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Minnesota Department of Human Services Community-Based Services Manual (CBSM)
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Assessment applicability and timelines

Page posted: 11/14/16

Page reviewed:

Page updated: 8/30/17

Legal authority

Minn. Stat. §256B.0911, subd. 3a and 5

Overview

This page provides information about the applicability of and timelines for long-term services and supports (LTSS) assessments. For more information about assessments, including who does them and how, see CBSM – MnCHOICES.

We divide applicability and timeline information by type of assessment:

The LTSS assessment is valid for 60 days from the face-to-face assessment visit.

This page also provides information about lead agency responsibilities during the reassessment process.

Initial assessment

Who needs it

A person or his or her legal representative may request an assessment at any time, whether he or she lives in an institution or the community.

Third party requests

When a third party requests an assessment on behalf of a person, the lead agency must contact the person to confirm it is his or her choice to have an assessment. If the person does not agree to an assessment, the lead agency does not do one. When a person is not in a position to actively communicate his or her agreement to have an assessment, the lead agency should use professional judgment in honoring the third party’s request.

Timelines

The lead agency must complete a face-to-face assessment no later than 20 calendar days from when the person accepts the assessment.

The lead agency must evaluate the person’s need within five working days of an emergency admission to an intermediate care facility for persons with developmental disabilities (ICF/DD).

Nursing facility admissions

For people admitted to a nursing facility, the following timelines apply.

The lead agency:

  • Must conduct an assessment with a person of any age who has a developmental disability or related condition (DD/RC) diagnosis within 80 calendar days of admission
  • Must conduct an assessment with a person under age 65 within 80 calendar days of admission
  • Is not required to offer a person age 65 or older an assessment. (These individuals may request an assessment at any time. In this case, the lead agency must conduct the assessment within 20 calendar days of the request.)
  • If the person leaves the nursing facility for another institutional setting (e.g., hospital) after he or she is admitted, the 80-day timeline resets when he or she re-enters the nursing facility.

    45-day temporary start of service

    When a provider requests a 45-day temporary start of service for personal care assistance (PCA) services, the lead agency must complete a telephone assessment with the person to determine his or her needs before services start. The lead agency must complete an in-person assessment within the 45-day authorization period.

    Annual reassessment

    Who needs it

    The following people require an annual reassessment:

  • • People who reside in an ICF/DD facility
  • • People of any age who have a DD/RC diagnosis and live in a nursing facility
  • • People who currently are on a waiver (BI, CAC, CADI, DD, EW), the AC, CSG or ECS program or receive PCA services
  • • People on a waiver waiting list
  • • People who receive Rule 185 DD/RC case management (see exceptions in the next section, “choice to waive”).
  • Choice to waive

    Although DHS strongly encourages an annual reassessment for everyone, the following people, or their legal representatives, may waive their annual reassessment for no more than two straight years:

  • • People under age 65 who live in a nursing facility (this does not include people who have a DD/RC diagnosis)
  • • People who receive Rule 185 DD/RC case management without any other services
  • • People who receive Rule 185 DD/RC case management with services not funded by Medicaid (e.g., SILS. county-paid DT&H).
  • For a person, or his or her legal representative, to waive his or her annual reassessment, certain conditions must be met. See CBSM – Choice to waive annual reassessment.

    Timelines

    AC, ECS and EW

    A person who uses one of the following programs must receive an annual reassessment within 60 days of the end of his or her current service agreement or program span, but no later than 365 days from his or her last in-person assessment:

    CAC, CADI, BI, DD, PCA and Rule 185

    A person who uses one of the following programs or services must receive an annual reassessment within 60 days of the end of his or her current service agreement:

    When a person does not have a service agreement, the annual reassessment must occur within the anniversary month of his or her last in-person assessment.

    Waiver waiting list

    A person who wishes to remain on the waiver waiting list must receive an annual reassessment during the anniversary month of his or her last assessment.

    Change-in-condition

    Who needs it

    When a person experiences a significant and potentially long-term change in his or her need for services and supports before his or her anticipated annual reassessment, the lead agency must conduct a change-in-condition reassessment.

    The following are potential reasons for a change-in-condition reassessment:

  • • Emerging need or risk
  • • Major health event
  • • Worsening health condition
  • • Current services and/or supports don’t meet the person’s needs.
  • The person, case manager or others (on behalf of the person) may request a change-in-condition reassessment.

    Exception

    The lead agency may address some short-term changes if the person already has an assessed need for supports by:

  • • Realigning resources within the person’s current support plan
  • • Using a 45-day temporary increase in PCA services.
  • For the person to access services that do not reflect an already assessed need, the lead agency must complete a face-to-face, change-in-condition reassessment.

    Timeline

    The lead agency must complete a change-in-condition reassessment no later than 20 calendar days from the request.

    The lead agency should conduct these assessments in a timely manner and expedite urgent requests. The lead agency should evaluate urgent requests based on the person’s needs and potential risks to the person if the reassessment is delayed.

    65th birthday assessments

    Who needs it

    The lead agency must do reassessments for all people on the BI, CADI and CAC waivers when they turn 65 years old.

    Timelines

    The lead agency has a four-month window to conduct the in-person assessment. The four-month window includes the two months before the birthday month, the birthday month and one month after. For example, if the person turns 65 in January, the lead agency would be able to conduct the reassessment in November, December, January or February.

    How to document

    To document the reassessment, the lead agency enters a new screening document into MMIS using an 08-activity type.

    There are two ways a lead agency can use the reassessment to renew a service authorization:

  • • Reset the existing service authorization to align with the 65th birthday assessment
  • • Combine the person’s annual reassessment with the 65th reassessment, but only if it falls within the four-month period.
  • More information

    People who receive disability waiver services may choose to stay on their current waiver when they turn 65 years old. For more information, see CBSM — BI, CAC, CADI and DD waiver general process and procedures page.

    Lead agency responsibilities

    Throughout the reassessment, both the certified assessor and the case manager are responsible to:

  • • Follow planning and referral responsibilities as warranted by the person’s needs
  • • Promote informed decision making by the person
  • • Apply person-centered practices to address what is important to the person as well as what is important for the person
  • • Work with the person to develop goals based on his or her strengths, needs and preferences.
  • Secure provider signatures on any new or updated support plans.
  • Certified assessor

    The certified assessor is responsible for the annual reassessment. In this important role, he or she:

  • • Schedules the annual reassessment with the person and his or her chosen representatives
  • • Conducts the person-centered reassessment
  • • Completes the Community Support Plan Worksheet, DHS-6791A (PDF) during the reassessment and gives it to the person
  • • Reviews what is working and not working for the person in his or her current Community Support Plan (CSP) or Collaborative Care Plan, incorporating collateral input from the person’s caregivers
  • • Develops the person’s Community Support Plan (CSP), DHS-6791B (PDF), and sends to the person and his or her case manager within 40 calendar days of the reassessment.
  • Case manager

  • The case manager supports the reassessment and assures the person continues to receive necessary services and supports throughout the process. In this important role, he or she:
  • • Uses his or her knowledge to inform the certified assessor about the person and his or her accomplishments, issues and/or needs during the previous year
  • • Provides information to the person about the benefits of the reassessment
  • • Encourages the person and his or her team to engage with and participate fully in the process
  • • Reviews what is working and not working for the person in his or her current Coordinated Services and Supports Plan (CSSP) or Collaborative Care Plan
  • • Develops the person’s new CSSP, DHS-6791B (PDF) within 10 business days of receiving the person’s CSP from the certified assessor
  • A case manager, the service provider (s) and the person (or his/her legal representative) sign the MnCHOICES Coordinated Services and Supports Plan Signature Sheet, DHS-6791D (PDF) to indicate agreement with the services and supports in the support plan.

    Managed care organizations (MCOs)

    If the person receives services through a managed care organization, the care coordinator should follow the MCO’s protocols for reassessments and support plans.

    Lead agency responsibilities when COR and CFR are different

    DHS created new lead-agency timelines/guidelines for annual and change-in-condition reassessments when the county of residence (COR) and county of financial responsibility (CFR) are different. These apply to people who use:

  • • BI, CAC, CADI and DD waivers
  • • Rule 185 case management.
  • For more information, including case manager and certified assessor responsibilities, see:

    Additional resources

    Policy

    CBSM — Choice to waive annual LTSS assessment
    CBSM — DD screening

    CBSM — FAQs about provider-signature requirements for HCBS support plans

    CBSM — Long-term care consultation

    CBSM — MnCHOICES

    CBSM — Provider-signature requirements for HCBS support plans

    CBSM — Rule 185 case management

    CBSM — Reassessments when the COR and CFR are different

    CBSM — Activity timelines for reassessments when the COR and CFR are different
    .

    Forms

    Community Support Plan Worksheet, DHS-6791A (PDF)
    Community Support Plan with the Coordinated Services and Supports Form, DHS-6791B (PDF)
    and instructions, DHS-6791C (PDF)
    Coordinated Services and Supports Plan Signature Sheet, DHS-6791D (PDF)

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    © 2017 Minnesota Department of Human Services Updated: 8/29/17 4:34 PM | Accessibility | Terms/Policy | Contact DHS | Top of Page | Updated: 8/29/17 4:34 PM