BEAS 3203
10/2013 – edits as of 12.16.2013
STATE OF NEW HAMPSHIRE
DEPARTMENT OF HEALTH & HUMAN SERVICES
DIVISION OF COMMUNITY BASED CARE SERVICES
BUREAU OF ELDERLY & ADULT SERVICES
Risk Identification, Mitigation and Planning Tool
Participant name: / Date of birth (month/day/year):Reasons for Completing BEAS 3203 Case review/consultation Initial Assessment
(check all that apply): Reassessment Redetermination
Transition to community APS Investigation
Significant Change in Condition (specify):
Risk Factor (1)PHYSICAL HEALTH STATUS
Definitions / Indicators of Risk / Source
Ability to manage one’s physical health and all medical conditions including upcoming surgeries and, particularly:
- chronic health conditions: defined as those that are persistent or ones lasting longer than 3 months, and
- acute care: active but short-term treatment for a brief but severe episode of illness, or conditions resulting from an accident or from other trauma or during recovery from surgery.
Person cannot perform all the tasks necessary to maintain his/her health, or
Person does not have assistance to manage his/her chronic medical condition(s)
----and/or----
Person is not knowledgeable of and does not understand all his/her acute medical condition(s).
Person cannot perform all the tasks necessary to manage his/her acute medical condition(s) to the extent that he/she is able to maintain his/her health, or
Person does not have assistance to manage his/her acute medical condition(s) / Participant
Legal representative
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? Include currentsupports and services that address the identified risk.
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Risk Factor (2)MENTAL HEALTH STATUSDefinitions / Indicators of Risk / Source
Ability to manage one’s mental health. / Person does currently have a mental health diagnosis(es) (delete “and”)
Person is knowledgeable of and does understand his/her mental health diagnosis(es).
Complete if appropriate
Person is unable to manage his/her mental health and cope with any symptoms
Person does not seek assistance when appropriate regarding his/her mental health by contacting:
primary care physician, and/or
mental health provider, and/or
other:
Person has sought services but they are not adequate or available / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? Include currentsupports and services that address the identified risk.
Risk Factor (3)FINANCIAL STATUS
Definitions / Indicators of Risk / Source
The adequacy of the person’s income and assets in meeting his/her needs. / (see also #7 and 11)
Person does not have adequate income to meet his/her needs, e.g., medication, housing, health care, personal care supplies, food, heat, utilities
Person does not have health care benefits, e.g. Medicare, Medicaid, VA benefits or private insurance
Person is at risk of eviction or shut-off of utility(ies) / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? Include currentsupports and services that address the identified risk.
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Risk Factor (4)ACTIVITIES OF DAILY LIVING (ADLs)Definitions / Indicators of Risk / Source
Ability to perform or seek assistance in maintaining one’s personal care, including grooming, toileting, eating, bathing, dressing, getting into or out of a bed or chair, walking. (see # 5 and 6) / Person reports on his/her ability to self-perform, to seek assistance, and/or to accept assistance; person reports on the adequacy of the assistance he/she is receiving.
Activity / Unable to self-perform but has adequate assistance / Unable to self perform, has assistance but is inadequate / Unable to self perform but unable to seek or is refusing assistance
Eating/feeding self
Bathing
Hygiene
Continence
Dressing
Toileting
Transferring
/ Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? Include currentsupports and services that address the identified risk.
Risk Factor (5)MOBILITY (consider deleting risk factor; addressed in #6??)
Definitions / Indicators of Risk / Source
Ability to safely move within and outside of the home, including with the use of assistive devices, if applicable. / Person does have difficulty with his/her ability to move:
Within the home, and/or
Outside the home.
-- and, check if applicable --
Person needs an assistive device(s) or
Person has the use of one or more assistance device(s) that meet his/her needs or
Person has an assistive device(s) but it/they do not meet his/her needs
Person needs an assistive device(s) but refuses to use / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? Include currentsupports and services that address the identified risk.
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Risk Factor (6)STABILITY/RISK OF FALLINGDefinitions / Indicators of Risk / Source
Ability to be stable and not at risk of falling. / Person is not stable and has fallen.
Person has fallen within the past 30 days either within or outside the home.
Risk Factors[i] re falls and fall-related injuries:
Person has physical mobility problems
lower extremity weakness
generalized deconditioning, poor endurance
stiffness and rigidity
slow reaction time
Person has problems due to medications:
change/decline in cognitive functioning
change/decline in physical functioning
Person has home safety concerns
obstacles inside home
obstacles immediately outside home
Person has environmental (beyond person’s home) safety concerns / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? Include currentsupports and services that address the identified risk.
Risk Factor (7)INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)
Definitions / Indicators of Risk / Source
Ability to perform or seek assistance in performing routine tasks, including preparing meals, laundry, cleaning, managing money, shopping, access to and use of transportation, correspondence, telephoning, obtaining and keeping appointments, socializing and recreation. / Person reports on his/her ability to self-perform, to seek assistance, and/or to accept assistance; person reports on the adequacy of the assistance he/she is receiving.
Activity / Unable to self-perform but has adequate assistance / Unable to self perform, has assistance but is in-adequate / Unable to self perform but unable to seek or is refusing assistance
Preparing meals
Housework
Managing medication(s) (see #8)
Managing finances
Using the telephone
Finding resources
Driving / arranging for travel
/ Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? Include currentsupports and services that address the identified risk.
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Risk Factor (8)MEDICATION MANAGEMENTDefinitions / Indicators of Risk / Source
- Ability to understand what medications have been prescribed, the purpose(s) for which they were prescribed and any accompanying directions and side effects.
Person does not know what his/her current medication(s) is/are, cannot list the medication(s), and cannot report the timing, dosage and side effects of one or more of the medications
Person does not understand the purpose of or directions for one or more of the medication(s)
Person is unable to take his/her medication(s) as prescribed or seeks assistance (see #7)
Person does not have a designated individual who supervises his/her medication(s) (see #7)
Person has more than one practitioner prescribing medication(s). / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Debilitating or death
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? Include currentsupports and services that address the identified risk.
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Risk Factor (9)SUBSTANCE USEDefinitions / Indicators of Risk / Source
Use of any prescribed, non-prescribed or over-the-counter substance in a manner other than prescribed, including use in a manner that results or could result in injury or illness. Includes misuse of alcohol. / Person does (check all that apply):
Take drugs not prescribed
Take more or less medication than is prescribed
Misuse alcohol, leading to health or safety concerns, e.g., combining alcohol and medication(s)
Misuse other substance(s) to the extent that the person’s ability to care for him/herself is impaired
Use tobacco to the extent that his/her health is a concern / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? Include currentsupports and services that address the identified risk.
Risk Factor (10)COMMUNICATION
Definitions / Indicators of Risk / Source
Ability to make needs and preferences known, whether independently or through the use of assistive devices or interpreters. / Person does (check all that apply):
Have difficulty communicating with his/her caregivers regarding his/her preferences and needs.
Not have the use of assistive device(s) that meet his/her needs
Need an interpreter
Not have a family member or friend to assist in making his/her needs and preferences known / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? ? Include currentsupports and services that address the identified risk.
Risk Factor (11)LIVING ARRANGEMENT
Definitions / Indicators of Risk / Source
- Location (address) where the person lives and type of living arrangement, i.e., home or apartment; residential care/assisted living, etc.;
- With whom the person lives and the relationship with the client;
- Whether the person is the owner of his/her home or if s/he is renting or squatting,.
Is homeless
Is not safe; his/her safety is threatened (check all that apply)
Is such that he/she is unable to remove himself/herself from the environment,
Includes violence, including domestic or family violence, in the home,
Is hazardous due to environmental conditions observed by case manager, such as:
broken, missing windows, doors / debris that blocks access or egress
blocked doorways / downed power line(s)
roof and flooring are not intact / flooding
exposed wiring / gas/oil leak(s)
excessive garbage / insect infestation
other: / diseased, violent and/or neglected animals
/ Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? ? Include currentsupports and services that address the identified risk.
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Risk Factor (12)ABUSE/EXPLOITATION/NEGLECT/SELF-NEGLECT(not applicable for APS staff)
Definitions / Indicators of Risk / Source
The person’s ability to manage his/her self and environment to ensure freedom from abuse, exploitation, neglect and/or self-neglect. / Person is currently experiencing, has recently experienced (within the past 30 days) or is suspected to be experiencing:
Abuse: emotional, physical and/or sexual
Exploitation
Neglect
Self-neglect / Participant
Legal rep.
Observation by person
completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk?
Check if report made to Adult Protective Services, and:
- provide date:
- identify reporter (agency/provider/other; include relationship to alleged victim)
Risk Factor (13)CONTINGENCY PLAN: BACK-UP PLAN
Definitions / Indicators of Risk / Source
Alternative arrangements made when the person’s designated provider(s) are unavailable (back-up plan) / Person does not have a plan with identified back-up provider(s) to provide services when his/her designated provider(s) are unavailable. / Participant
Legal rep.
Observation by person
completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss f function / What are the options to prevent or mitigate the identified risk? ? Include currentsupports and services that address the identified risk.
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Risk Factor (14)CONTINGENCY PLAN: EMERGENCYDefinitions / Indicators of Risk / Source
Alternative living arrangements are made due to emergency weather conditions or other environmental concerns, such as power outage. / Person does not have a plan for an alternative living arrangement due to inclement weather or other environmental concern(s). / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? ? Include currentsupports and services that address the identified risk.
Risk Factor (15)SOCIAL SUPPORTS
Definitions / Indicators of Risk / Source
The network of the person’s unpaid resources available to assist with providing or arranging for social activity / Person does not:
Have someone (friend and/or relative) available to talk with, keep in contact with (in person and/or phone and/or by computer)
Have someone (friend and/or relative) available for social activities / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? ? Include currentsupports and services that address the identified risk.
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Risk Factor (16)QUALITY OF LIFEDefinitions / Indicators of Risk / Source
(self-report) The extent to which a person’s daily life is consistent with his/her preferences. / Person is not satisfied with:
His/her current residence and/or location, or residence/location he/she is transitioning to, and/or
His/her plan of care, for example:
Access to and quality of services he/she needs
Choice regarding services and help he/she needs
Ability to do things in his/her community
Other:
Level of respect and dignity by his/her caregivers/providers / Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? ? Include currentsupports and services that address the identified risk.
Risk Factor (17)LEGAL
Definitions / Indicators of Risk / Source
Ability to manage or direct one’s affairs including financial and medical / Person is unable or refusing to manage his/her own:
Financial affairs and/or
Medical care.
…..and……
Person reports that he/she has:
guardian of the person / verified
guardian of the estate / verified
durable power of attorney / verified
durable power of attorney for healthcare / verified
none of the above
person refusing to appoint substitute decision maker
/ Participant
Legal rep.
Observation by person completing form
Review of documentation
Other (specify)
Impact
No current indicator(s)
Unlikely harmful due to current supports/services
Likely harmful to health and welfare
Immediate risk to health and welfare
Unanticipated death or permanent loss of function / What are the options to prevent or mitigate the identified risk? ? Include currentsupports and services that address the identified risk. If substitute decision maker is identified but not verified, explain:
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