| For each Activity of Daily Living, the minimum level of assistance required in: | ||
| Self Performance is: | Support Provided is: | |
| Eating | N/A | Setup |
| Toileting | Supervision | N/A |
| Bathing | Supervision | N/A |
| Dressing | Supervision | N/A |
| Transfer | Supervision | Setup |
| Bed Mobility | Supervision | Setup |
| Walk in Room OR Locomotion in Room OR Locomotion Outside Immediate Living Environment |
Supervision | Setup |
| Medication Management | Assistance Required | N/A |
| Personal Hygiene | Supervision | N/A |
| Body care which
includes: Application of ointment or lotions; Toenails trimmed; Dry bandage changes; or Passive range of motion treatment. |
Need | N/A |
| Your need for assistance in any of the activities listed in subsection (a) of this section did not occur because you were unable or no provider was available to assist you will be counted for the purpose of determining your functional eligibility. | ||
| For each Activity of Daily Living, the minimum level of assistance required in | ||
| Self Performance is: | Support Provided is: | |
| Eating | Supervision | One person physical assist |
| Toileting | Extensive Assistance | One person physical assist |
| Bathing | Limited Assistance | One person physical assist |
| Dressing | Extensive Assistance | One person physical assist |
| Transfer | Extensive Assistance | One person physical assist |
| Bed Mobility and Turning and repositioning |
Limited
Assistance and Need |
One person physical assist |
| Walk in Room OR Locomotion in Room OR Locomotion Outside Immediate Living Environment |
Extensive Assistance | One person physical assist |
| Medication Management | Assistance Required Daily | N/A |
| Personal Hygiene | Extensive Assistance | One person physical assist |
| Body care which
includes: Application of ointment or lotions; Toenails trimmed; Dry bandage changes; or Passive range of motion treatment. |
Need | N/A |
| Your need for assistance in any of the activities listed in subsection (b) of this section did not occur because you were unable or no provider was available to assist you will be counted for the purpose determining your functional eligibility. | ||