	2
E4	Ambulating and moving about	2 or more	4
		3 or more	2
E6	Maintaining a nutritious diet	2 or more	2 or more
		3 or more	1
E8	Maintaining emotional well-being	2 or more	3 or more
		3 or more	2
F6	Using appropriate social skills	2 or more	3 or more
		3 or more	2
G2	Managing money and personal finances	2 or more	2 or more
		3 or more	1

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If your raw score for the following SIS subscale is:
Home Living	Community Living	Lifelong Learning	Employment Support	Health and Safety	Social Activities	Then your percentile rank for the SIS subscale is:
						>99
>88	>94					>99
87-88	93-94					>99
85-86	91-92			>97		99
81-84	88-90	>96	>95	92-97	>97	98
77-80	84-87	92-96	91-95	86-91	91-97	95
73-76	79-83	86-91	85-90	79-85	84-90	91
68-72	74-78	79-85	78-84	72-78	76-83	84
62-67	69-73	72-78	70-77	65-71	68-75	75
55-61	63-68	64-71	61-69	57-64	58-67	63
48-54	56-62	55-63	52-60	49-56	48-57	50
40-47	49-55	46-54	42-51	42-48	38-47	37
32-39	41-48	36-45	32-41	34-41	28-37	25
25-31	33-40	27-35	23-31	27-33	19-27	16
18-24	25-32	18-26	15-22	20-26	10-18	9
11-17	16-24	9-17	7-14	13-19	3-9	5
3-10	6-15	<9	<7	7-12	<3	2
<3	<6			1-6		1
				<1		<1
						<1

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     (2) The Protective Supervision Acuity Scale is not used when determining your Medicaid personal care or waiver personal care; and

     (3) The information is used for reporting purposes to the legislature and the department.

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     (1) What level of monitoring does the client typically require during awake hours?

Answers	Definitions	Score
Independent	Can be left unattended. Might occasionally show poor judgement, but does not require routine access to a support person.	0
Remote (e.g., a week or more)	Can be left unattended for extended periods of time, but requires access to a support person either via phone or someone who visits the person weekly or so.	1
Periodic (e.g., every couple of days)	Can be left unattended for a couple of days, but requires access to a support person who checks in every few days via telephone or in person.	2
Monitoring (e.g., half day, unstructured)	Can be left unattended for several hours at a time (2-4 hours) to engage in independent activities, but needs access to a support person daily for guidance or assistance.	3
Close Proximity (e.g., 1-2 hours, structured)	Can be left unattended for short periods of time (1-2 hours), provided that the environment is strictly structured and that a support person can respond quickly in an emergency situation.	4
Onsite (e.g., on property)	Cannot be left unattended. Requires a support person on the property at all times, at least during awake hours.	5
Line of Sight/Earshot (e.g., close observation)	Cannot be left unattended. Requires a support person within the room or within earshot of the client's location at all times during awake hours.	6

     (2) What assistance does the client need to handle unfamiliar or unexpected situations?

Answers	Definitions
Can resolve independently	The client can generally handle unfamiliar or unexpected situations. The client shows generally good judgment and awareness of personal safety.
Can resolve with remote assistance	The client can handle unfamiliar or unexpected situations by calling or contacting someone remotely for assistance (e.g., by telephone or email). The support person does not need to be physically present.
Needs someone physically present to assist	When unfamiliar or unexpected situations occur, generally someone must be present or come to the client to help the client resolve the issue.
Needs full physical assistance	The client cannot generally participate in resolving such situations; someone else must resolve them.

     (3) Is client able to summon help?

Answers	Definitions
Can call someone on telephone	Client can discern when help is needed and contact someone via telephone or other electronic means. This includes dialing 911, using speed dial to contact someone, email, radio, or dialing a phone number.
Can seek help outside the house, nearby	Client can discern when help is needed and can summon a remote caregiver, neighbor, or other person outside the house or nearby to assist when necessary.
Can seek help inside house	Client can discern when help is needed and can summon a caregiver or roommate within the house to assist when necessary.
Cannot summon help	Client is unable to summon help or discern a dangerous situation that would require help.

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If you are:	Then your age-based score adjustment is:
18 years or older	Score is equal to your level of monitoring score
16-17 years of age	Subtract 1 from your level of monitoring score
12-15 years of age	Subtract 2 from your level of monitoring score
8-11 years of age	Subtract 3 from your level of monitoring score
5-7 years of age	Subtract 4 from your level of monitoring score
0-4 years of age	Subtract 5 from your level of monitoring score
If your adjusted level of monitoring score is a negative number, your adjusted protective supervision acuity score is zero.

     Example: If you are fifteen years old and "close proximity, (e.g., 1-2 hours, structured)" is identified as your level of monitoring score, your adjusted protective supervision acuity score is: Your close proximity score of four minus age-based score adjustment of two. For age twelve through fifteen, this equals an adjusted protective supervision score of two.

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If your Adjusted Protective Supervision score is:	Then your Protective Supervision Support Level is:
5-6	High
3-4	Medium
1-2	Low
0	None

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     (2) The DDD Caregiver Status Acuity Scale does not affect service determination for the Medicaid personal care or waiver personal care assessment; and

     (3) The information is used for reporting purposes to the legislature and the department.

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     (1) He or she has been identified as an informal caregiver; and

     (2) He or she is available to provide assistance as an informal caregiver when other caregivers are unavailable.

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     (1) Overall, how stressed do you feel in caring for the client?

Answers	Score
Not stressed	0
Somewhat stressed	4
Very stressed	9

    
     (2) Other care giving for persons who are disabled, seriously ill, or under age 5?

Answers	Score
Client is the only person who requires direct care	0
Part-time responsibility for one or more additional persons	1
Full-time responsibility for one additional person	2
Full-time responsibility for two or more additional persons	4

     (3) Factors that make it hard to be a caregiver for client?

Answers	Score
Decline in physical health	1
Decline in emotional health	1
Negative impact on employment	1
Getting less than 5 hours of uninterrupted sleep because of care giving	1
Health or safety impact	1
Other issues than impact care giving	1

     (4) How much do these things impact your ability to care for the client?

Answers	Score
Little or no impact	0
Possible impact, no concrete evidence	1
Concrete evidence of reduced care	4
Unable	9

     (5) Is the client creating significant stress on other household members?

Answers	Score
Stable and healthy	0
Clearly identifiable signs of stress	4
Serious risk of failure	9

     (6) How long do you expect to continue providing care?

Answers	Score
2 or more years	0
6 months to 2 years	0
1 to 6 months	4
Less than 1 month	9

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If the following criteria are met:	Then your caregiver risk factor (s) are:
(1) You have a score of "less than 1 month" for question 6 ("How long do you expect to continue providing care?") in WAC 388-828-5260.	Immediate risk of loss of caregiver
(2) You have not identified any collateral contacts in the CARE system as having a contact role of "informal caregiver;" and      (3) You have not identified any collateral contacts in the CARE system as having a contact role of "formal caregiver;" and      (4) You have not identified any collateral contacts in the CARE system as having a contact role of "backup caregiver;" and      (5) You do not have a paid provider, authorized by DDD, to provide supports for a DDD paid service; and      (6) You have an adjusted protective supervision score of 3 or more in WAC 388-828-5080.	No caregiver, and needs one
(7) You have identified one of your collateral contacts in the CARE system as having a contact role of primary caregiver; and      (8) Your primary caregiver is 70 years of age or older; and      (9) Your primary caregiver lives with you in the same residence.	Aging caregiver

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Your scores for the following questions in WAC 388-828-5240			Your Caregiver Risk Level
Your score for question 4	Your score for question 5	Your score for question 6
0	0	0	None
0	0	4	Medium
0	0	9	Immediate
0	4	0	Medium
0	4	4	Medium
0	4	9	Immediate
0	9	0	High
0	9	4	High
0	9	9	Immediate
1	0	0	Low
1	0	4	Medium
1	0	9	Immediate
1	4	0	Medium
1	4	4	Medium
1	4	9	Immediate
1	9	0	High
1	9	4	High
1	9	9	Immediate
4	0	0	Medium
4	0	4	Medium
4	0	9	Immediate
4	4	0	Medium
4	4	4	Medium
4	4	9	Immediate
4	9	0	High
4	9	4	High
4	9	9	Immediate
9	0	0	High
9	0	4	High
9	0	9	Immediate
9	4	0	High
9	4	4	High
9	4	9	Immediate
9	9	0	High
9	9	4	High
9	9	9	Immediate

     (2) If your maximum scores for questions four, five, and six are four or less and you have an "Aging Caregiver" risk factor in WAC 388-828-5280, your caregiver risk level is medium.

     (3) If your caregiver risk factor is "No caregiver, and needs one" in WAC 388-828-5280, your caregiver risk level is immediate regardless of your scores for questions four, five, and six.

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     (1) Under what conditions are other caregivers available?

Answers available for selection	Score
Routinely provides care	0
Upon request	2
Emergency only	4
No other caregiver available	9

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If the availability of your back caregiver is:	Then your risk level score is:
(1) Your backup caregivers are available routinely or upon request as evidenced by a score of 0 to 2 for question 1 of the backup caregiver subscale; and      (2) You have a person identified as a backup caregiver that does not live with you evidenced by the "Lives with client" checkbox not being selected as contact details information for him or her.	1 (Not at risk)
(3) Your backup caregivers are available upon an emergency only basis evidenced by a score of 4 for question 1 of the backup caregiver subscale; and      (4) "Lives with client" has been selected for all of the persons you have identified as your backup caregivers.	2 (Some risk)
(5) You have no other caregiver available evidenced by a score of 9 for question 1 of the backup caregiver subscale.	3 (High risk)

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     (1) The DDD Activities of Daily Living Acuity Scale does not affect service determination for the Medicaid personal care or waiver personal care assessments; and

     (2) The information is used for reporting purposes to the legislature and the department.

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     (1) Your ADL support needs level from the Support Assessment for Children if you are age birth through fifteen years old; or

     (2) Your ADL support needs level from the SIS Assessment if you are age sixteen or older.

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ADL questions from the Support Assessment for Children in WAC 388-828-3040
Question #	Text of ADL Questions:
1	Dress and Groom self
2	Toilet self
3	Eat at age level
4	Move around

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If your ADL support needs score is:	Then your ADL support need level is:	Value
11 to 16	High	3
7 to 10	Medium	2
2 to 6	Low	1
0 or 1	None	0

     (2) If your acuity score is four for any of the ADL questions in WAC 388-828-3040, your ADL support needs level is determined to be high.

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ADL questions from the SIS assessment in WAC 388-828-4200 and WAC 388-828-4280
Question #	Text of ADL questions:
A1	Using the toilet
A4	Eating food
A6	Dressing
A7	Bathing and taking care of personal hygiene and grooming needs
E1	Taking medications
E4	Ambulating and moving about

     (2) If your "Frequency of Support" score for a SIS ADL question is zero or one, adjust your "Type of Support" score for that question to zero.

     (3) If your "Frequency of Support" score for a SIS ADL support question is two, three, or four, no adjustment is needed to your "Type of Support" score.

     Example:

SIS ADL Questions	Text of SIS ADL Questions	If your "Frequency of Support" score is:	And your "Type of Support" score is:	Then your adjusted "Type of Support" score is:
A1	Using the toilet	3	3	3
A4	Eating food	1	2	0
A6	Dressing	3	3	3
A7	Bathing and taking care of personal hygiene and grooming needs	1	2	0
E1	Taking medications	3	2	2
E4	Ambulating and moving about	0	0	0
Your SIS ADL support needs score:				8

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If the sum of your adjusted ADL support needs score for the SIS is:	Then your ADL support needs level for the SIS is:	Value
16 to 24	High	3
10 to 15	Medium	2
2 to 9	Low	1
0 or 1	None	0

     (2) If you have a "Type of Support" score of four for any of the questions listed in WAC 388-828-5460, your ADL support needs level for the SIS Assessment is determined to be high.

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     (2) The DDD Behavioral Acuity Scale does not affect service determination for the Medicaid personal care or waiver personal care assessment.

     (3) The information is used for reporting purposes to the legislature and the department.

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If the frequency of occurrence of your most prominent behavior is:	Then your score for frequency is:
Less than once per month	Rare
1 to 3 times per month	Occasional
1 to 4 times per week	Occasional
1 to 3 times daily	Frequent
4 or more times daily	Frequent

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If the characteristics of your most prominent behavior are:	Then your score for severity is:
Your behavior may be uncooperative, inconvenient, repetitive, and/or require time intensive support. However, your behavior is not considered aggressive or self-injurious.	Minor incidents
Your behavior, if allowed to continue over time, may result in life-threatening harm for yourself and/or others.	Potentially dangerous
Your behavior without immediate intervention will result in life-threatening harm for yourself and/or others.	Life threatening

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If the caregiver assistance provided to support your most prominent behavior is:	Then your score for caregiver assistance is:
Your respondent reports that you do not require any assistance to keep your most prominent behavior under control.	No supervision, Oversight
Your respondent reports that you may at times require supervision and verbal redirection to keep your most prominent behavior under control.	Verbal redirection
Your respondent reports that you require occasional physical guidance of limbs and/or caregiver intervention to keep your most prominent behavior under control.	Occasional physical guiding or intervention
Your respondent reports that you require in-sight supervision at all times and may require 1 to 2 person physical restraint or removal from the area to keep your most prominent behavior under control.	In-Sight Supervision -Physical restraint