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CFSS Policy Manual

CFSS Policy Manual


Resource: Instructions for CFSS Assessment, DHS-6893A

Page updated: 10/22/25

Transition from personal care assistance (PCA) to Community First Services and Supports (CFSS)

DHS is in the process of replacing PCA with CFSS. For more information, refer to CFSS Manual – Transition from PCA and CSG to CFSS.

CFSS Assessment, DHS-6893A replaces:

  • · PCA Assessment and Service Plan, DHS-3244.
  • · Supplemental Waiver PCA Assessment and Service Plan, DHS-3428D.

    • This resource page replaces PCA Assessment and Service Plan Instructions and Guidelines, DHS-3244A.

    Assessors must read this page before completing their first CFSS assessment. DHS-6893A has functionality differences compared to DHS-3244.

    Overview

    CFSS Assessment, DHS-6893A and the MnCHOICES assessment use the same criteria and formula to calculate a person’s CFSS eligibility.

    CFSS Assessment, DHS-6893A is for:

  • · Certain counties to conduct an assessment for CFSS services when not using MnCHOICES.
    Note: Counties may only use DHS-6893A if DHS grants an exception to that county. If the county uses DHS-6893A, they cannot conduct the assessment remotely.
  • · Lead agencies to conduct an assessment for a 45-day start.

    • The lead agency must also complete CFSS Program Information and Signature Sheet, DHS-6893G (PDF) when using DHS-6893A.

    45-day temporary increase

    Lead agencies use CFSS Assessment for 45-Day Increase, DHS-6893M to complete 45-day increase assessments.

    Form instructions

    CFSS Assessment, DHS-6893A is a dynamic PDF that:

  • · Contains all information that the assessor must document.
  • · Calculates the person’s home care rating and total units.

    • The assessor can choose to print DHS-6893A for use when they conduct the assessment and then transfer the information into the dynamic PDF to perform the calculations.

    This page describes each section of the form:

  • · Information section.
  • · Section 1: Directing own care determination.
  • · Section 2: Health description.
  • · Section 3: Abuse/neglect.
  • · Section 4: Medications.
  • · Section 5: Activities of daily living (ADLs).
  • · Section 6: Complex health-related needs.
  • · Section 7: Behaviors.
  • · Section 8: Authorization summary.
  • · Section 9: Signatures.
  • · Section 10: Referrals.
  • · CFSS assessment summary page.

    • Information section

    Overview

    The assessor uses this section to record basic information about the person.

    Form instructions

    Person who receives services

    The assessor:

  • · Completes all fields.
  • · Confirms the person does not live in provider-controlled housing by selecting “no” for the “does the person live in provider-controlled housing?” field.

    • Services/programs

    The assessor completes all fields.

    Direct own care/participant’s representative

    The assessor returns to this field after completing section 1.

    For the “does the person appear to be able to direct their own care?” field, the assessor:

  • · Selects “yes” if the assessor answered “yes” to the “is the participant’s representative required?” field in section 1 and then leaves the rest of the fields blank.
  • · Selects “no” if the assessor answered “no” to the “is the participant’s representative required?” field in section 1 and completes all other fields.

    • Diagnosis

    The assessor:

  • · Enters at least one diagnosis.
  • · Enters the primary diagnosis first.
  • · Uses the “add diagnosis” button to add more rows, as needed.

    • Health care provider information

    The assessor enters information about the person’s primary care provider.

    Selected consultation services provider (if known)

    The assessor enters information about the person’s consultation services provider, if selected.

    Comments

    The assessor enters comments about the referral, if needed.

    Requesting provider information

    If the person’s provider agency or financial management services (FMS) provider submitted the request for assessment, the assessor completes all required fields.

    If the person’s provider agency or FMS provider did not submit the request for assessment, the assessor leaves this section blank.

    Section 1: Directing own care determination

    Legal authority

    Minn. Stat. §256B.85, subd. 14a

    Overview

    The assessor uses this section to determine if the person needs a participant’s representative.

    Definition

    Directing your own care: Situation in which the person can identify their needs, direct and evaluate caregiver task accomplishments and provide for their health and safety.

    Participant’s representative: An individual who is age 18 or older and capable of directing care on behalf of a person receiving PCA/CFSS services when the person is assessed as unable to direct their own care.

    Policy

    The assessor is responsible to determine if the person needs a participant’s representative during the assessment.

    For information about who must have a participant’s representative and what they do, refer to CFSS Manual – Responsible party (PCA) and participant’s representative (CFSS).

    Form instructions

    The assessor completes all fields by selecting “yes” or “no.”

    For the “Is the participant’s representative required?” field, the assessor selects “yes” if any of the following are true:

  • · The person is a minor.
  • · The person has a court-appointed guardian.
  • · The assessor selected “no” for any of the first three fields.

    • Guidance

    A person’s behavior can vary each day, so it may be difficult for the assessor to determine if they need a participant’s representative. The following sections include considerations to help make the determination.

    Can the person identify their own needs?

    The assessor can pay attention to the person’s answers to questions in other portions of the form to help determine if the person can identify their own needs. Examples that a person can identify their own needs include, but are not limited to when the person:

  • · Is able to tell the assessor about their needs for assistance.
  • · Knows their schedule for a day.
  • · Knows their medications.
  • · Knows about all of their health-related interventions.

    • Can the person direct and evaluate CFSS worker tasks and accomplishments?

    Example of questions the assessor might ask the person include, but are not limited to:

  • · How would you tell your CFSS worker what tasks to do?
  • · How would you tell staff you don’t like something they are doing?

    • Can this person provide and/or arrange for their health and safety?

    Example of questions the assessor might ask the person include, but are not limited to:

  • · How would you get to a safe place in an emergency?
  • · How could you get help via the phone?
  • · How do you know when you need to make a doctor’s appointment?
  • · What would you do if your worker were verbally or physically abusive to you?

    • Identifying the participant’s representative

    If the person needs a participant’s representative, they must identify one before they can receive CFSS services.

    Participant’s representative already identified

    If the person already has a participant’s representative, the assessor:

  • · Enters their contact information in the information section.
  • · Obtains their signature in section 9.

    • Participant’s representative not identified

    The person must identify a participant’s representative before they can receive CFSS services. The assessor can suggest a common participant’s representative, such as:

  • · Family member.
  • · Friend.
  • · Neighbor.

    • Section 2: Health description

    Legal authority

    Minn. Stat. §256B.85, subd. 8

    Overview

    The assessor uses this section to record whether the person meets the definition of ventilator dependence and record their overall health.

    Definitions

    Health description: Documentation of the person’s health status, including their overall health condition and ability to function in the community.

    Ventilator dependence: A need for a mechanical ventilator for life support at least six hours a day for at least 30 days. This includes both invasive and non-invasive ventilation.

    Form instructions

    Ventilator dependence

    The assessor must:

  • · Complete the field about ventilator dependence.
  • · Complete all fields, regardless of their answer to the first field.
  • · Complete this section before completing section 8.

    • Overall health

    The assessor enters a description of the person’s overall health, including but not limited to:

  • · Applicable medical and health history.
  • · Living environment.
  • · Sensory deficits.
  • · Hospitalizations.
  • · Informal supports.
  • · Changes in health status.
  • · New diagnoses with date of onset.
  • · Description of assessed needs for assistance.
  • · Environmental observations.

    • Section 3: Abuse and neglect

    Legal authority

    Minn. Stat. §626.557, Minn. Stat. §626.5572, Minn. Stat. §402A.10, Minn. Stat. §626.556

    Overview

    The assessor uses this section to ask questions and record observations about potential abuse and/or neglect.

    Policy

    Assessors are mandated reporters of suspected abuse and/or neglect.

    Form instructions

    The assessor:

  • · Asks the person all questions listed in the “for the person” section.
  • · Completes the questions in the “for the assessor” section based on the assessor’s observations.
  • · Reports any suspected maltreatment through their lead agency’s procedures.

    • Section 4: Medications

    Overview

    The assessor uses this section to record all medications the person takes.

    Definition

    Medications: Prescribed or over-the-counter medication taken by mouth, injection, insertion, nebulizer or applied topically.

    Form instructions

    The assessor:

  • · Completes a row for each medication the person takes, regardless of whether the person’s CFSS worker can or will assist the person with taking them.
  • · Selects responses for the three fields.

    • Guidance

    During the assessment, the assessor can ask the person to:

  • · Show the assessor their medications.
  • · Explain why and how they use the medications.
  • · Explain how much help they need to pick up the medications at the pharmacy.

    • These questions might help the assessor complete the medications section, as well as determine the person’s ability to direct their own care.

    Section 5: Activities of daily living (ADLs)

    Legal authority

    Minn. Stat. §256B.85, subd. 2(b)

    Overview

    The assessor uses this section to record the person’s ADL dependencies that meet the definition for the purposes of this assessment. The number of ADL dependencies affects the person’s home care rating. The number of critical ADLs affects their additional units or time.

    Definitions

    ADLs: Activities a person must do on a daily basis to remain health and safe: The ADLs are:

  • · Grooming.
  • · Dressing.
  • · Bathing.
  • · Transferring.
  • · Mobility.
  • · Positioning.
  • · Eating.
  • · Toileting.

    • ADL dependency: A need for assistance to begin and complete an ADL, as defined by the assessment. A person has a dependency in an ADL if the person requires both:

  • · Hands-on assistance and/or cueing and constant supervision to begin and complete the activity.
  • · Assistance on a daily basis or on the days they complete the activity.

    • Critical ADLs:

  • · Mobility.
  • · Transfers.
  • · Toileting.
  • · Eating.

    • Policy

    For policy about ADL dependencies, refer to:

  • · CFSS Manual – PCA/CFSS unit determination (all people).
  • · CFSS Manual – PCA/CFSS age-appropriate dependencies (people younger than age 18 only).

    • Form instructions

    For each ADL, the assessor:

  • · Selects the box if the person meets the definition for the ADL and does not select the box if they do not.
  • · Selects “observed” and/or “reported,” depending on how the assessor made the determination.
    Note: The assessor does not have to observe the person attempting to complete the task. Requiring a person to demonstrate an attempt could result in injury.
  • · Completes the description field.
  • · Completes the comments field, if needed.

    • If the assessor needs to record other information about ADLs, they enter that information in the ADL comments field.

    Notes:

  • · The assessor can add comments for an ADL without selecting that ADL’s checkbox. They may choose to add comments if the person does not meet the ADL’s definition but still has needs the assessor wants to communicate to the provider.
  • · If the assessor checks a box for one of the critical ADLs, the form automatically accounts for additional time.

    • Section 6: Complex health-related needs

    Legal authority

    Minn. Stat. §256B.85, subd. 4(c)

    Overview

    The assessor uses this section to record the person’s complex health-related needs that meet the definition for the purposes of this assessment. The person’s complex health-related needs affect their home care rating and eligibility for additional time.

    Definitions

    Complex health-related needs: Interventions that are both:

  • · Ordered by a medical practitioner.
  • · Required at the time of the assessment.

    • Medical practitioner: For the purposes of this section, this term includes a doctor, advanced practice registered nurse (e.g., nurse practitioner) and physician’s assistant.

    Note: The assessor does not need to verify the medical practitioner’s orders.

    Policy

    For policy about complex health needs, refer to CFSS – PCA/CFSS unit determination.

    Form instructions

    For each complex health need, the assessor:

  • · Selects the box if the person meets the definition for that complex health need and does not select the box if they do not.
  • · Selects at least one subcategory (except for the “other congenital acquired diseases” box).
  • · Selects “observed” and/or “reported,” depending on how the assessor made the determination.
  • · Completes the description field.
  • · Completes the comments field, if needed.

    • If the assessor needs to record other information about a complex health need, they enter that information in the complex health needs comments box.

    Section 7: Behaviors

    Legal authority

    Minn. Stat. §256B.85, subd. 4(c)

    Overview

    The assessor uses this section to record information about the person’s behaviors that meet the definition for the purposes of this assessment. The presence of a level 1 behavior affects the person’s home care rating. The presence of any of the behaviors four or more times in the last week influence the person’s additional time.

    Definitions

    Level I behavior: Physical aggression toward self or others, or destruction of property that requires the immediate response of another person.

    Immediate response: Intervention required at the time of the behavior to prevent injury to self, others or property.

    Policy

    For policy about behaviors, refer to CFSS – PCA/CFSS unit determination.

    Form instructions

    For each behavior, the assessor:

    1. Selects the box if the person meets the definition for that behavior (regardless of how often it occurs) and does not select the box if they do not.

    Note: Selecting the box for “presence of Level I behavior” affects the person’s home care rating, regardless of whether the behavior occurs more than four times per week.

    2. Selects “observed” and/or “reported,” depending on how the assessor made the determination.

    3. Completes the “does the behavior happen more than four times per week?” field.

    Note: The form only adds additional time if the assessor selects “yes” for the behavior.

    4. Completes the description field with relevant information, such as:

  • · Frequency or predictability.
  • · Results of the behavior.
  • · What helps the person when the behavior occurs.
  • · Informal and formal supports in place to address the behavior issues.
  • · Medications.
  • · Physician or other mental health professional involvement.

    • The assessor completes the comments field if needed.

    Guidance for observed behaviors

    Examples of information the assessor can consider when determining if they observed a behavior include:

  • · Inability to keep a daycare placement.
  • · Incident reports.
  • · Physical wounds.
  • · Crisis team visits.
  • · Property destruction.
  • · Out-of-home placement for treatment purposes.
  • · Positive behavioral intervention plan.

    • The need for a 24-hour plan of care and supervision due to age is not considered a behavior.

    Guidance for people younger than age 18

    Examples of questions the assessor can ask a parent to determine if their child meets the definition of a behavior include:

  • · Do you or anyone else have any concerns about your child’s behavior at home, school or the community?
  • · Has any part of your or your child’s life been affected by this behavior?
  • · Can you tell me about the behaviors your child has experienced in the past week? What happens?
  • · What are the triggers for the behavior?
  • · What helps you or your child when the episode happens?
  • · Who is helping you (e.g., county worker, doctor, others)?
  • · What changes the behavior to a more appropriate or acceptable behavior?

    • Section 8: Authorization summary

    Overview

    The authorization summary calculates the person’s home care rating and total units based on the assessor’s input in sections 2, 5, 6 and 7. If the assessor does not complete those sections correctly, the determination in section 8 will not be accurate.

    Form instructions

    Calculating the rating/units

    The assessor:

  • · Reviews and confirms completion of sections 1 through 7.
  • · Confirms they only selected ADL and complex health-related needs if the person meets the definition for that ADL or complex health-related need.
  • · Confirms they completed the “does the behavior happen more than four times a week?” field.
  • · Selects “yes” to confirm they have completed the required fields.

    • If the assessor did not complete section 2, the form will not give a determination. The assessor must:

  • · Select “no” to the question in section 8.
  • · Return to section 2 and complete it.
  • · Select “yes” when they return to section 8.

    • MMIS entry summary

    If the assessor followed the instructions for calculating the rating/units correctly, the form displays a list of the items they will enter on the AHC2 screen in MMIS. For more information, refer to DSD MMIS Reference Guide – AHC2 screen for PCA/CFSS.

    Note: If the assessor makes changes to section 7 (behaviors) after selecting “yes” in section 8 (authorization summary), the MMIS summary might not reflect the changes. The assessor must select “no” and then “yes” again in section 8 to ensure the summary is accurate.

    Overall results since last assessment

    The assessor:

  • · Selects “yes” if instrumental activities of daily living (IADLs) are a covered service for the person. For more information, refer to CFSS Manual – PCA/CFSS covered services.
  • · Compares the units/hours to the person’s last assessment (if applicable) and completes the units/hours field.
  • · Records the time the assessor spent performing the assessment and identifies if it was a phone assessment.

    • Agreements

    The assessor and person or participant’s representative must select all applicable boxes before signing the assessment in section 9.

    Section 9: Signatures

    Form instructions

    The following people sign the assessment results:

  • · Person.
    Note: A minor’s parent can sign on their behalf.
  • · Participant’s representative, if applicable.
  • · Assessor.

    • The person and their legal representative, if applicable, must also sign CFSS Program Information and Signature Sheet, DHS-6893G (PDF).

    Interpreter

    The assessor answers the question about whether the person used an interpreter. If yes, the assessor must have the interpreter complete and sign the fields.

    Section 10: Referrals

    Form instructions

    The assessor:

  • · Selects any other services the person is receiving or the assessor recommends.
  • · Enters contact information for services they recommend, if any.

    • CFSS assessment summary page

    Overview

    The summary page provides an eligibility summary for the person.

    Form instructions

    The assessor completes all applicable fields on the summary page.

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