Consumer Assessment to Manage PCA Services
Introduction
The Personal Care Management (PCM) agency must conduct a written assessment to determine the
consumer’s ability to manage PCA services independently. This assessment must be completed face-to-face for
each new consumer before the submission of the prior-authorization request for PCA services to MassHealth or
the Massachusetts Commission for the Blind (MCB).
A full assessment must also be completed during the PA year and at the time of reevaluation if:
• the consumer’s medical, cognitive, or emotional condition changes in a way that affects the consumer’s ability to
manage PCA services independently;
• the consumer is not managing the PCA program effectively as evidenced by the consumer exhibiting a pattern of
overutilization, or inappropriate use of PCA services, and not responding to intervention from a skills trainer; or
• at the request of the fiscal intermediary or MassHealth.
For all other reviews, the Review of Consumer Assessment to Manage PCA services form should be completed.
The result of the Consumer Assessment to Manage PCA Services is a decision that either:
• the consumer can manage PCA services independently; or
• the consumer requires the assistance of a surrogate.
Consumer Name Date of Birth
Date of Assessment Name of Assessor
Reason for Assessment:
Initial assessment
Change in condition - if checked, describe:
Difficulty managing PCA services
Requested by EOHHS or the FI
Guardianship Status
If the consumer is a minor, or has a court-appointed legal guardian, a surrogate is required.
a. Is the consumer a minor child (under 18 years old)? . . . . . . . . . . . . . . . . .
yes
no
b. Does the consumer have a court-appointed legal guardian?. . . . . . . . . . . . .
yes
no
If no to both (a) and (b), proceed to Part I, Section 1, Communication and Decision Making.
If yes to (a) or (b), no further assessment is necessary: a surrogate is required. Complete (c) and (d)
and proceed to Part III, Decision.
c. Print the name of the parent/legal guardian:
d. Describe the evidence of guardianship:
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PCA-CA-1 (01/07)
