The Kentucky Map 351 form is a document used for Medicaid waiver assessments in the Commonwealth of Kentucky. It collects essential information about the member's demographics, waiver eligibility, and daily living activities. This form is crucial for determining the level of care and services required for individuals seeking assistance through Medicaid programs.
The Kentucky Map 351 form plays a crucial role in the assessment and eligibility determination for various Medicaid waiver programs within the state. This comprehensive document is designed to gather essential information about individuals seeking assistance, ensuring that their unique needs are met. Key sections of the form include member demographics, which capture vital personal details such as name, date of birth, and Medicaid Member ID. It also assesses the individual's eligibility for specific waiver programs, including Home and Community Based Waiver and Acquired Brain Injury Waiver, among others. Furthermore, the form delves into the member's daily living activities, evaluating their independence in tasks like dressing, grooming, and eating. It also addresses instrumental activities of daily living, such as meal preparation and financial management. By documenting these aspects, the Map 351 form not only helps in determining eligibility but also facilitates the development of tailored support plans that promote the member's well-being and autonomy. Understanding the intricacies of this form is essential for both applicants and their caregivers, as it lays the groundwork for accessing necessary services and supports.
MAP 351
Commonwealth of Kentucky
(Rev. 7/08)
Cabinet for Health and Family Services
Department for Medicaid Services
MEDICAID WAIVER ASSESSMENT
SECTION I – MEMBER DEMOGRAPHICS
Name (last, first, middle)
Date of birth (mo., day, yr.)
Medicaid Member ID #
Street address
County code
Sex (check one)
Marital status (check one)
Male
Divorced
Married
Separated
Female
Single
Widowed
City, state and zip code
Emergency contact (name)
Emergency contact (phone #)
Member phone number
Is member able to read and
Member’s height
write
Yes
No
Member’s weight
SECTION II – MEMBER WAIVER ELIGIBILITY
Type of program applied for (CHECK ONE)
Adjudicated
/Nonadjudicated
_____
Home and Community Based Waiver
Type of application (check one)
Acquired Brain Injury Waiver
Certification
Re-certification Re-application
Acquired Brain Injury/Long Term Care Waiver
Supports for Community Living Waiver
Michelle P. Waiver
Consumer Directed Option Blended
Member admitted from (check one)
Certification period (enter dates below)
Home Hospital Nursing facility
ICF/MR/DD
Begin date
End date
Other:
number:
Has member’s freedom of choice been explained and
Has member been informed of the process to make
verified by a signature on the MAP 350 Form Yes
a complaint
No (see instructions)
Physician’s name
Physician’s license number
Physician’s phone number
(enter 5 digit #)
Enter member’s primary diagnosis: HCB (ICD-9 code); SCL (DSM code); ABI (ICD-9 and/or DSM)
Enter all diagnoses including DSM or ICD-9 codes:
Is the member diagnosed with one of the following?
AXIS I: (mental illness)
Mental Retardation/ IQ=
(Date-of-onset
)
Developmental Disability
AXIS II: (MR/DD)
Mental Illness
AXIS III: (Medical)
Brain Injury
Cause of Brain Injury:
Date of Brain Injury:
Rancho Scale
SECTION III – ASSESSMENT PROVIDER INFORMATION
Assessment/Reassessment provider
Provider number
Provider phone number
name:
Provider contact person
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NAME (LAST, FIRST)
MEDICAID NUMBER
SECTION IV SELF ASSESSMENT
*For SCL, MP and ABI waivers only
*add additional pages as needed
Community Inclusion (what do you like to do or where would you like to go in the community, where do you go for recreation, do you not get to go somewhere that you would like to)
Relationships (How do you stay in contact with your friends and family, do you need assistance in making or keeping friends, who are your friends)
Rights (do you understand your rights, are any of your rights restricted, do you know what is abuse or neglect)
Dignity and Respect (how are you treated by staff, do you have a place you can go to be with friends or to be alone or have privacy)
Health (who are your doctors ,do you have any health concerns, what medicine do you take, how do they make you feel,)
Lifestyle (do you have a job, do you want to work, do you want to go to school, do you go to the bank, do you have spending money to carry)
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Name (LAST, FIRST)
Medicaid Number
SECTION V – ACTIVITIES OF DAILY LIVING
1) Is member independent with
Comments:
dressing/undressing
No(If no, check below all that apply and comment)
Requires supervision or verbal cues
Requires hands-on assistance with upper body
Requires hands-on assistance with lower body
Requires total assistance
2) Is member independent with grooming
Requires hands-on assistance with
oral care
shaving
nail care
hair
3) Is member independent with bed mobility
No (If no, check below all that apply and comment)
Occasionally requires hands-on assistance
Always requires hands-on assistance
Bed-bound
Required bedrails
4) Is member independent with bathing
Requires Peri-Care
5) Is member independent with toileting
Bladder incontinence
Bowel incontinence
Bowel and bladder regimen
6) Is member independent with eating Yes No
(If no, check below all that apply and comment)
Requires assistance cutting meat or arranging food
Partial/occasional help
Totally fed (by mouth)
Tube feeding (type and tube location)
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7) Is member independent with ambulation
Dependent on device
Requires aid of one person
Requires aid of two people
History of falls (number of falls, and date of last fall)
8) Is member independent with transferring
Hands-on assistance of one person
Hands-on assistance of two people
Requires mechanical device
Bedfast
SECTION VI - INSTRUMENTAL ACTIVITIES OF DAILY LIVING
1) Is member able to prepare meals
(If no, check below all that apply and explain in the comments)
Arranges for meal preparation
Requires assistance with meal preparation
Requires total meal preparation
2) Is member able to shop independently
Yes No
Arranges for shopping to be done
Requires assistance with shopping
Unable to participate in shopping
3) Is member able to perform light housekeeping
Arranges for light housekeeping duties to be performed
Requires assistance with light housekeeping
Unable to perform any light housekeeping
4) Is member able to perform heavy housework
Arranges for heavy housework to be performed
Requires assistance with heavy housework
Unable to perform any heavy housework
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5) Is member able to perform laundry tasks
Arranges for laundry to be done
Requires assistance with laundry tasks
Unable to perform any laundry tasks
6) Is member able to plan/arrange for pick-up,
delivery, or some means of gaining possession of
medication(s) and take them independently
Arranges for medication to be obtained and taken correctly
Requires assistance with obtaining and taking medication
correctly
Unable to obtain medication and take correctly
7) Is member able to handle finances independently
Arranges for someone else to handle finances
Requires assistance with handling finances
Unable to handle finances
8) Is member able to use the telephone independently
Requires adaptive device to use telephone
Requires assistance when using telephone
Unable to use telephone
SECTION VII-NEURO/EMOTIONAL/BEHAVIORAL
1) Does member exhibit behavior problems
No (If yes, check below all that apply and explain
Date of functional analysis:
and/or
the frequency in comments)
Date of behavior support plan:
Disruptive behavior
Agitated behavior
Assaultive behavior
Self-injurious behavior
Self-neglecting behavior
Page 5 of 15
2) Is member oriented to person, place, time
Yes No (If no, check below all that apply and comment)
Forgetful
Confused
Unresponsive
Impaired Judgment
3) Has member experienced a major change or
Description:
crisis within the past twelve months
(If yes, describe)
4) Is the member actively participating in social
and/or community activities Yes
5) Is the member experiencing any of the following
(For each checked, explain the frequency and details in the
comments section)
Difficulty recognizing others
Loneliness
Sleeping problems
Anxiousness
Irritability
Lack of interest
Short-term memory loss
Long-term memory loss
Hopelessness
Suicidal behavior
Medication abuse
Substance abuse
Alcohol Abuse
Page 6 of 15
6) Cognitive functioning (Participant’s current
level of alertness, orientation, comprehension,
concentration, and immediate memory for simple
commands)
Alert/oriented, able to focus and shift
attention, comprehends and recalls task
directions independently.
Requires prompting (cueing, repetition,
reminders) only under stressful or unfamiliar
conditions.
Requires assistance and some direction in
specific situations (e.g., on all tasks
involving shifting of attention), or
consistently requires low stimulus
environment due to distractibility.
Required considerable assistance in routine
situations. Is not alert and oriented or is
unable to shift attention and recall directions
more than half the time.
Totally dependent due to disturbances such
as constant disorientation, coma, persistent
vegetative state, or delirium.
7) When Confused (Reported or Observed):
Never
In new or complex situations only
On awakening or at night only
During the day and evening, but not
constantly
Constantly
NA (non-responsive)
8) When Anxious (Reported or Observed):
None of the time
Less often than daily
Daily, but not constantly
All of the time
9) Depressive Feelings (Reported or Observed):
Depressed mood (e.g., feeling sad, tearful)
Sense of failure or self-reproach
Recurrent thoughts of death
Thoughts of suicide
None of the above feelings reported or
observed
Page 7 of 15
10) Member Behaviors (Reported or Observed):
Indecisiveness, lack of concentration
Diminished interest in most activities
Sleep disturbances
Recent changes in appetite or weight
Agitation
Suicide attempt
None of the above behaviors observed or
reported
11) Behaviors Demonstrated at Least Once a
Week:
Memory deficit: failure to recognize
familiar persons/places, inability to recall
events of past 24-hours, significant memory
loss so that supervision is required.
Impaired decision-making: failure to
perform usual ADL’s, inability to
inappropriately stop activities, jeopardizes
safety through actions.
Verbal disruption: yelling, threatening,
excessive profanity, sexual references, etc.
Physical aggression: aggressive or
combative to self and others (e.g. hits self,
throws objects, punches, dangerous
maneuvers with wheelchair or other
objects).
Disruptive, infantile, or socially
inappropriate behavior (excludes verbal
actions).
Delusional, hallucinatory, or paranoid
behavior.
None of the above behaviors demonstrated.
12 ) Frequency of Behavior Problems (Reported or
Observed) such as wandering episodes, self abuse,
verbal disruption, physical aggression, etc.:
Less than once a month
Once a month
Several times each month
Several times a week
At least daily
Page 8 of 15
13)
Mental Status:
Oriented
Depressed
Disoriented
Lethargic
Agitated
Other
14) Is this member receiving Psychiatric Nursing
Services at home provided by a qualified psychiatric
nurse?
SECTION VIII-CLINICAL INFORMATION
1) Is member’s vision adequate (with or without
glasses)
Undetermined
Difficulty seeing print
Difficulty seeing objects
No useful vision
2) Is member’s hearing adequate (with or without
hearing aid)
(If no, check below all that apply, and comment)
Difficulty with conversation level
Only hears loud sounds
No useful hearing
3) Is member able to communicate needs
Speaks with difficulty but can be understood
Uses sign language and/or gestures/communication device
Inappropriate context
Unable to communicate
4) Does member maintain an adequate diet
No (If no, check all that apply and comment)
Uses dietary supplements
Requires special diet (low salt, low fat, etc.)
Refuses to eat
Forgets to eat
Tube feeding required (Explain the brand, amount, and
frequency in the comments section)
Other dietary considerations (PICA, Prader-Willie, etc.)
Page 9 of 15
5) Does member require respiratory care and/or
equipment
No (If yes, check all that apply and comment)
Oxygen therapy (Liters per minute and delivery device)
Nebulizer (Breathing treatments)
Management of respiratory infection
Nasopharyngeal airway
Tracheostomy care
Aspiration precautions
Suctioning
Pulse oximetry
Ventilator (list settings)
6) Does member have history of a stroke(s)
Residual physical injury(ies)
Swallowing impairments
Functional limitations (Number of limbs affected)
7) Does member’s skin require additional,
specialized care
(If yes, check all that apply and comment)
Requires additional ointments/lotions
Requires simple dressing changes (i.e. band-aids,
occlusive dressings)
Requires complex dressing changes (i.e. sterile dressing)
Wounds requiring “packing” and/or measurements
Contagious skin infections
Ostomy care
8) Does member require routine lab work
No (If yes, what type and how often)
9) Does member require specialized genital and/or
urinary care Yes
Management of reoccurring urinary tract infection
In-dwelling catheter
Bladder irrigation
In and out catheterization
10) Does member require specific, physician-
ordered vital signs evaluation necessary in the
management of a condition(s) Yes No (If yes,
explain in the comments section)
11) Does member have total or partial paralysis
No (If yes, list limbs affected and comment)
Page 10 of 15
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