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Long
-Ter
m C
are
Div
isio
nEl
igib
ility
Cri
teri
a fo
rN
ursi
ng F
acili
ty B
(N
F-B)
Leve
l of C
are
(LO
C)
PRES
ENT
ERS
�C
hris
tine
Kin
g-Br
oom
field
, RN
Nur
se E
valu
ator
IVC
hief
, In-
Hom
e O
pera
tions
, Nor
ther
n Se
ctio
nC
hris
tine.
Kin
g@dh
cs.c
a.go
v
Pegg
y Ba
rrow
, RN
Nur
se E
valu
ator
III
Supe
rvis
or, I
n-H
ome
Ope
ratio
nsM
arga
ret.B
arro
w@
dhcs
.ca.
gov
CA
Dep
t. of
Hea
lth C
are
Serv
ices
2
HA
ND
OU
TS
�A
vaila
ble
for
dow
nloa
d at
:ht
tp://
ww
w.d
hcs.
ca.g
ov/s
ervi
ces/
med
i-ca
l/Pag
es/A
DH
C/A
DH
C.a
spx
1.Po
wer
Poin
t2.
Initi
al A
sses
smen
t R
epor
t (1
6 pa
ges)
3.A
DH
C C
over
She
et4.
Exce
rpts
from
Cal
iforn
ia C
ode
of
Reg
ulat
ions
(C
CR
), Titl
e 22
�Se
ctio
n 51
124
�Se
ctio
n 51
335
CA
Dep
t. of
Hea
lth C
are
Serv
ices
3
ON
-LIN
E C
CR
REF
EREN
CE
�T
he C
alifo
rnia
Cod
e of
Reg
ulat
ions
can
be
acc
esse
d at
htt
p://w
ww
.oal
.ca.
gov/
�C
lick
on t
he t
ab la
bele
d “C
CR
”
�C
lick
on t
he w
ord
“Titl
es”
in t
he s
econ
d se
nten
ce
�C
lick
on “
TIT
LE 2
2. S
OC
IAL
SEC
UR
ITY
”
�C
lick
the
+ be
fore
“D
IVIS
ION
3. H
EALT
H C
AR
E SE
RVIC
ES”
�C
lick
the
+ be
fore
“SU
BDIV
ISIO
N 1
. CA
LIFO
RN
IA M
EDIC
AL
ASS
ISTA
NC
E PR
OG
RA
M”
�C
lick
the
+ be
fore
“C
HA
PTER
3. H
EALT
H C
AR
E SE
RVIC
ES”
�C
lick
the
+ be
fore
“A
RTIC
LE 4
. SC
OPE
AN
D D
UR
ATIO
N O
F BE
NEF
ITS”
CA
Dep
t. of
Hea
lth C
are
Serv
ices
4
NF-
B LE
VEL
OF
CA
RE
�Pr
ovis
ion
of c
are
by a
lice
nsed
nur
se
(not
lim
ited
to):
�Tr
ache
osto
my
care
�A
dmin
istr
atio
n of
rou
tine
and
as-n
eede
d m
edic
atio
n�
Tube
feed
ings
�Su
ctio
ning
�In
dwel
ling
cath
eter
s in
con
junc
tion
with
ot
her
cond
ition
s
CA
Dep
t. of
Hea
lth C
are
Serv
ices
5
NF-
B LE
VEL
OF
CA
RE
�Pr
ovis
ion
of c
are
by a
lice
nsed
nur
se
(con
tinue
d):
�A
pplic
atio
n of
dre
ssin
gs w
ith p
resc
ribe
d m
edic
atio
n�
Exte
nsiv
e w
ound
car
e�
Inta
ke a
nd o
utpu
t m
onito
ring
CA
Dep
t. of
Hea
lth C
are
Serv
ices
6
NF-
B LE
VEL
OF
CA
RE
�T
here
are
alte
rnat
ives
to
rece
ivin
g lo
ng-t
erm
ser
vice
s an
d su
ppor
ts in
in
stitu
tiona
l set
tings
�R
equi
rem
ents
:�
Hav
e on
e or
mor
e ph
ysic
al d
isab
ility
�El
igib
le t
o re
ceiv
e se
rvic
es in
a s
kille
d nu
rsin
g fa
cilit
y
CA
Dep
t. of
Hea
lth C
are
Serv
ices
7
NF-
B LE
VEL
OF
CA
RE
�R
equi
rem
ents
(co
ntin
ued)
�M
edic
al n
eed
for
cont
inuo
us n
ursi
ng c
are
for:
�Te
achi
ng o
f spe
cific
tas
ks a
nd p
roce
dure
s�
Obs
erva
tion
�A
sses
smen
t�
Judg
men
t�
Supe
rvis
ion
�D
ocum
enta
tion
CA
Dep
t. of
Hea
lth C
are
Serv
ices
8
NF-
B LE
VEL
OF
CA
RE
�Ph
ysic
al li
mita
tions
�C
onfin
ed t
o be
d�
Qua
drip
legi
a�
Inab
ility
to
feed
one
self
�Ps
ycho
logi
cal l
imita
tions
�Se
vere
inca
paci
tatio
n du
e to
men
tal h
ealth
or
dev
elop
men
tal i
ssue
s
CA
Dep
t. of
Hea
lth C
are
Serv
ices
9
NF-
B LE
VEL
OF
CA
RE
�R
evie
w:
�In
itial
Ass
essm
ent
Rep
ort
�Ex
plai
n:�
Purp
ose
of A
DH
C C
over
She
et�
Proc
ess
for
subm
ittin
g co
mpl
eted
Initi
al
Ass
essm
ent
Rep
orts
CA
Dep
t. of
Hea
lth C
are
Serv
ices
10
Cas
e St
udy
#1�
Age
:91
Year
-Old
�D
x:St
atus
Pos
t C
VA W
ith R
esid
ual R
ight
-Si
ded
Wea
knes
s; H
TN
, Dem
entia
, H
ypot
hyro
idis
m, H
yper
chol
este
role
mia
, D
M T
ype
2�
Mob
ility
:Wal
ker, W
heel
chai
r, 1-
2 Pe
rson
Ass
ist
With
Tra
nsfe
rs�
Feed
ing:
Gas
tros
tom
y Tub
e Fe
edin
g�
Elim
inat
ion:
Inco
ntin
ence
�A
DLs
:D
epen
dent
CA
Dep
t. of
Hea
lth C
are
Serv
ices
11
Cas
e St
udy
#2�
Age
: 63
Yea
r-O
ld�
Dx:
Stat
us P
ost
MI(1
982)
and
CVA
(19
86);
Mod
. Ex
pres
sive
Aph
asia
; Die
t C
ontr
olle
d D
M;
�M
obili
ty:
Non
-Am
bula
tory
; Pow
er W
heel
chai
r; M
inim
al
Func
tiona
l Mob
ility
; Una
ble
to M
ove
All
Extr
emiti
es; C
ontr
actu
re –
R A
rm &
Bila
tera
l Lo
wer
Ext
rem
ities
; 2
Pers
on L
ift F
or T
rans
fers
; PT
Dai
ly�
Feed
ing:
Req
uire
s M
eal S
et-U
p an
d A
ssis
tanc
e�
Elim
inat
ion:
Inco
ntin
ent
of B
owel
; Sup
ra-P
ubic
C
athe
ter
�A
DLs
:D
epen
dent
�Sk
in:
Red
dene
d H
eels
CA
Dep
t. of
Hea
lth C
are
Serv
ices
12
Cas
e St
udy
#3�
Age
: 79
Yea
r-O
ld�
Dx:
Stat
us P
ost
Brai
n In
jury
; DM
--D
iet
Con
trol
led;
CO
PD--
Oxy
gen
Dep
ende
nt;
Seiz
ure
Dis
orde
r; H
xof
Fre
quen
t U
TIs
�M
obili
ty:
Wal
ker;
Req
uire
s Su
perv
isio
n an
d A
ssis
tanc
e�
Feed
ing:
Req
uire
s M
eal S
et-U
p an
d A
ssis
tanc
e�
Elim
inat
ion:
Con
tinen
t of
Bow
el; B
ladd
er
Urg
e In
cont
inen
ce
�A
DLs
:R
equi
res A
ssis
tanc
e�
Cog
niti
on:
Shor
t an
d Lo
ng T
erm
Mem
ory
Def
icits
; Po
or Im
puls
e C
ontr
ol CA
Dep
t. of
Hea
lth C
are
Serv
ices
13
Cas
e St
udy
#4
�A
ge:
41 Y
ear-
Old
�D
x:St
atus
Pos
t M
I; A
noxi
c Br
ain
Dam
age;
Sta
tus
Post
pac
emak
er/d
efib
rilla
tor
plac
emen
t�
Mob
ility
:1:
1 A
ssis
t to
Am
bula
te; R
equi
res
Supe
rvis
ion
and
Ass
ista
nce
�Fe
edin
g:R
equi
res
Mea
l Set
-Up
and
Ass
ista
nce
�E
limin
atio
n:In
cont
inen
t�
AD
Ls:
Req
uire
s Ass
ista
nce
�C
ogni
tion
: Sh
ort
and
Long
Ter
m M
emor
y D
efic
its
CA
Dep
t. of
Hea
lth C
are
Serv
ices
14
Cas
e St
udy
#5
�A
ge:
82 Ye
ar-O
ld�
Dx:
DM
II; O
steo
arth
ritis
; Alz
heim
er's
�M
obili
ty:W
heel
chai
r D
epen
dent
; tw
o pe
rson
tr
ansf
er; U
nabl
e to
bea
r w
eigh
t�
Feed
ing:
Req
uire
s M
eal S
et-U
p an
d A
ssis
tanc
e –
Diff
icul
ty F
eedi
ng S
elf
�E
limin
atio
n:In
cont
inen
t�
AD
Ls:
Dep
ende
nt�
Cog
niti
on:
Shor
t an
d Lo
ng T
erm
Mem
ory
Def
icits
; Ori
ente
d to
Per
son
Onl
y
CA
Dep
t. of
Hea
lth C
are
Serv
ices
15
Cas
e St
udy
#6�
Age
: 78
Yea
r-O
ld�
Dx:
DM
II; S
tatu
s Po
st C
VA; H
emip
legi
a; H
TN
�C
ogni
tion
: So
me
Dis
orie
ntat
ion
�M
edic
atio
ns:
Insu
lin (S
lidin
g Sc
ale)
and
Ora
l H
ypog
lyce
mic
Med
icat
ion
�M
obili
ty:
Una
ble
to A
mbu
late
–W
heel
chai
r Bo
und;
R
equi
res
Hoy
er L
ift fo
r Tra
nsfe
rs�
Feed
ing:
Req
uire
s M
eal S
et-U
p an
d A
ssis
tanc
e�
Elim
inat
ion:
Inco
ntin
ent;
Supr
apub
icC
athe
ter
�A
DLs
:D
epen
dent
CA
Dep
t. of
Hea
lth C
are
Serv
ices
16
NF-
B LE
VEL
OF
CA
RE
Ope
n tim
e fo
r qu
estio
ns
CA
Dep
t. of
Hea
lth C
are
Serv
ices
17