Form 2333 - Nursing Facility Risk Criteria Scoring Form
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1Form 2333
June 2010-E
Nursing Facility Risk Criteria Scoring Form
I. Identifying Data
1. Individual's Name
2. Medicaid No.
3. Responder, if Different from Individual
4. Responder's Relationship to Individual
II. Risk Factors (Identification and Scoring)
This individual:
1. has a history of nursing facility placement within the last five years?........................................................
Yes
No
Yes
No
2. has a neurological diagnosis of (check all the apply): ...........................................................................
A-Alzheimer's
B-Dementia (other
D-Multiple
C-Head Trauma
E-Parkinsonism
Disease
than Alzheimer's)
Sclerosis
3. goes out of his residence one or fewer days a week? ...........................................................................
Yes
No
4. has a history of falling two or more times in the past 180 days? ..............................................................
Yes
No
5. required hands-on guidance or physical assistance on three or more occasions during the last seven days to
Yes
No
accomplish any of the following tasks: (check all that apply) ......................................................................
A-Dressing – putting clothes on and taking clothes off.
B-Personal Hygiene – combing hair, brushing teeth, shaving, applying makeup, washing hands/face and perineum. (Excludes
baths and showers.)
C-Eating – taking in food by any method, including tube feeding.
D-Toilet Use – using toilet, bedpan or urinal, transferring on/off toilet, cleaning self after toilet use, changing pad or managing
special devices required (ostomy or catheter) or adjusting clothes.
or any assistance, including supervision, in:
E-Bathing – included shower, full tub or sponge bath. (Exclude washing back or hair.)
Yes
No
6. has multiple episodes of urinary incontinence daily? ............................................................................
7. had a functional decline in the last 90 days?.......................................................................................
Yes
No
If yes; A. When did functional decline occur?
B. What was the functional decline?
C. Document rational for identified response:
III. Comments (use back of form if necessary)
IV. Eligibility/Non-Eligibilty (check appropriate action):
A-Two or more Yes identified; Continue Eligibility Process.
B-Fewer than two Yes identified; Does Not Meet Risk Factor Criteria.
(Send a denial notice.)
Signature - Case Manager
Date
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