Fillable Printable Protective Level Of Care Rule Citations And Form

Protective Level Of Care Rule Citations And Form

ProtectiveLevelofCareRuleCitations

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5101:3‐3‐05(B)Levelofcaredefinitions

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(2)"Activityofdailyliving(ADL)"meansapersonalorself‐caretaskthatenables anindividualtomeetbasiclife

needs.Forpurposesofthisrule,theterm"ADL"includesthefollowingdefinedactivities:

(a)"Bathing"meanstheabilityofanindividualtocleanseone'sbodybyshowering,tub,orsponge

bath,oranyothergenerallyacceptedmethod.

(b)"Dressing"meanstheabilityofanindividualtocompletetheactivities

necessarytodressoneself

andincludesthefollowingtwocomponents:

(i)Puttingonandtakingoffanitemofclothingorprosthesis;and

(ii)Fasteningandunfasteninganitemofclothingorprosthesis.

(c)"Eating"meanstheabilityofanindividualtofeedoneself.Eating includestheprocessesof



gettingfoodintoone'smouth,chewing,andswallowing,and/ortheabilitytouseandself‐

manageafeedingtube.

(d)"Grooming"meanstheabilityofanindividualtocareforone'sappearanceandincludesthe

followingthreecomponents:

(i)Oralhygiene;

(ii)Haircare;and

(iii)Nailcare.

(e)"Mobility"

meanstheabilityofanindividualtousefineandgrossmotorskillstoreposition

ormoveoneselffromplacetoplaceandincludesthefollowingthreecomponents:

(i)"Bedmobility"meanstheabilityofanindividualtomovetoorfromalyingposition,

turnfromsideto

side,orotherwisepositionthebodywhileinbedoralternative

sleepfurniture;

(ii)"Locomotion"meanstheabilityofanindividualtomovebetweenlocationsby

ambulationorbyothermeans;and

(iii)"Transfer"meanstheabilityofanindividualtomovebetweensurfaces,including

butnotlimitedto,

toandfromabed,chair,wheelchair,orstandingposition. 

(f)"Toileting"meanstheabilityofanindividualtocompletetheactivitiesnecessarytoeliminate

anddisposeofbodilywasteandincludesthefollowingfourcomponents:

(i)Usingacommode,bedpan,orurinal;

(ii)Changingincontinencesuppliesorfemininehygiene

products;

(iii)Cleansingself;and

(iv)Managinganostomyorcatheter.

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(5)"Assistance"meansthehands‐onprovisionofhelpintheinitiationand/orcompletionofatask.

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(17)"Instrumentalactivityofdailyliving(IADL)"meanstheabilityofanindividualtocompletecommunity

livingskills.Forthepurposesofthisrule,theterm"IADL"includesthefollowingdefinedactivities:

(a)"Communityaccess"meanstheabilityofanindividualtouseavailablecommunityservices

andsupportstomeetone'sneedsandincludesthefollowingthreecomponents:

(i)"Accessingtransportation"meanstheabilityto

getandusetransportation.

(ii)"Handlingfinances"meanstheabilityofanindividualtomanageone'smoneyand

doesnotincludetransportation.Handlingfinancesincludesallofthefollowing:

(a)Knowingwheremoneyis;

(b)Knowinghowtogetmoney;

(c)Payingbills;and

(d)Knowinghowtogetandusebenefitsandservices,

includingbutnotlimitedto:

(i)Healthbenefitsandinsurance;

(ii)Socialbenefits;and

(iii)Homeutilities.

(iii)"Telephoning"meanstheabilitytomakeandanswertelephonecallsorusetechnologyto

connecttocommunityservicesandsupports.

(b)"Environmentalmanagement" meanstheabilityofanindividual tomaintainthe

livingarrangement

inamannerthatensuresthehealthandsafetyoftheindividualandincludesthefollowingthree

components:

(i)"Heavychores"meanstheabilitytomoveheavyfurnitureandappliancesforcleaning,turn

mattresses,andwashwindowsandwalls;and

(ii)"Housecleaning"meanstheability to

makebeds,cleanthebathroom,sweepand

mopfloors,dust,cleanandstoredishes,pickupclutter,andtakeouttrash;

(iii)"Yardworkand/ormaintenance"meanstheabilitytocareforthelawn,rakeleaves,

shovelsnow,completeminorhomerepairs,andpaint.

(c)"Mealpreparation"meanstheability

ofanindividualtoprepareorcookfoodforoneself.

(d)"Personallaundry"meanstheabilityofanindividualtowashanddryone'sclothingand

householditemsbymachineorbyhand.

(e)"Shopping"meanstheabilitytoobtainorpurchaseone'snecessaryitems.Necessaryitems

include,but

arenotlimitedto,groceries,clothing,andhouseho ld items.Shoppingdoesnot

includehandlingfinancesoraccessingtransportation.

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(18)"Lessthantwenty‐fourhoursupport"meansthatanindividualrequiresthepresenceofanotherperson,

orthepresenceofaremotemonitoringdevicethatdoesnotrequiretheindividual toinitiatearesponse,

duringaportionofatwenty‐fourhourperiodoftime.

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(25)"Need"meanstheinabilityofanindividualtocompleteanecessaryandapplicabletaskindependently,

safely,andconsistently.Anindividualdoesnothaveaneedwhen:

(a)Theindividualisnotwillingtocompleteataskordoesnothavethechoicetocompleteatask.

(b)Thetaskcanbecompletedwiththeuseofavailableassistivedevicesandaccommodations.

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(38)"Supervision"meanseither

ofthefollowing:

(a)Remindinganindividualtoperformorcompleteanactivity;or

(b)Observingwhileanindividualperfor ms anactivitytoensuretheindividual'shealthandsafety.

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PROTECTIVELEVELOFCAREREVIEWWORKSHEET

(March2012)

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Individual’sname:

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Personcompletingworksheet:

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Date:

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5101:3‐3‐06Criteriafortheprotectivelevelofcare

Thecriteriafortheprotectivelevelofcareismetwhentheindividualhasaneedfor:

1.Supervisionof1ADLANDassistancewith3IADLsasdefinedin5101:3‐3‐05;or

2.SupervisionofmedicationadministrationANDassistancewith3IADLsasdefinedin5101:3‐3‐05;or

3.Lessthan24‐hoursupportinordertopreventharmduetoacognitiveimpairment,asdiagnosedbyaphysician

orotherlicensedhealthprofessionalactingwithinhisorherapplicablescopeofpractice,asdefinedbylaw.

Indicatebelowthecriteriawithwhichtheindividualmeetscriteriaforprotective

levelofcare.

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Option1:

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RequiressupervisionofoneADL

Bathing

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Dressing(requiressupervisiongettingitemson/offANDfastening/unfasteninganitemor

prosthesis)

Eating

Grooming(requiressupervisionwithoralhygiene,haircare,ANDnailcare)

Toileting(requiressupervisionwithoneofthefollowing):

Usingcommode,bedpan,orurinal

Changingincontinencesuppliesorfemininehygieneproducts

Cleansingself

Managinganostomyorcatheter

Mobility(requiressupervisioninoneofthefollowingareas:)

Bedmobility

Locomotion

Transfer

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AND

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Requiresassistancewith3IADLS

Mealpreparation

Environmentalmanagement(aneedmustexistinallofthefollowingthreeareas:)

Housecleaning

Heavychores

Yardwork/maintenance

Personallaundry

Communityaccess(aneedmustexistinatleastoneofthefollowingthreeareas:)

Accessingtransportation

Handlingfinances

Telephoning

Shopping

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Option2:

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Requiressupervisionofmedicationadministration

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