Login

Fillable Printable Protective Level Of Care Rule Citations And Form

Fillable Printable Protective Level Of Care Rule Citations And Form

Protective Level Of Care Rule Citations And Form

Protective Level Of Care Rule Citations And Form

ProtectiveLevelofCareRuleCitations
5101:3305(B)Levelofcaredefinitions
(2)"Activityofdailyliving(ADL)"meansapersonalorselfcaretaskthatenables anindividualtomeetbasiclife
needs.Forpurposesofthisrule,theterm"ADL"includesthefollowingdefinedactivities:
(a)"Bathing"meanstheabilityofanindividualtocleanseone'sbodybyshowering,tub,orsponge
bath,oranyothergenerallyacceptedmethod.
(b)"Dressing"meanstheabilityofanindividualtocompletetheactivities
necessarytodressoneself
andincludesthefollowingtwocomponents:
(i)Puttingonandtakingoffanitemofclothingorprosthesis;and
(ii)Fasteningandunfasteninganitemofclothingorprosthesis.
(c)"Eating"meanstheabilityofanindividualtofeedoneself.Eating includestheprocessesof

gettingfoodintoone'smouth,chewing,andswallowing,and/ortheabilitytouseandself‐
manageafeedingtube.
(d)"Grooming"meanstheabilityofanindividualtocareforone'sappearanceandincludesthe
followingthreecomponents:
(i)Oralhygiene;
(ii)Haircare;and
(iii)Nailcare.
(e)"Mobility"
meanstheabilityofanindividualtousefineandgrossmotorskillstoreposition
ormoveoneselffromplacetoplaceandincludesthefollowingthreecomponents:
(i)"Bedmobility"meanstheabilityofanindividualtomovetoorfromalyingposition,
turnfromsideto
side,orotherwisepositionthebodywhileinbedoralternative
sleepfurniture;
(ii)"Locomotion"meanstheabilityofanindividualtomovebetweenlocationsby
ambulationorbyothermeans;and
(iii)"Transfer"meanstheabilityofanindividualtomovebetweensurfaces,including
butnotlimitedto,
toandfromabed,chair,wheelchair,orstandingposition.
(f)"Toileting"meanstheabilityofanindividualtocompletetheactivitiesnecessarytoeliminate
anddisposeofbodilywasteandincludesthefollowingfourcomponents:
(i)Usingacommode,bedpan,orurinal;
(ii)Changingincontinencesuppliesorfemininehygiene
products;
(iii)Cleansingself;and
(iv)Managinganostomyorcatheter.
(5)"Assistance"meansthehandsonprovisionofhelpintheinitiationand/orcompletionofatask.
(17)"Instrumentalactivityofdailyliving(IADL)"meanstheabilityofanindividualtocompletecommunity
livingskills.Forthepurposesofthisrule,theterm"IADL"includesthefollowingdefinedactivities:
(a)"Communityaccess"meanstheabilityofanindividualtouseavailablecommunityservices
andsupportstomeetone'sneedsandincludesthefollowingthreecomponents:
(i)"Accessingtransportation"meanstheabilityto
getandusetransportation.
(ii)"Handlingfinances"meanstheabilityofanindividualtomanageone'smoneyand
doesnotincludetransportation.Handlingfinancesincludesallofthefollowing:
(a)Knowingwheremoneyis;
(b)Knowinghowtogetmoney;
(c)Payingbills;and
(d)Knowinghowtogetandusebenefitsandservices,
includingbutnotlimitedto:
(i)Healthbenefitsandinsurance;
(ii)Socialbenefits;and
(iii)Homeutilities.
(iii)"Telephoning"meanstheabilitytomakeandanswertelephonecallsorusetechnologyto
connecttocommunityservicesandsupports.
(b)"Environmentalmanagement" meanstheabilityofanindividual tomaintainthe
livingarrangement
inamannerthatensuresthehealthandsafetyoftheindividualandincludesthefollowingthree
components:
(i)"Heavychores"meanstheabilitytomoveheavyfurnitureandappliancesforcleaning,turn
mattresses,andwashwindowsandwalls;and
(ii)"Housecleaning"meanstheability to
makebeds,cleanthebathroom,sweepand
mopfloors,dust,cleanandstoredishes,pickupclutter,andtakeouttrash;
(iii)"Yardworkand/ormaintenance"meanstheabilitytocareforthelawn,rakeleaves,
shovelsnow,completeminorhomerepairs,andpaint.
(c)"Mealpreparation"meanstheability
ofanindividualtoprepareorcookfoodforoneself.
(d)"Personallaundry"meanstheabilityofanindividualtowashanddryone'sclothingand
householditemsbymachineorbyhand.
(e)"Shopping"meanstheabilitytoobtainorpurchaseone'snecessaryitems.Necessaryitems
include,but
arenotlimitedto,groceries,clothing,andhouseho ld items.Shoppingdoesnot
includehandlingfinancesoraccessingtransportation.
(18)"Lessthantwentyfourhoursupport"meansthatanindividualrequiresthepresenceofanotherperson,
orthepresenceofaremotemonitoringdevicethatdoesnotrequiretheindividual toinitiatearesponse,
duringaportionofatwentyfourhourperiodoftime.
(25)"Need"meanstheinabilityofanindividualtocompleteanecessaryandapplicabletaskindependently,
safely,andconsistently.Anindividualdoesnothaveaneedwhen:
(a)Theindividualisnotwillingtocompleteataskordoesnothavethechoicetocompleteatask.
(b)Thetaskcanbecompletedwiththeuseofavailableassistivedevicesandaccommodations.
(38)"Supervision"meanseither
ofthefollowing:
(a)Remindinganindividualtoperformorcompleteanactivity;or
(b)Observingwhileanindividualperfor ms anactivitytoensuretheindividual'shealthandsafety.
PROTECTIVELEVELOFCAREREVIEWWORKSHEET
(March2012)
Individual’sname:
Personcompletingworksheet:
Date:
5101:3306Criteriafortheprotectivelevelofcare
Thecriteriafortheprotectivelevelofcareismetwhentheindividualhasaneedfor:
1. Supervisionof1ADLANDassistancewith3IADLsasdefinedin5101:3305;or
2. SupervisionofmedicationadministrationANDassistancewith3IADLsasdefinedin5101:3305;or
3. Lessthan24hoursupportinordertopreventharmduetoacognitiveimpairment,asdiagnosedbyaphysician
orotherlicensedhealthprofessionalactingwithinhisorherapplicablescopeofpractice,asdefinedbylaw.
Indicatebelowthecriteriawithwhichtheindividualmeetscriteriaforprotective
levelofcare.
Option1:
RequiressupervisionofoneADL 
Bathing
Dressing(requiressupervisiongettingitemson/offANDfastening/unfasteninganitemor
prosthesis)
Eating
Grooming(requiressupervisionwithoralhygiene,haircare,ANDnailcare)
Toileting(requiressupervisionwithoneofthefollowing):
Usingcommode,bedpan,orurinal
Changingincontinencesuppliesorfemininehygieneproducts
Cleansingself
Managinganostomyorcatheter
Mobility(requiressupervision inoneofthefollowingareas:)
 Bedmobility
 Locomotion
 Transfer
AND 
Requiresassistancewith3IADLS 
Mealpreparation
Environmentalmanagement(aneedmustexistinallofthefollowingthreeareas:)
 Housecleaning
 Heavychores
 Yardwork/maintenance
Personallaundry
Communityaccess(aneedmustexistinatleastoneofthefollowingthreeareas:)
 Accessingtransportation
 Handlingfinances
 Telephoning
Shopping
Option2:
Requiressupervisionofmedicationadministration
AND 
Requiresassistancewith3IADLS 
Mealpreparation
Environmentalmanagement(aneedmustexistinallofthefollowingthreeareas:)
 Housecleaning
 Heavychores
 Yardwork/maintenance
Personallaundry
Communityaccess(aneedmustexistinatleastoneofthefollowingthreeareas:)
 Accessingtransportation
 Handlingfinances
 Telephoning
Shopping
Option3:
Requireslessthantwentyfourhoursupport,asdefinedinrule5101:3305 oftheAdministrative
Code,inordertopreventharmduetoacognitiveimpairment,asdiagnosedbyaphysicianorother
licensedhealthprofessionalactingwithinhisorherapplicablescopeofpractice,asdefinedby
law
Login to HandyPDF
Tips: Editig or filling the file you need via PC is much more easier!
By logging in, you indicate that you have read and agree our Terms and Privacy Policy.