Form H6516, Community First Choice Assessment

Effective Date

9/2025

Instructions

Updated: 9/2025

Purpose

Form H6516 is completed for applicants or individuals being assessed for Community First Choice (CFC) services. The form helps collect and document essential information to determine the functional needs of applicants or individuals 21 and over for CFC services.

Individuals in the Home and Community-based Services (HCS), Texas Home Living (TxHmL), Community Living Assistance and Support Services (CLASS) and Deaf Blind with Multiple Disabilities (DBMD) waivers will not use this tool. Existing tools used in these waivers are used to assess for CFC services.

For the remainder of the instructions, the term individual is defined as an applicant or member requesting CFC services.

Form H6516:

is developed through a person-centered planning process;
occurs with the support of a group of people chosen by the individual and the legally authorized representative (LAR) on the individual's behalf; and
accommodates the individual's style of interaction, communication and preferences regarding time and setting.

Use Form H6516 to:

determine the Habilitation (HAB), Personal Assistance Services (PAS), Emergency Response Services (ERS) and Support Management needs of an individual;
assess the individual's needs, functional impairments, ability to perform activities of daily living (ADLs), instrumental activities of daily living (IADLs) and health-related tasks;
document the individual’s preferences for when to receive CFC services;
document the risks to the individual’s health and safety, as well as a plan to mitigate those risks;
identify any special needs, requests or considerations staff should know when supporting this individual; and
document the individual’s unmet needs.

Procedure

When to Prepare or Update

Form H6516 is completed by the local intellectual and developmental disability authority (LIDDA) or managed care organization (MCO) in its entirety when an individual applies for CFC services and at least annually for individuals receiving CFC services. The form is also updated whenever the individual’s needs have substantially changed, or at the request of the individual or LAR, if applicable.

Assessor from this point forward refers to the LIDDA or MCO completing the form.

If an individual or LAR does not know the information requested or refuses to answer, document that in the space provided.

Form Retention

The LIDDA must keep the original copy of the form in the individual's case record and provide a copy to the MCO.

The LIDDA must keep Form H6516 per the retention requirements found in the LIDDA Performance Contract and state and federal regulations.

The MCO must keep the form for five years after the case is closed, per record retention requirements.

Detailed Instructions

Individual’s Name - Enter the individual’s name. Required on each page of the assessment.

Medicaid No. – Enter the individual’s nine-digit Medicaid number.

Date of Birth – Enter the individual’s date of birth.

Date of Assessment – Enter the date this assessment is completed.

Sex – Select Male or Female to indicate the individual’s sex.

Employment Status – Check the appropriate box to indicate the individual’s employment status: employed, unemployed or retired.

Education Level - Check the appropriate box to indicate the individual’s education level. If none of the boxes apply to the individual’s education level, select other and document the individual’s education level.

Participants – List each person who participated in this assessment.

Type of Assessment – Check the type of assessment being conducted: initial, renewal or revision.

Note: The information in this form is about the individual’s abilities, preferences and goals, in line with person centered planning principles. It is obtained through an information gathering conversation called the discovery process.

Section 2 – Needs Assessment Questionnaire and Task and Hour Guide

The Needs Assessment Questionnaire and Task and Hour Guide is comprised of three sections:

Part A – Functional Assessment. This part is used to assess an individual’s level of support needs, who currently provides the service and if the individual needs that service purchased.
Part B – Task and Hour Guide. When a task needs to be purchased, the Task and Hour Guide details how much time is needed to provide either the PAS or HAB service.
Part C – Subtasks and PAS Minute Ranges. This section is used to indicate the subtasks the individual needs help or training with when a task is purchased.

Note: The Task and Hour Guide must be completed for each purchased task. Each purchased task must have subtasks indicated in Part C.

Part A – Functional Assessment

The functional assessment is comprised of the support level and service arrangement.

Support Level (SL)

The support level is designed to assess an individual’s capacity for self-care. Score each item per this capacity for self-care and not per the individual’s access to a resource to help with the task. In scoring each item, use the individual’s response, plus any observations or knowledge of the individual from other sources. The support level is not required for an individual receiving only habilitation.

Each PAS task has an associated question to help score the support level. The first time an item is addressed, use the wording of the question as written. Then, explain or paraphrase, if necessary. Ask follow-up questions if there is a need to verify the first response. PAS task items 1-23 must be given a support level.

For PAS activities only, score the individual per the following scale:

Score	Score Details
0	None. No functional impairment. The individual can conduct activities without difficulty and has no need for assistance.
1	Mild. Minimal or mild functional impairment. The individual can conduct activities with minimal difficulty and needs minimal help.
2	Severe. Extensive or severe functional impairment. The individual has extensive difficulty carrying out activities and needs extensive help.
3	Total functional impairment. The individual is completely unable to carry out any part of the activity.

An individual has an impairment with respect to a particular activity if he or she is limited, either physically or mentally, in his or her ability to carry out that activity. An impairment could also be a behavioral challenge resulting in difficulty accomplishing the task.

Numbers 0 and 3 are absolutes because they indicate no functional impairment or total dependency. Example: If an individual can perform any of the dressing tasks for himself or herself, a 3 is not appropriate. If he or she can perform the dressing task completely without difficulty, a 0 is appropriate.

Enter a score for each question in the Support Level column.

Use the following examples for each item to help differentiate between scores of 1 and 2. An individual may score 1, but not request help with a task. The following are only examples of appropriate scores based on the individual’s abilities. If an example is appropriate for an individual, but the score for that example is not, give the appropriate score and explain your choice.

Tasks	1 = Minimal or Mild Impairment	2 = Extensive or Severe Impairment
1. Bathing	Individual can bathe self, but needs supplies laid out. Individual can bathe self but needs help drawing and testing the temperature of the water. Individual needs standby help for safety or reminding and monitoring. Individual needs minimal help getting in and out of tub or shower. Individual may accomplish bath for self by using a chair or other adaptive device for assistance. Individual requires partial supervision or cueing. Individual requires help bathing but can be left alone to soak in the tub. Individual refuses to bathe without multiple prompts.	Individual needs extensive help getting in and out of tub or shower. Individual needs hands-on help with actual bathing and drying of body. Individual must always use adaptive devices and needs help arranging adaptive devices for the bath. Individual can only manage sponge baths due to disabilities. Individual requiring a bed bath can help with some part of the task. Individual always requires cueing or ongoing supervision while bathing. Individual gets out of the tub multiple times while bathing due to behavioral challenges such as fear of water, or cognitive ability such as not understanding reason for showering.
2. Dressing	Individual needs occasional help with zippers, buttons or putting on shoes and socks. Individual may need help laying out or selecting clothes. Individual needs reminding or monitoring for completion of dressing. Individual occasionally refuses to get dressed.	Individual always needs help with zippers, buttons or shoes and socks. Individual needs help getting into garments. This includes putting arms in sleeves, legs in pants or pulling up pants. Individual may dress totally inappropriately without help or would not finish dressing without physical help. Individual needs help dressing because he or she routinely undresses him or herself.
3. Exercising	Not scored.
4. Eating	Individual may need standby help but only occasional physical help. Individual needs verbal reminders or encouragement. Individual eats with adaptive devices but requires help with applying and positioning. Individual can feed self but occasionally smears food on table due to behavioral challenges or cognitive ability.	Individual usually needs extensive hands-on help eating. Individual may hold eating utensils but needs continuous help during meals and would not complete meal without continual help. Spoon feeding of most foods is required, but individual can eat some finger foods. Individual needs constant supervision because he or she has Prader Willi Syndrome, pica disorder or polydipsia. Individual requires constant supervision during eating due to risk of choking.
5. Grooming	Support level is based on the highest level of support level needed on any grooming task in (5a-5b).
5a. Shaving, Oral Care and Nail Care	Individual can manage grooming, but needs supplies laid out or handed to him and needs standby for safety and help with grooming tools. Individual can accomplish grooming but needs reminding or monitoring. Individual occasionally refuses to complete grooming tasks.	Individual cannot adequately shave face or under arms and legs because of inability to see well, to reach or to successfully use equipment. Individual cannot adequately brush teeth and perform oral care. Individual cannot adequately care for nails. Individual routinely refuses to complete grooming tasks.
5b. Routine Hair and Skin Care	Individual can manage hair and skin care but needs supplies laid out. Individual needs reminding to do tasks. Individual needs help to comb or brush hair. Individual needs help applying non-prescription lotion to skin. Individual sometimes requires prompting to complete tasks. Individual pushes hands away when hair is brushed.	Individual cannot adequately perform washing and shampooing hair, drying hair, or setting, rolling or braiding hair. Individual cannot adequately wash hands and face or apply makeup. Individual refuses to complete tasks or has moderate behaviors surrounding these tasks. Individual always needs help because he or she screams when face gets wet. Individual always requires prompting to complete tasks.
6. Toileting	Individual has instances of urinary incontinence and occasionally needs help because of this. Fecal incontinence does not occur unless caused by a specific illness episode. Individual may need help with supplies or equipment. Individual needs some help with clothing during toileting. Individual needs standby help. Individual may have catheter or colostomy bag, and occasionally needs help with management.	Individual often cannot get to the bathroom on time to urinate or has occasional episodes of fecal incontinence. Individual may wear incontinence products to manage the problem and needs help with them. Individual usually needs help with catheter or colostomy bag. Individual needs help with a bedpan or urinal, or with emptying a catheter bag or changing an external catheter or colostomy bag. Individual needs diapers changed or needs help with feminine hygiene products.
7. Hygiene in Toileting	Individual can usually manage cleaning self after toileting except on occasional days when bending or moving is particularly difficult, or when incontinence occurs. Individual may have catheter or colostomy bag, and occasionally needs help with management. Individual occasionally needs help toileting due to cognitive ability such as lack of understanding of hygiene, or due to behavioral challenges such as fecal smearing.	Individual often needs help with cleaning after toileting because of difficulty in reaching, or due to incontinence problems. Clothes are sometimes soiled and odorous. Individual usually needs help with catheter or colostomy bag. Individual routinely needs help toileting due to cognitive ability such as lack of understanding of hygiene, or due to behavioral challenges such as fecal smearing.
8. Transfer	Individual usually can get out of bed or chair with minimal or standby help. Individual may accomplish transfer without help but needs standby assistance for safety. Individual needs some help adjusting or changing position in a bed or chair, called positioning. Individual may sometimes need prompting to complete transfers.	Individual usually needs hands-on help when rising to a standing position or moving into a wheelchair to prevent losing balance or falling. Individual can help with the transfer by holding on and supporting him or herself. Individual can help some with non-ambulatory movement from one stationary position to another, called a transfer. This task does not include carrying. Individual usually needs help transferring due to behavioral challenges or cognitive ability.
9. Walking (Ambulation)	Individual walks alone without help for only short distances. Individual can walk with minimal difficulty using an assistive device or by holding onto walls or furniture. Individual needs help positioning for use of a walking apparatus or putting on and removing leg braces and prostheses for ambulation. Individual may need repeated prompts while ambulating.	Individual has considerable difficulty walking even with an assistive device. Individual can walk only with help from another person and never walks alone outdoors without help. Individual may use a wheelchair periodically. Individual needs help with wheelchair ambulation. Wheelchair ambulation is defined as pushing the wheelchair for the individual. Individual needs help walking due to behavioral challenges or cognitive ability.
10. Cleaning	Individual can do most tasks around the house, like picking up, dusting, washing dishes, sweeping, straightening the bed, carrying out trash, light vacuuming or cleaning sinks. Individual cannot move heavy furniture or do extensive scrubbing or mopping. Individual may be capable of cleaning but may refuse or sometimes require repeated prompts to complete tasks.	Individual can do only very light housework like dusting, washing a few dishes or straightening up magazines or newspapers. Individual cannot see well enough or does not have the strength or flexibility to sweep floors, change bed linens or carry heavy objects. Individual may excessively collect items or neglect to pick up after themselves. Individual may be capable of cleaning but routinely refuses or requires repeated prompts to complete tasks.
11. Laundry	Individual does hand washing but has difficulty wringing and hanging heavy laundry to dry. Individual can do most laundry tasks but needs minimal help to put clothes in machines, sort clothes, fold them and put them away. Individual may have strength but may not be able to see or turn washer dials or, may require supervision or instruction to use a washer. Individual may be capable of doing laundry activities but may refuse or require repeated prompts to complete tasks.	Individual may do light hand washing but cannot bend or lift or carry loads of clothes to manage most laundry, and cannot hang clothes out at all or get them off a line, but may fold them and help put them away. Individual may not be able to wring out clothes without help. If a laundromat is used, the individual has considerable difficulty getting there. Individual has special laundry needs due to incontinence or other physical problems and needs laundry more frequently than once a week.
12. Meal Preparation	Individual can do some meal preparation but has some difficulty. Individual can prepare simple foods or warm up food like frozen meals or food prepared by others. Individual may have difficulty with cutting meats or other foods. Individual can prepare foods but needs help with meal planning or minimal help preparing meals. Individual may need help carrying food items or meal preparation items. Individual needs help with hygienic and safe practices around food preparation and storage.	Individual cannot cook meals due to physical impairment and can only do minimal preparation of simple cold foods like sandwiches or cereal. Individual has difficulty opening cans and preparing fresh foods for cooking. Individual regularly has difficulty seeing or turning burners on and sometimes forgets to turn them off. Individual needs prepared meals pureed or ground up for serving. Individual may be fearful or unable to use kitchen appliances safely due to behavioral challenges or cognitive ability.
13. Escort	Not scored.
14. Shopping	Individual decides what to buy but needs help preparing a shopping list. Individual can shop if someone goes along to help. This could be prompting or help using money to purchase items. Individual may shop by phone but needs help carrying or storing groceries. Individual can do most shopping, but needs extra items picked up between shopping trips.	Individual may still decide what to buy, but seldom, if ever, goes to a store and needs shopping for all items and picking up medications. Individual may not be able to shop by phone because of communication difficulties. Individual cannot regularly carry or store most of the purchases without help. Individual may wander off during shopping due to cognitive ability or yell or cry during shopping trips due to behavioral challenges.
15. Help with Medications	Individual can self-direct* medications, but occasionally needs help with opening the containers. Individual may need to be reminded to take medications. *Self-direct means the individual can: identify the proper medication by name or sight including color and shape; identify the purpose of the medication such as for my heart, for pain, for allergies; determine the correct dosage is being taken such as one pill; and identify the time medication is needed for example morning or lunchtime.	Individual or LAR can self-direct* medications but needs help opening containers or needs the medication brought within reach. Individual or LAR can self-direct * medications but has a visual impairment and may not be able to read labels. Individual or LAR can self-direct* medications but must be reminded to ensure that medications are taken as prescribed. Unless medication is a delegated task, it cannot be purchased if the score for medication is 3. Total help indicates the individual cannot self-direct medications and requires either skilled assistance or supervision from informal support. Total help indicates the individual can self-direct medications, but due to a functional limitation, is unable to self-administer medications, or due to cognitive limitations where the individual refuses to take medications.
16. Trim Nails	Individual can trim his or her own fingernails but may have difficulty doing his or her toenails by him or herself. Individual may be capable of trimming nails but refuses or is unable due to behavioral challenges or cognitive ability.	Individual trims fingernails only when no one is available to help. Individual cannot reach and trim toenails and has difficulty using scissors or clippers. Individual may be capable of helping but refuses or is unable due to behavioral challenges or cognitive ability.
Note: A diagnosis of diabetes does not automatically indicate a score of 3. Many people with diabetes can trim their nails. If a medical practitioner has instructed an individual with diabetes not to trim the nails, score the task 3.
17. Balance	Individual occasionally gets dizzy or needs to steady him or herself by holding onto furniture or a person and may need to hold someone's arm to go up and down stairs. Individual may have experienced an occasional fall because of imbalance or the individual's movement is restricted because of fear of falling.	Individual usually experiences some imbalance and needs to hold onto a support when he or she first stands up to steady him or herself. Individual suffers from dizziness that affects his or her balance and would likely fall if help was not available.
18. Open Jars, Cans and Bottles	Individual can open some containers but may have difficulty with very large jars, special medicine caps or containers that require special opening instructions or procedures. Individual may use an assistive device.	Individual cannot open large jars or new bottles or jars without help or an assistive device. Individual may be able to open small jars and bottles that have been previously opened.
19. Phone	Individual can use phone but may have difficulty hearing or getting to the phone quickly when it rings. Individual may need to go out of the home to use the phone but can do so without much difficulty.	Individual may be able to answer or talk on the phone but may not be able to dial the correct number. Individual is sometimes not able to get to a phone when necessary. Individual may be able to use the phone but may require repeated prompting and monitoring to use appropriately. For example, the individual is susceptible to being taken advantage of by telemarketers.

Items 20-23 are assessed for PAS only.

On Items 20 and 21, the assessor can use information other than the individual’s perception of him or herself only if:

the individual provides inaccurate information because of his or her physical or mental impairment;
there are inconsistencies between the information the individual is providing and the assessor's observation of the individual; or
there is conflicting information provided by a family member present during the interview.

To properly score these questions, if the assessor is unsure of the information given by the individual, he or she will:

get as much information as possible from the individual;
contact a third party such as a family member or friend, who is aware of the individual's cognitive abilities; or
use his or her judgment to score the question if no one is available who knows the individual's cognitive abilities.

20. Initial scoring: These questions are based on the individual's perception of self.

0 – If the answer to both questions is No, stop here.

Final scoring:

1 – If the answer to all four questions is No.
2 – If the answer to any one of these four questions is Yes.
3 – If the answer to at least two of these four question is Yes.

21. Scoring instructions: This question is based on the individual's perception of self. Does the individual indicate he or she has trouble concentrating and has memory lapses? Does the individual indicate he or she needs help making decisions?

0 – If the answer to the question is not at all.
1 – If the answer to the question is occasionally or a couple times.
2 – If the answer to the question is frequently, more than a couple times but not every day.
3 – If the answer to the question is every day.

22. Scoring instructions: This question is based on someone's observation of the individual. This may be a family member, relative, caregiver or the person who called in the intake. Information from home health attendants or assessor observation can be used to score this question, but only as a last resort. The assessor must make every effort to contact a third party to provide the information. There should be documented attempts in the case record to contact other resources. If no other source is available, and the assessor feels the information provided by the attendant is accurate, he or she can score the information based on the attendant’s knowledge and observation of the individual.

0 = The answer to the question is the individual makes consistent and reasonable decisions independently. For example, he or she pays bills and makes financial decisions, keeps own medical appointments, and maintains own household.
1 = The answer to the question is the individual makes simple decisions without help. For example, he or she decides what to wear, what to buy at the grocery store, and when to do housekeeping chores.
2 = The answer to the question is the individual makes poor decisions and needs cues or supervision for most decisions.
3 = The answer to the question is the individual is severely impaired and rarely makes his own decisions.

23. Scoring instructions: This question is based on someone's observation of the individual. This may be a relative, caregiver or the person who called in the intake. Information from home health attendants or assessor observation can be used to score this question, but only as a last resort. The assessor must make every effort to contact a third party to provide the information. There must be documented attempts in the case record to contact other resources. If no other source is available, and the assessor feels the information provided by the attendant is accurate, he or she can score the information based on the attendant's knowledge and observation of the individual.

0 = The answer to the question is No.
1= The answer to the question is the individual has some short-term memory problems and can perform tasks for himself with occasional reminders.
2 = The answer to the question is the individual has memory lapses resulting in frequently not performing tasks even with reminders.
3 = The answer to the question is the individual has memory lapses resulting in inability to perform routine daily tasks.

Service Arrangement (SA) – Enter the following codes to show the service provider for PAS and HAB activities.

Code	Details
S	Self. Use S if the Individual performs the task without any help.
C	Caregiver. Use C when all of the task is being performed by or training is being provided by an unpaid relative, neighbor or friend regularly.
P	Purchased. Use P if any part of the task will be purchased all the time or at times when another service arrangement type is not available to help. For PAS only, if the functional score is 3, a service arrangement code of P should only appear under Item 15, Assistance with Medications, if it is a delegated task. Unless delegated, since 3 indicates total inability to perform any aspect of the task, only a licensed nurse or designated informal support or caregiver may fulfill this need. Habilitation may still be provided, if appropriate, for an individual with a functional score of 3.
P/C	Purchased or Caregiver. Use P/C when the caregiver is helping with, performing a purchased task or training the individual on how to perform the task during the time the attendant is present. Document in the Preferences and Special Considerations section the part of the task the caregiver performs or provides training on. Example 1: The caregiver helps with bathing by laying out supplies but needs the attendant to help with the bath. Example 2: The individual requests a five-day plan and the daughter, who is the caregiver, works Monday, Wednesday and Friday. The daughter helps the individual with bathing on Tuesday and Thursday during the time the attendant is present performing other tasks. When the caregiver is not available during the time purchased tasks are delivered and helps only in the evenings or on weekends, a general comment may be entered in the Comments section. The tasks are not coded as P/C, but P only for purchased tasks. Example 3: The individual requests a five-day plan and the caregiver works full time. The caregiver will help in the evenings and on the weekend but does not help with tasks during the time the attendant is present. A comment, Caregiver (use name and relationship) helps in the evenings and on weekends in the Preferences and Special Considerations section is adequate documentation. Code the task as P. Example 4: The caregiver packs breakfast and lunch for the individual but the attendant provides training to the individual on meal preparation for dinner. Example 5: The caregiver helps the individual on and off the toilet but the attendant teaches the individual about toileting hygiene.
A	Other agency. Use A when a non-contracted agency is performing the task.
P/A	Purchased/Agency. Use P/A when another agency is available to perform the task on some days, but not other days. Document in the Preferences and Special Considerations section the part of the task the other agency performs.
NA	Not Applicable or None Available. Not Applicable: The only tasks that can be not applicable are Walking and Assistance with Medications. Use NA when the individual cannot perform any part of the walking task, exercise task or assistance with medications task, and there is no caregiver or other agency totally performing the task. For example, an individual is a double amputee and cannot walk or use wheelchair ambulation. No time will be allotted for the task. Explain in the Preferences and Special Considerations section the task is not applicable.

Additional Habilitation Activities

The information below includes examples of habilitation activities. You may use them to determine if an individual needs habilitation training in these specific tasks.

Information about the service arrangement is below the examples.

Service Arrangement (SA)	Example
24. Money Management	Individual may need help counting money, learning how to budget and paying for items, among other things.
25. Interpersonal Communication	Individual may need help communicating with others in person, on the phone or on the computer.
26. Community Integration	Individual may need help finding, participating in and accessing community activities.
27. Reduction of Challenging Behaviors to allow individuals to accomplish ADLs, IADLs, and health-related tasks	Individual may have challenging behaviors that can be reduced through behavior support plans, prompting, rewards or redirection, among others.
28. Accessing Leisure Time and Recreational Activities	Individual may need help finding activities he or she wants to participate in during leisure time or accessing those activities.
29. Self-Advocacy	Individual may need help learning how to advocate for him or herself. Advocating for oneself could include asserting preferences or requesting needed services.
30. Socialization and Development of Relationships	Individual may need help with development and maintenance of relationships or appropriate social behaviors.
31. Personal Decision Making	Individual may need help making decisions for him or herself. This includes help assessing what is important to that individual, pros and cons, as well as consequences.
32. Accessing Community Resources	Individual may need help finding, participating in, and accessing community resources such as free meal programs, churches, parks, self-advocacy training or events.
33. Use of Augmentative Communication Devices	Individual may need help operating, learning to use, or accessing an augmentative communication device.
34. Other	Include other activities when the individual may have a need for habilitation training in the other category if it does not fit in an existing category.
35. Other	Include other activities when the individual may have a need for habilitation training in the other category if it does not fit in an existing category.

Part B – Task or Hour Guide Column

Minutes Per Day – To have each task authorized as PAS, enter the daily number of minutes needed to conduct that task, based on the support level and the minute range for that task shown in Part C. Times must be shown in five-minute increments and, if needed, rounded up to the next five-minute increment. For each task to be authorized as HAB, enter the daily number of minutes needed to provide training on that task.

The time allotted for PAS must be within the range shown in Part C for the support level and cannot be higher or lower, except in the following situations:

If an individual has a compelling reason for not wanting any of the subtasks under the appropriate support level, but only wants subtasks listed in a lower support level, document the individual's request and allocate minutes in the minute range for the subtasks selected. Document the reason and no supervisory approval is required. Example: The individual scores 2 on bathing. She needs help with drying. However, when discussing subtasks, she states she wants standby help for safety and drawing of water, all under the support level of 1. She states her skin is very sensitive and she would not allow help with drying as she is afraid it would hurt her. The subtasks checked are all under the support level of 1, so ten minutes is allowed. Documentation is required to explain the variance. No supervisory approval is required.
If an individual has a caregiver or other agency performing part of a task and only subtasks in a lower support level are needed, the assessor must document the individual's request and allocate minutes in the minute range for the subtasks selected. Document the reason and no supervisory approval is required. Example: The individual scores 2 for bathing, but only wants help laying out supplies and drawing water because her daughter provides all hands-on help with the bathing task. The task is marked P/C. The subtasks under the support level of 1 are checked and ten minutes is allowed for the subtasks to be purchased. Documentation is required to explain the variance. No supervisory approval is required.

A task may be purchased if it is performed at least once a month by the provider. Time allotted for the task must be prorated into a weekly amount. Example: Escort 1 time a month × 120 minutes ÷ 4.33 = 28 minutes per week. Round up to the next five-minute increment to equal 30 minutes per week.

Escort may be shown as PRN, as needed, if it occurs less than once a month and no time is allocated.

Note: Get supervisory approval if:

the individual has extenuating circumstances, other than the exceptions listed above; and
requires time outside the range, either more or less, for the subtasks within the appropriate support level.

Do not change the support level to adjust the minutes or for the convenience of a provider or attendant. For supervisory approval, document the individual's extenuating circumstances and justify the need for minutes outside the range. The request must be in writing and the supervisor's approval or disapproval must be in writing. Documentation of the request and the approval or disapproval must be filed in the case record. Supervisory approval is required for the adjustment of time outside the ranges to specific tasks and to combinations of tasks that have ranges.

Companion Cases – For PAS only. Check the box in each companion case eligible section to show if there is a companion case. For general household tasks, including cleaning, shopping and meal preparation, use the companion minute range rather than the individual range. Time is assigned per individual based on the individual's support level. Check the box(es) in the Total Minutes Per Week column for cleaning, meal preparation or shopping to show that time is authorized for these tasks to the companion case. In situations where there are more than two companions in the household, assign time based on the individual's support level using the companion minute ranges.

Example 1: On cleaning, Mr. Jones scores 3 and Mrs. Jones scores 1. Mrs. Jones can do some light housekeeping, but due to her husband's incapacity, he needs all cleaning tasks performed in his area. Mrs. Jones is allowed the maximum of 45 minutes under support level 1 in the companion range. Mr. Jones is allowed the maximum of 180 minutes under support level 3 in the companion range.
Example 2: On meal preparation, Mr. and Mrs. Smith both score 2. However, they have different schedules and need some meals shared and others on an individual basis. Calculate everyone’s time based on the meals needed within the impairment range. Use the time in the companion minute range for shared meals and time in the individual range for non-shared meals. Use the Optional Meal Preparation Chart as a tool for calculating time.

Optional Meal Preparation Chart for a Varied Meal Schedule – This is an optional chart to help calculate time for meals for individuals who have a varied schedule. There is no requirement for this chart to be completed as it is a tool only to help calculate times. Enter the time for each meal by the number of days the meal is needed for the total minutes for each type of meal. Use the individual or companion range, as appropriate, and check the box. Total the minutes for the Total Minutes per Week.

Divide the Total Minutes per Week by the number of days per week meals will be authorized for the Average Daily Minutes. If needed, round this amount up to the next five-minute increment. Enter this amount in Part B, Minutes Per Days for the task of Meals. In Days Per Week, enter the highest number of days meals are prepared, even if not all meals are prepared daily.

Days Per Week – For each task to be authorized as PAS or HAB, enter the number of days per week the attendant will conduct that task. Enter in the Preferences and Special Considerations section if the task is performed less than once a week. For the task of Feeding, enter the total number of meals per week.

Sub-Total Minutes Per Week –- Multiply the minutes per day by the days per week to get the Sub-Total Minutes Per Week for each PAS or HAB task.

Part C – Subtasks and PAS Minute Ranges

Note: The minute ranges in this section only apply to PAS activities. Indicate using the checkbox if habilitation is needed for any of the subtasks, but when completing the Task and Hour Guide for habilitation, do not use the minute ranges indicated in Part C.

The subtasks in Part C must be checked to show specifically what the individual needs. An individual scoring of 2 or 3 may need all subtasks under the support level for 1 and additional subtasks under the support level of 2.

Preferences or Special Considerations

Indicate preferences or special considerations identified during the discovery process in the space provided for each activity. This could include the individual’s preference to take baths over showers, or factors such as behaviors that result in higher scores. Additionally, any comments regarding each task can also be documented in this space.

Calculating Total PAS and Habilitation Hours

Total PAS Minutes Per Week - Add the subtotal minutes for each task 1-19 to get the Total PAS Minutes for all tasks.

Total PAS Hours Needed Per Week –Divide the Total PAS Minutes by 60 to determine the weekly total in hours. Round the weekly number of hours to the next highest quarter hour to determine the total hours to authorize. Example: If an individual needs 7 hours and 10 minutes of service each week, enter 7.25 in Hours Needed. This field is NA for HCBS STAR+PLUS Waiver.

Total Habilitation Minutes Per Week – Add the subtotal HAB minutes for each task 1-19, and 24-36 to get the Total HAB Minutes for all tasks.

Total Habilitation Hours Needed Per Week – Divide the Total HAB Minutes by 60 to determine the weekly total in hours. Round the weekly number of hours to the next highest quarter hour to determine the total hours to authorize. Example: If an individual needs 7 hours and 10 minutes of service each week, enter 7.25 in Hours Needed.

Total Combined PAS and Habilitation Hours Per Week - Enter the total weekly hours that can be authorized. Do this by adding together the Total PAS Hours Per Week and the Total HAB Hours Needed Per Week. Round the time up to the next highest quarter hour.

Section 3 – Health-Related Tasks Screening Tool

The Health-Related Tasks Screening Tool is used to determine if the individual may have nursing tasks when the individual or his or her LAR is requesting CFC PAS/HAB. The assessor asks the individual or LAR and then records his or her answer. The assessor is not expected to answer these questions for the individual or LAR.

A. Physician Delegation - Answer Yes or No to the question about physician delegation. Physicians may delegate medical acts to an unlicensed person when the unlicensed person can carry out the act properly and safely. As the physician remains responsible for the medical act performed, delegation is made to a specific person and does not encompass any person who is caring for the individual. Writing an order for an individual’s care does not constitute delegation to an unlicensed person. If the answer is Yes, skip to Section C.

B. Medication Administration – Check Yes or No to the question about medication administration. If the answer is Yes, check all the routes of medication administration that are currently used.

C. Special Procedures – Answer Yes or No to the questions about special procedures.

D. Eating - Answer Yes or No to the questions about eating.

E. Bathing – Answer Yes or No to the question about bathing.

F. Toileting – Answer Yes or No to the questions about toileting.

G. Mobility – Answer Yes or No to the questions about mobility.

H. Health-Related Task Screening Tool Review – Review the Yes responses in Section B-G. Make a referral to the MCO to take further action if any tasks are shown to need to be delegated tasks or HMAs.

Section 4 – Emergency Response Service (ERS)

Check Yes or No to show if the individual needs ERS. If Yes, describe how the individual will benefit from ERS in the space provided. Any more comments about special considerations or preferences should also go in this space.

Section 5 – Information and Referrals

Check the box or boxes from the list to show the referrals appropriate for the individual.

STAR+PLUS Home and Community Based Services (STAR+PLUS HCBS)
Waiver Interest List (Community Living Assistance and Support Services (CLASS), Deaf Blind with Multiple Disabilities (DBMD), Medically Dependent Children Program (MDCP), Texas Home Living (TxHmL), Home and Community Based Services (HCS))
State Supported Living Center crisis diversion slot
Preadmission Screening and Resident Review (PASRR) crisis diversion slot
Other Medicaid services, such as durable medical equipment, augmentative communication systems, seating and positioning systems, power or custom mobility equipment, nursing and therapy services
Other non-Medicaid or community service
Housing options which refers to housing-only services such as Section 8 housing assistance and other independent or subsidized housing arrangements that are affordable, integrated and accessible
Community living options which refers to services and programs that support community living, including in-home nursing, attendant and habilitation services, minor home modifications, respite, and adaptive aids, among others
Other – Specify any other referrals that are appropriate for the individual

Notes: Provide any additional information about information and referrals for the individual. For example, show why the individual was or was not referred for a service.

Section 6 – Support Management

Check Yes or No to show if the individual is currently receiving support management.
Check Yes or No to show if the individual wants to receive support management.

If Yes for 1 or 2, complete 3.

Identify any needs, requests or considerations specific to this service necessary for the staff to know when supporting the individual to achieve his or her outcomes.

Section 7 – Service Delivery Options

For initial assessment: Check Yes or No to show if the individual is interested in self-directing CFC services.

For renewal: Check the appropriate box to show what service delivery option the individual is currently using. The service delivery options are Agency, Consumer Directed Services or Service Responsibility Option. Check Yes or No to show if the individual wants to change his or her service delivery option.

Section 8 – Summary of Recommended Community First Choice Services

Community First Choice PAS/HAB Recommended Total Hours – Show the total combined recommended CFC PAS/HAB hours as listed at the end of Section 2.

Support Management: Check Yes or No to indicate the response given in Section 6.

ERS – Check Yes or No to indicate the response given in Section 4.

Health-Related Tasks indicated in Section 3 – Indicate Yes or No if there are health-related tasks indicated in Section 3.

Section 9 – Acknowledgement

Signing this page affirms:

The hours suggested on Form H6516 are informed by the goals the individual has identified for themselves on Form 1701, Support Plan Narrative.
The individual, LAR, representative or assessor participated in the service planning process.
The individual, LAR, representative and assessor understand that this document and the hours listed on this plan are only a recommendation and not a guarantee of services to be provided. However, this recommendation will be used to guide the approval and provision of services for CFC.

Signature of Individual or Legally Authorized Representative and Date – The individual or LAR must sign and date Form H6516 after completion. Any updates to the form must be initialed and dated by the individual or LAR. If the individual or LAR refuses to sign the form, the assessor should notate this on the signature line of the form.

Printed Name of Individual or LAR – Print or enter the individual or LAR’s name.

Signature of Assessor and Date – The assessor must sign and date Form H6516 after completion. Any updates to the form must be initialed and dated by the assessor.

Printed Name of Assessor – Print or enter the assessor’s name.

Signature of Representative and Date – If a representative participates in the completion of the assessment, he or she must sign and date Form H6516 after completion. Any updates to the form must be initialed and dated by the representative, if applicable.

Printed Name of Representative – Print or enter the representative’s name.

Signature of Other Person and Date – If there is another person who participates in the completion of the assessment, he or she must sign and date Form H6516 after completion.

Printed Name of Other Person – Print or enter the other person’s name.

Signature of MCO Staff and Date – If there is an MCO staff other than the assessor who participates in the completion of the assessment, he or she must sign and date Form H6516 after completion.

Printed Name of MCO Staff – Print or enter the MCO staff’s name.