411-015-0006 Activities of Daily Living (ADL) (1) Evaluation of the individual's need for assistance in activities of daily living is based on: (a) The individual's ability to complete activities, components, and tasks rather than the services provided; (b) How the individual functioned during the 30 days prior to the assessment date, with consideration of how the person is likely to function in the 30 days following the assessment date; and (c) Evidence of the actual or predicted need for assistance of another person within the assessment time frame, and it must not be based on possible or preventive needs. (2) Bathing and personal hygiene. This activity of daily living is comprised of two components, which are bathing and personal hygiene. To be considered assist, the individual must require assistance in bathing or full assistance in hygiene. To be considered full assist, the individual must require full assistance in bathing. (a) Bathing means the tasks of getting in and out of a bathtub or shower, washing hair, and washing the body, while using assistive devices, if needed. This includes, but is not limited to, sponge baths, bed baths, bathing in a tub, or showering, as chosen by an individual. For individuals who are confined to a bed, bathing is assessed without considering the need to get in or out of the bathtub or shower. (A) Assist: Even with assistive devices, the individual requires assistance of another person for a task of bathing at least one day each week totaling four days per month. This means hands-on assistance, cueing, or stand-by presence during the activity. (B) Full Assist: Even with assistive devices, the individual is unable to accomplish any task of bathing without the assistance of another person. This means the individual needs hands-on assistance of another person through all tasks of the activity, every time the activity is attempted. (b) Personal hygiene means the tasks of shaving, caring for the mouth, or assistance with tasks of menstruation care. This includes, but is not limited to, shaving the face, legs, or other desired areas, brushing teeth, maintaining dentures, caring for gums, and using feminine hygiene products to address menstrual needs. (A) Assist: Even with assistive devices, the individual requires assistance of another person for a task of personal hygiene at least one day each week totaling four days per month. This means hands-on assistance, cueing, or stand-by presence during the activity. (B) Full Assist: Even with assistive devices, the individual is unable to complete at least two personal hygiene tasks without the assistance of another person. This means the individual needs hands-on assistance of another person through all tasks, every time the activity is attempted. (3) Cognition refers to how the individual is able to use information, make decisions, and ensure their daily needs are met. There are four components to cognition: self-preservation, decision-making, ability to make one's self-understood, and unsafe behaviors. For purposes of this rule, assist levels are defined within each of the four components. Individuals assessed as minimal assist may receive cognition hours as defined in OAR 411-030. For each assist level, individuals must have a documented history of actions or behaviors demonstrating they need assistance with ensuring their health and safety. (a) An individual's ability to manage any component of cognition, as defined in this rule, is assessed by how the individual is able to function without the assistance of another person. (b)The assessment time frame in OAR 411-015-0008 shall be expanded when assessing cognition. A documented history demonstrating the need for assistance that occurred more than 30 days prior to the assessment date shall be considered if need would likely reoccur in the absence of existing supports. (c) An individual under age 65, with cognition needs driven by a mental illness, emotional disorder, or substance abuse disorder does not meet the criteria for service eligibility per OAR 411-015-0015. (d) To assess an individual as meeting the assist criteria for cognition, an individual must require: (A) Substantial assistance in one of the four components of cognition; or (B) Minimal assistance in at least two of the four components of cognition. (e) To meet the criteria for full assist in cognition an individual must require: (A) Full assistance in at least one of the four components of cognition; or (B) Substantial Assistance in at least two of the four components. (f) The four components of cognition are: (A) SELF-PRESERVATION. Self-Preservation means an individual’s actions or behaviors reflecting the individual's understanding of their health and safety needs and how to meet those needs. Self-preservation refers to an individual's cognitive ability to recognize and take action in a changing environment or a potentially harmful situation. (i) Self-Preservation includes, but is not limited to an individual: (I) Being oriented to their community and surroundings such that they can find their way to their home or care setting. (II) Understanding how to safely use appliances. (III) Understanding how to take their medications. (IV) Understanding how to protect themselves from abuse, neglect, or exploitation. (V) Understanding how to meet their basic health and safety needs. (ii) Self-preservation does not include the individual engaging in acts that may be risky or life threatening when the individual understands the potential consequences of their actions. (iii) Self-preservation includes the following assistance types (see OAR 411-015-0005) unless otherwise indicated in the assist level: (I) Cueing. (II) Hands-on. (III) Monitoring. (IV) Reassurance. (V) Redirection. (VI) Support. (iv) Minimal Assist: The individual needs assistance at least one day each month to ensure they are able to meet their basic health and safety needs because they are unable to act on the need for self-preservation or they are unable to understand the need for self-preservation. The need may be event specific. (v) Substantial Assist: The individual requires assistance because they are unable to act on the need for self-preservation nor understand the need for self-preservation at least daily. (vi) Full Assist: The individual requires assistance to ensure that they meet their basic health and safety needs throughout each day. The individual is not able to be left alone without risk of harm to themselves or others or the individual would experience significant negative health outcomes. This does not include assistance types of support or monitoring. (B) DECISION-MAKING. Decision-making means an individual’s ability to make everyday decisions about ADLs, IADLs, and the tasks that comprise those activities. An individual needs assistance if that individual demonstrates they are unable to make decisions, needs help understanding how to accomplish the tasks necessary to complete a decision, or does not understand the risks or consequences of their decisions. (i) Decision-making includes the following assistance types, unless otherwise indicated in the assist definitions: (I) Cueing. (II) Hands-on. (III) Monitoring. (IV) Redirection. (V) Support. (ii) Minimal Assist: The individual requires assistance at least one day each month with decision-making. The need may be event specific. (iii) Substantial Assist: The individual requires assistance in decision-making and completion of ADL and IADL tasks at least daily. (iv) Full Assist: The individual requires assistance throughout each day to make decisions, understand the tasks necessary to complete ADLs and IADLs critical to one’s health and safety. The individual may not be left alone without risk of harm to themselves or others or the individual would experience significant negative health outcomes. This does not include assistance types of support or monitoring. (C) ABILITY TO MAKE SELF-UNDERSTOOD. Ability to make self-understood means an individual’s cognitive ability to communicate or express needs, opinions, or urgent problems, whether in speech, writing, sign language, body language, symbols, pictures, or a combination of these including use of assistive technology. An individual with a cognitive impairment in this component demonstrates an inability to express themselves clearly to the point their needs cannot be met independently. (i) Ability to make self-understood does not include the need for assistance due to language barriers or physical limitations to communicate. (ii) Ability to make self-understood includes the following assistance types, unless otherwise indicated in the assist definitions: (I) Cueing. (II) Monitoring. (III) Reassurance. (IV) Redirection. (V) Support. (iii) Minimal Assist: The individual requires assistance at least one day each month in finding the right words or in finishing their thoughts to ensure their health and safety needs. The need may be event specific. (iv) Substantial Assist: The individual requires assistance to communicate their health and safety needs at least daily. (v) Full Assist: The individual requires assistance throughout each day to communicate and is rarely or never understood and cannot be left alone without risk of harm to themselves or others or the individual would experience significant negative health outcomes. Full assist includes hands on assistance in addition to the assist definition included in paragraph (C). This does not include assistance types of support or monitoring. (D) CHALLENGING BEHAVIORS. Challenging Behaviors means an individual exhibits behaviors that negatively impact their own, or others’, health or safety. An individual who requires assistance with challenging behaviors does not understand the impact or outcome of their decisions or actions. (i) Challenging behaviors include, but are not limited to, those behaviors that are verbally or physically aggressive and socially inappropriate or disruptive. (ii) Challenging behaviors does not include the individual exhibiting behaviors when the individual understands the potential risks and consequences of their actions. (iii) Challenging behaviors includes the following assistance types, unless otherwise indicated in the assist definitions: (I) Cueing. (II) Hands-on. (III) Monitoring. (IV) Redirection. (iv) Minimal Assist: The individual requires assistance at least one day each month dealing with a behavior that may negatively impact their own or others’ health or safety. The individual sometimes displays challenging behaviors, but can be distracted and is able to self-regulate behaviors with reassurance or cueing. Minimal assist includes reassurance assistance. (v) Substantial Assist: The individual requires assistance in managing or mitigating their behaviors at least daily. The individual displays challenging behaviors and assistance is needed because the individual is unable to self-regulate the behaviors and does not understand the consequences of their behaviors. (vi) Full Assist: The individual displays challenging behaviors that require additional support to prevent significant harm to themselves or others. The individual needs constant assistance to the level that the individual may not be left alone without risk of harm to themselves or others or the individual would experience significant negative health outcomes. This does not include assistance types of monitoring. (4) Dressing and Grooming: This activity of daily living is comprised of two components: dressing and grooming. To be considered Assist, the individual must require assistance in dressing or full assistance in grooming. To be considered Full Assist the individual must require full assistance in dressing: (a) Dressing is comprised of three tasks; putting on clothing, taking off clothing, and putting on or taking off shoes and socks. This includes, but is not limited to, the consideration of an individual’s ability to use clothing with buttons, zippers, and snaps, and reflects the individual’s choice and reasonable preferences. (A) Assist: Even with assistive devices, the individual is unable to accomplish some tasks of dressing without the assistance of another person at least one time each week totaling four days per month. This means hands-on assistance, cueing, or stand-by presence during the activity. (B) Full Assist: Even with assistive devices, the individual is unable to accomplish any tasks of dressing without the assistance of another person. This means the individual needs hands-on assistance through all tasks of the activity, every time the activity is attempted. (b) Grooming means the tasks of nail and hair care based on the individual’s reasonable personal preferences. This includes, but is not limited to, tasks of clipping and filing both toe nails and finger nails, and brushing, combing, braiding, or otherwise maintaining one’s hair or scalp. (A) Assist: Even with assistive devices, the individual is unable to accomplish tasks of grooming, without the assistance of another person at least one time each week totaling four days per month. This means hands-on assistance, cueing, or stand-by presence during the activity. (B) Full Assist: Even with assistive devices, the individual is unable to perform any tasks of grooming without the assistance of another person. This means the individual needs hands-on assistance of another person through all tasks of the activity, every time the activity is attempted. (5) Eating means the tasks of eating, feeding, nutritional IV set up, or feeding tube set-up by another person and may include using assistive devices. (a) Assist: When eating, the individual requires another person to be within sight and immediately available to actively provide hands-on assistance with feeding, special utensils, or immediate hands-on assistance to address choking, or cueing during the act of eating at least one time each week totaling four days per month during the assessment timeframe. (b) Full Assist: When eating, the individual always requires one-on-one assistance through all tasks of the activity for direct feeding, constant cueing to prevent choking or aspiration every time the activity is attempted. (6) Elimination is comprised of three components, which are bladder, bowel, and toileting. To be considered assist, the individual must require assistance in at least one of the three components inside the home or care setting. To be considered full assist the individual must require full assistance in any of the three components inside the home or care setting. Dialysis care needs are not assessed as part of elimination. (a) Bladder means the tasks of catheter care and ostomy care. The tasks of catheter or ostomy care are specific to the individual. (A) Assist: Even with assistive devices, the individual requires hands-on assistance with a task of bladder at least one day each week totaling four days per month during the assessment timeframe. (B) Full Assist: The individual requires hands-on assistance of another person to complete all tasks of bladder care every time the task is attempted even with assistive devices. (b) Bowel means the tasks of digital stimulation, suppository insertion, ostomy care, and enemas. (A) Assist: Even with assistive devices, the individual requires hands-on assistance with a task of bowel care at least one day each week totaling four days per month during the assessment timeframe. (B) Full Assist: The individual requires hands-on assistance of another person to complete all tasks of bowel care every time the task is attempted, even with assistive devices. (c) Toileting means the assessed tasks of cleansing after elimination, changing soiled incontinence supplies or soiled clothing, adjusting clothing to enable elimination, or cueing to prevent incontinence. (A) Assist: Even with assistive devices, the individual requires hands-on assistance from another person with a task of toileting or cueing to prevent incontinence at least one day each week totaling four days per month during the assessment timeframe. (B) Full Assist: The individual is unable to accomplish all tasks of toileting without the assistance of another person. This means the individual needs assistance of another person through all tasks of the activity, every time the activity is attempted. (7) Mobility is comprised of two components, which are ambulation and transfer. The activity of mobility is organized into three assistance levels. To be considered Minimal Assist, the individual must require minimal assistance in ambulation. To be considered Substantial Assist, the individual must require substantial assistance with ambulation or an assist with transfer. To be considered Full Assist, the individual must require full assistance with ambulation or transfer. (a) Mobility does not include getting in and out of a motor vehicle, or getting in or out of a bathtub or shower. (b) For the purposes of this rule, inside the home or care setting, means inside the entrance to the individual's home or apartment unit or inside the care setting (as defined in OAR 411-015-0005). Courtyards, balconies, stairs or hallways exterior to the doorway of the home or apartment unit are not considered inside. (c) A history of falls with an inability to rise without the assistance of another person, or with negative physical health consequences, may be considered in assessing ambulation or transfer if they occur within the assessment time frame. Falls prior to the assessment time frame, or the need for prevention of falls alone, even if recommended by medical personnel, is not sufficient to qualify for assistance in ambulation or transfer. (d) Ambulation means the tasks of moving around inside and outside the home or care setting. This includes assessing the individual’s needs after taking into consideration their level of independence while using assistive devices such as walkers, canes, crutches, manual and electric wheelchairs, and motorized scooters. Ambulation does not include exercise or physical therapy. (A) Minimal Assist: Even with assistive devices, the individual requires hands-on assistance from another person to ambulate outside the home or care setting at least once each week, totaling four days per month. The individual requires hands-on assistance from another person to ambulate inside their home or care setting less than one day each week. (B) Substantial Assist: Even with assistive devices the individual requires hands-on assistance from another person to ambulate inside their home or care setting at least one day each week totaling four days per month. (C) Full Assist: Even with assistive devices, the individual requires hands-on assistance from another person to ambulate every time the activity is attempted. Individuals who are confined to bed are a full assist in ambulation. (e) Transfer means the tasks of moving to or from a chair, bed, toileting area, or wheelchair using assistive devices, if needed. This includes assessing one’s ability to transfer from areas used on a daily or regular basis, such as sofas, chairs, recliners, beds, and other areas inside the home or care setting based on their reasonable personal preferences. When individuals are confined to their bed or a wheelchair, repositioning is also considered as a transfer task. This assistance must be required because of the individual's physical limitations, not their physical location or personal preference. (A) Assist: Even with assistive devices, the individual requires hands-on assistance with a task of transferring inside the home or care setting at least one day each week totaling at least four days per month. (B) Full Assist: The individual requires hands-on assistance from another person every time the activity is attempted, even with assistive devices. Statutory/Other Authority: ORS 410.070 Statutes/Other Implemented: ORS 410.070 History: APD 39-2018, amend filed 11/15/2018, effective 11/18/2018 APD 12-2018, temporary amend filed 05/23/2018, effective 05/23/2018 through 11/18/2018 APD 10-2018, amend filed 03/28/2018, effective 03/29/2018 APD 19-2017, temporary amend filed 09/29/2017, effective 10/01/2017 through 03/29/2018 APD 35-2014, f. & cert. ef. 10-1-14 APD 9-2014(Temp), f. 4-17-14, cert. ef. 4-21-14 thru 10-18-14 SPD 19-2006, f. 5-26-06, cert. ef. 6-1-06