New Jersey Department of Human Services

Division of Aging Services

LONG TERM CARE RE-EVALUATION
1. Participant Name (Print)

4. Date (mm/dd/yyyy)

2. Care Manager Name (Print)

5. Previous Re-evaluation Date (mm/dd/yyyy)

3. JACC Number

6. Program

JACC Other
7. Functional Status
A.	Can Participant recall 3 items from memory after 5 minutes?	Yes No

B.	Can Participant perform or verbalize all or almost all steps in a multi-task sequence without cues for initiation?	Yes No

C.	How well does participant make decisions about organizing the day? (Check one)

Independent	Modified	Minimally	Moderately	Severely

Independence	Impaired	Impaired	Impaired

D.	How well does participant express or make self understood? (Check one)

Understood	Usually	Often	Sometimes	Rarely/Never

Understood	Understood	Understood	Understood

E.	Does participant receive nourishment through an enteral tube feeding?	Yes No

F.	ADL Self Performance (score over past 3 days):
Independent	Set Up	Supervision	Limited Assistance	Extensive Assistance	Maximal Assistance	Total

Dependence	Did Not Occur
Bed Mobility
Eating
Transfer
Toilet Use
Locomotion in Home/Building
Locomotion Outside Home/Building
Upper Body Dressing
Lower Body Dressing
Bathing

(score over past 7 days)
G.	Nursing Facility Level of Care Criteria:

1.	Does Participant meet the ADL Index criteria of 6 or greater and have any 3 ADL’s (limited assist or greater)?	Yes No

** NOTE: If 3 ADL criteria is not met, conference case with OCCO.

2.	Does participant meet the CPS Score criteria of 3 or greater and have any 3 ADLs (supervision or greater)?	Yes No

** NOTE: If 3 ADL criteria is not met, conference case with OCCO.

3.	Does Participant meet the ADL Assistance criteria by requiring limited assistance or greater in Locomotion, Dressing, AND Bathing?	Yes No

**NOTE: Participant must meet at least one of the above three (3) criteria to continue to meet clinical eligibility for Nursing Facility Level of Care.

8. Social Support Network

9. Physical Environment

10. Verification of Nursing Facility Level of Care
I have assessed the above participant and verify (check one):

A. Participant continues to require nursing facility services, as defined by the New Jersey Medicaid regulations (NJAC 8:85-2.1 nursing facility services; eligibility).

B. Participant no longer requires nursing facility services, as defined by the New Jersey Medicaid regulations (NJAC 8:85-2.1 nursing facility services; eligibility).

I discussed voluntary withdrawal from the program and other service options with the participant.

Referred to OCCO for Nursing Facility Level of Care Assessment on (date): _______________

Outcome of OCCO assessment done on (date): _______________

Eligible Ineligible
Signature of Care Manager	Date

Reviewed by (Name)

Title

Date

LONG TERM CARE RE-EVALUATION

(Continued)

1. Participant Name (Print)

3. JACC Number

WPA-1

OCT 14	- 2 -

OCT 14

WPA-1, Long Term Care Re-Evaluation

WPA-1, LTC, long term care, reevaluation, Re-Evaluation, aging and community services, ACS

Windows User

2014-10-31

human services