Supports and Training for Employing People Successfully (STEPS)

Services Assessment

Contents

STEPS Services Assessment demographics	3

Diagnosis Information	4

Health & Safety Information	5

Services Descriptions	6

Pre-Vocational Assessment	7

Independent Living Skills Assessment	9

Transportation Assessment	11

Supported Employment	12

Personal Assistance Services Assessment	13

Activities of Daily Living	13

Instrumental Activities of Daily Living	19

Supplemental Services	25

Personal Assistance Services Summary	27

STEPS Services Summary Page	28

STEPS Services Assessment Signature Page	29

*To navigate to the assessment you need, click the name or page number of the assessment.

STEPS (Support and Training for Employing People Successfully)

Services Assessment

Participant Name: First and Last	Participant address: Street Address
Phone number: Contact Number	City, State: City, State
DOB: M/D/Y	Zip code: Zip Code
Gender: ☐ Female ☐ Male ☐ Non-Binary ☐ Trans-masc ☐ Trans-femme
CC/CM: Who completed the assessment	MCO: Choose One	Email: Enter email
Attendees: Others who attended and their role
Attendees: Others who attended and their role
Attendees: Others who attended and their role
Attendees: Others who attended and their role

Assessment Type	Reason for completion	Date Completed
Choose type.	Why was the assessment completed/re-completed? Example: New job, initial assessment, life change.	Choose date.

*Only to be completed for annual or revised re-assessments.
Services	Was the service assessed?	What services remain the same?	What services were changed?
Pre-vocational	☐	☐	☐
Independent living skills	☐	☐	☐
Transportation	☐	☐	☐
Supported Employment	☐	☐	☐
Personal Assistance Services	☐	☐	☐
Supplemental Services – Only available with PAS – Only mark as assessed if it will appear on the Service Plan	Enhanced Services	☐	☐	☐
Home-Delivered Meals	☐	☐	☐
PERS	☐	☐	☐
Medication Management System	☐	☐	☐

If a service wasn’t assessed, please provide an explanation why.
Pre-vocational	Enter explanation
Independent living skills	Enter explanation
Transportation	Enter explanation
Supported Employment	Enter explanation
Personal Assistance Services	Enter explanation

Diagnosis Information

Primary Diagnosis/Condition: Click or tap here to enter text.
Source of information: Click or tap here to enter text.

Please review every condition with the participant
Health Conditions	*Primary Condition	Secondary Condition	Notes: List diagnosis and impairments. Example, if paralyzed, to what extent does the paralysis limits the member's function.
Alcoholism/Drug use	☐	☐	Enter notes if applicable
Alzheimer's Disease, other memory loss conditions (specify)	☐	☐	Enter notes if applicable
Arthritis (specify)	☐	☐	Enter notes if applicable
Behavioral Health (specify)	☐	☐	Enter notes if applicable
Cancer/Leukemia	☐	☐	Enter notes if applicable
Circulation Problems (Swelling limbs, clotting problems, etc.)	☐	☐	Enter notes if applicable
Diabetes	☐	☐	Enter notes if applicable
GI Tract Problems (Ulcer, Colitis, etc.)	☐	☐	Enter notes if applicable
Head Injury (include date of onset)	☐	☐	Enter notes if applicable
Hearing Problem	☐	☐	Enter notes if applicable
Heart Problems	☐	☐	Enter notes if applicable
High Blood Pressure	☐	☐	Enter notes if applicable
Infectious Diseases (specify)	☐	☐	Enter notes if applicable
Kidney/Bladder Problems	☐	☐	Enter notes if applicable
Lung/Breathing Problems (specify)	☐	☐	Enter notes if applicable
Intellectual/Developmental Disability (specify)	☐	☐	Enter notes if applicable
Missing Limb (specify)	☐	☐	Enter notes if applicable
Open Wounds, Bed Sores	☐	☐	Enter notes if applicable
Osteoporosis	☐	☐	Enter notes if applicable
Paralysis (specify)	☐	☐	Enter notes if applicable
Neurological Disease (such as Parkinson's) or mobility problems	☐	☐	Enter notes if applicable
Seizures	☐	☐	Enter notes if applicable
Significant Weight Loss/Gain, Obesity or Under Weight (specify)	☐	☐	Enter notes if applicable
Speech Problem	☐	☐	Enter notes if applicable
Stroke	☐	☐	Enter notes if applicable
Uses Wheelchair, Walker, or other aid	☐	☐	Enter notes if applicable
Vision Problems (Glaucoma, Cataracts, etc.)	☐	☐	Enter notes if applicable
Other (Specific)	☐	☐	Enter notes if applicable
*Must check a Primary Condition

Health & Safety Information

Please check the appropriate boxes and provide explanations where needed.
1.	Current place of residence	9.	Are there any abuse, neglect, or exploitation issues that should be reported to help you?
☐	House/Townhouse	☐	Duplex
☐	Apartment/Condominium	☐	Assisted Living	☐ Yes	☐ No
☐	Congregate/Group Living	☐	Mobile Home	If yes, please identify. Click or tap here to enter text.
☐	Nursing Facility	☐	Transitional housing
☐	Homeless
2.	Consumer’s current residence is?	10.	Does your home have the following?
☐	Owned (or being purchased/mortgage)	1 = Does not have, 2 = Not working, 3 = Working
☐	Rented, private	☐	Rented, subsidized	(indicate the code that applies)
☐	Rent free (e.g., family, friends)	Electricity	Refrigerator
☐	Other	Gas/propane	Stove
Piped water, hot/cold	Oven/Toaster oven
3.	How many addresses has the consumer had in the last 12 months	Air conditioner/fan	Microwave
Heating system	Flush toilet
Laundry facilities	Tub/shower
Smoke detector	Radio/television
4.	Client’s residence location	Carbon Monoxide detector	Telephone
☐	Rural (< 20,000)
☐	Town (20,000 – 100,000)
☐	Urban (> 100,000)	11.	What type of housing has the consumer had in the past 12 months? (Check all that apply)
5.	Do you feel safe inside your home?	☐	Owned own	☐	Transitional housing
☐ Yes	☐ No	☐	Rental home	☐	Correctional facility
If no, why not? Click or tap here to enter text.	☐	Someone else’s home	☐	Homeless
☐	Group home setting	☐	Other
☐	Hotel
6.	Do you feel safe in your neighborhood?	12.	Are there health or physical safety problems?
☐ Yes	☐ No	Check all that apply
If no, why not? Click or tap here to enter text.	☐	Dirt/garbage	☐	Furnishings/rugs
☐	Yard/storage buildings	☐	House/basement
☐	Animals/pets	☐	Poor lighting
☐	Other: Click or tap here to enter text.
7.	Do you feel safe outside your neighborhood?
☐ Yes	☐ No	13.	Do you have difficulty getting into your home or any room in your home (Check all that apply)
If no, why not? Click or tap here to enter text.
☐	Entrance(s)
☐	Living/family room
☐	Bathing facility/tub
8.	Is there anything inside or outside of your home that you worry about or are uncomfortable about?	☐	Toilet facility
☐	Laundry
☐ Yes	☐ No	☐	Bedroom
If yes, why? Click or tap here to enter text.	☐	Kitchen
☐	No difficulty

Services Descriptions

Services	Description
Pre-vocational services	Pre-Vocational Services are designed to lead to integrated competitive employment by assisting participants to determine vocational goals, develop or re-establish employment related skills, and participate in internships or work experiences.
Independent living Skills	Independent Living Skills (ILS) Training is designed to improve participant’s ability to live as independently as possible at home and in the community using existing community resources. The provision of ILS Training may reduce or eliminate the need for Personal Assistance Services and/or Transportation
Transportation	Transportation to and from job interviews, work, and essential locations such as grocery stores and banks.
Supported Employment	Supported Employment is designed to provide assistance to participants to determine vocational goals, to learn job responsibilities, determine and request job accommodation, as well as other supports to maintain successful employment.
Personal Assistance Services	Personal Assistance Services (PAS) are designed to provide hands-on assistance, or cuing and prompting, for Activities of Daily Living (ADLs) and Instrumental Activities of Daily Living (IADLs). Cuing/prompting must be face-to-face. Participants will need to show need for supports for 2 Activities of Daily Living before they are eligible for supports for Instrumental Activities of Daily Living. *Informal support policy will be considered for this assessment. General Limitation: An informal support living in the home of the participant with whom he or she has a significant relationship shall not be paid to provide PAS or similar services for IADLs that the person would ordinarily perform or be responsible to perform.
Supplemental Services – Only available with PAS	Enhanced Services	Assistance for participants who require hands-on care during the night, including re-positioning, tracheotomy care, and care for chronic incontinence; need must be documented by a physician.
Home-Delivered Meals	Meal delivery if determined cost effective when compared to meal preparation by a personal assistant.
PERS	Personal Emergency Response Systems (PERS) allowing participants to seek help when alone.
Medication Management Systems	A device, monitored or unmonitored, that provides reminders for medication times and dispenser proper doses.

Pre-Vocational Assessment

*Once completed and if service provision is indicated the service provider will develop a more thorough plan that uses a person-centered approach to learn Pre-Vocational skills. Only completed at Initial Assessment, if indicated.

Have the consumer indicate yes or no if they feel competent in the skills listed below. Then ask if they would like assistance to develop this skill. If they do not feel competent in the skill, they do not have to want to develop it.

40 skills Are you able to do the following skills?	Yes	No	Would you like to develop this skill?
Communication Skills
Speak in public or present an idea Notes	☐ Yes	☐ No	☐
Writing reports Notes	☐ Yes	☐ No	☐
Accepting constructive criticism Notes	☐ Yes	☐ No	☐
Following multi-step directions Notes	☐ Yes	☐ No	☐
Reading and following employee documents/training materials Notes	☐ Yes	☐ No	☐
Technical Skills
Use physical coordination (hand-eye coordination) Notes	☐ Yes	☐ No	☐
Using tools safely and efficiently Notes	☐ Yes	☐ No	☐
Operating vehicles, machines, and electronic equipment Notes	☐ Yes	☐ No	☐
Repairing machines and equipment Notes	☐ Yes	☐ No	☐
Gardening, landscaping, or faming Notes	☐ Yes	☐ No	☐
Using a computer Notes	☐ Yes	☐ No	☐
Using programs like word, excel, adobe etc. Notes	☐ Yes	☐ No	☐
Management Skills
Managing or motivating others Notes	☐ Yes	☐ No	☐
Selling or promoting products Notes	☐ Yes	☐ No	☐
Prioritizing task so that larger goals are met on time Notes	☐ Yes	☐ No	☐
Following rules Notes	☐ Yes	☐ No	☐
Presenting a professional image Notes	☐ Yes	☐ No	☐
Number Skills
Using percentages, decimals, and fractions Notes	☐ Yes	☐ No	☐
Do simple addition and subtraction Notes	☐ Yes	☐ No	☐
Creative Skills
Using artistic abilities (Photography, decorating, painting, sculpting) Notes	☐ Yes	☐ No	☐
Using Musical abilities (singing, composing) Notes	☐ Yes	☐ No	☐
Drawing, sketching, illustrating, graphic design Notes	☐ Yes	☐ No	☐
People and Social Skills
Physically care for others Notes	☐ Yes	☐ No	☐
Host, welcome, or serve customers (Like in retail or a restaurant) Notes	☐ Yes	☐ No	☐
Helping someone complete a task Notes	☐ Yes	☐ No	☐
Leading groups and activities Notes	☐ Yes	☐ No	☐
Problem solving Notes	☐ Yes	☐ No	☐
Using courtesy when dealing with others Notes	☐ Yes	☐ No	☐
Ability to follow a routine Notes	☐ Yes	☐ No	☐
Telling time to the nearest 5 minutes Notes	☐ Yes	☐ No	☐
Knowing at what times things happen (work schedule, mealtimes, etc.) Notes	☐ Yes	☐ No	☐
Recognizing break time Notes	☐ Yes	☐ No	☐
Behaving appropriately on break Notes	☐ Yes	☐ No	☐
Independently returning from break on time Notes	☐ Yes	☐ No	☐
Business Skills
Using a business phone (Multiple lines, transferring calls, etc.) Notes	☐ Yes	☐ No	☐
Knowing how to follow a business budget Notes	☐ Yes	☐ No	☐
Setting up/Closing out a cash register Notes	☐ Yes	☐ No	☐
Managing money and bills (Physically handling money, recognizing currency) Notes	☐ Yes	☐ No	☐
Organizing and categorizing information Notes	☐ Yes	☐ No	☐
Are there any skills not listed that you feel very comfortable with or that you feel you excel at?	Describe
Are there any skills not listed that you recognize that you need to improve to become more employable?	Describe
If you have been employed previously, do you feel that employment was based on your skills and knowledge?	Describe
Do you feel that you would benefit from pre-vocational skills training to become employed?	☐ Yes	☐ No

If a consumer indicates that they would like assistance to develop at least 3 skills, they qualify for this service (within program limits).
Does the assessment indicate that this support is needed?	☐ Yes	☐ No
Is the individual requesting this support?	☐ Yes	☐ No
Are they receiving this service from another source?	☐ Yes	☐ No

Independent Living Skills Assessment

* Once completed and if service provision is indicated the service provider will develop a more thorough plan that uses a person-centered approach to learn Independent Living skills. Only completed at Initial Assessment, if indicated.

Have the consumer indicate yes or no if they feel competent in the skills listed below. Then ask if they would like assistance to develop this skill. If they do not feel competent in the skill, they do not have to want to develop it.

27 skills	Yes	No	Would you like to develop this skill?
Communication Skills
Reading and comprehending complex sentences Notes	☐ Yes	☐ No	☐
Reading and following instructions Notes	☐ Yes	☐ No	☐
Comparing/cross-checking two or more list Notes	☐ Yes	☐ No	☐
Filling out forms Notes	☐ Yes	☐ No	☐
Comfortably speaking to people that you don’t know Notes	☐ Yes	☐ No	☐
Finding information Notes	☐ Yes	☐ No	☐
Relates experiences when asked Notes	☐ Yes	☐ No	☐
Knowing when to ask for help Notes	☐ Yes	☐ No	☐
Listening to others for comprehension. (Being able to put what was said or what was read into your own words) Notes	☐ Yes	☐ No	☐
Explaining your disability Notes	☐ Yes	☐ No	☐
Accepting your disability Notes	☐ Yes	☐ No	☐
Describing the accommodations that you need Notes	☐ Yes	☐ No	☐
Knowing your legal rights Notes	☐ Yes	☐ No	☐
Self - Management Skills
Setting task goals and priorities Notes	☐ Yes	☐ No	☐
Planning and making decisions Notes	☐ Yes	☐ No	☐
Being patient with others Notes	☐ Yes	☐ No	☐
Motivating yourself to get things done even when you don’t want to Notes	☐ Yes	☐ No	☐
Knowing how to take directions even if you don’t like it Notes	☐ Yes	☐ No	☐
Seeking help when you need it Notes	☐ Yes	☐ No	☐
Speaking up for yourself Notes	☐ Yes	☐ No	☐
Can handle frequent changes Notes	☐ Yes	☐ No	☐
Being on time/punctual Notes	☐ Yes	☐ No	☐
Creating/maintaining a personal budget Notes	☐ Yes	☐ No	☐
Critical Thinking Skills
Problem solving Notes	☐ Yes	☐ No	☐
Evaluating consequences and outcomes Notes	☐ Yes	☐ No	☐
Making safe and reasonable decisions Notes	☐ Yes	☐ No	☐
Using maps Notes	☐ Yes	☐ No	☐
Are there any skills not listed that you feel very comfortable with or that you feel you excel at?	Describe
Are there any skills not listed that you recognize that you need to improve to become more independent?	Describe
Do you feel that you would benefit from independent skills training to be more independent?	☐ Yes	☐ No

If a consumer indicates that they would like assistance to develop at least 3 skills, they qualify for this service (within program limits).
Does the assessment indicate that this support is needed?	☐ Yes	☐ No
Is the individual requesting this support?	☐ Yes	☐ No
Are they receiving this service from another source?	☐ Yes	☐ No

Transportation Assessment

Transportation
This portion of the assessment only applies to employment-related transportation for obtaining and maintaining employment and essential transportation.
Informal support policy applies to personal assistance; employment transportation is separate. Transportation is limited to up to 10 hours a week as NEEDED.
NOTES: 1) Transportation support is allowed only for people who cannot drive due to their disability and includes both private and public transportation methods. 2) If a STEPS participant drives for any reason the expectation is that the member provides their own transportation. 3) When transportation for medical appointments is needed, consumers must use NEMT (non-emergency medical transportation) services.
Do you have a driver’s license?	☐ Yes	☐ No
Do you have a vehicle?	☐ Yes	☐ No
Do you have limitations for driving?	☐ Yes	☐ No
If Yes, Please Describe
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Scheduling transportation needs	20 min/week	15 min/week	10 min/week	5 min/week
Transportation to/from store/bank/laundry mat	Up to 1 hour per week based on distance/drive time	NA
Transportation to/from work (Must include work address and how many days per week member works)	Up to 1 hour per workday based on distance/drive time	NA
In the last 3 days how did you get this done and for what purpose?
Please Describe
What transportation options are you considering? All options must be considered for the most cost-effective option.
Please Describe (Public transport, agency provided, attendant care, reason for need, etc.):
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend Independent living skills training?	☐ Yes	☐ No
Describe skills needed (ex: learning how to ride the bus, how to schedule rides, etc.

Complete one calculation depending on the transportation option chosen (if known):

Agency, Bus Pass Cost, or Reimbursement to Participant
Service providers name	If known
Monthly Cost	$0.00

OR

PA Provided Transportation
Weekly Hours
Monthly Hours	Weekly Hours x 4.33	Total: 0 (Rounded)	0.00
Monthly Cost	Monthly Hours x $15	Total: $ 0.00

Supported Employment

* Once completed and if service provision is indicated the service provider will develop a more thorough plan that uses a person-centered approach to provide Supported Employment services.

The Job Coach or Employment Specialist should provide a summary regarding supports and services required to obtain and/or maintain the participant’s employment.

Supported Employment
Orienting and training participants to new or evolving job responsibilities Reminders to practice work-appropriate behaviors Reminders to interact appropriately with other employees and the public Reminders to practice safety measures Support to increase accuracy and/or speed Support to deal with mental health symptoms Overseeing and directing Job Coaches Consulting with, and providing technical assistance for, participants and/or their employers Negotiating customized jobs for participants	Determining participants interests and skills Locating employment possibilities for participants Analyzing job tasks to determine suitability for participants Addressing employer’s concerns regarding hiring individuals with disabilities Facilitating the hiring of participants by employers Identifying workplace supports that help participants maintain employment and facilitating additional support as indicated Communicating and coordinating with participants’ Community Service Coordinators.
Support can be provided for up 13.25 hours per month for the first 15 months on the program

Please provide a detailed report of the participants on-going support needs for Supported Employment.	Please describe.
Number of hours per month:	0.00	*Within 13.25 hours
* Completed using information from the Job Coach or Employment Specialist ONLY

Personal Assistance Services Assessment

Activities of Daily Living

Bathing and Personal Hygiene
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Bathing: Tub/shower or Sponge bath (includes transfer & washing hair; 2 hrs/day Maximum)	45-60 minutes	30-45 minutes	10-30 minutes	5-10 minutes
Oral Care: Brush Teeth/Denture Care	10 minutes	8 minutes	5 minutes	5 minutes
Hair Care: Style, Set, Comb/Brush (no haircuts, color, etc.)	15-20 minutes	10-15 minutes	5-10 minutes	5 minutes
Skin Care: Dry Off, Inspect Skin, Apply Lotion, Deodorant	15-20 minutes	10 minutes	5 minutes	5 minutes
Shaving (No haircuts)	15 minutes	10 minutes	5 minutes	5 minutes
Inspect/Clean/Trim Nails (once per week, no mani/pedi)	15 minutes	10 minutes	5 minutes	5 minutes
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Mobility
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Transfers for bathing, toileting, bed, etc.	10 minutes	8 minutes	5 minutes	NA
Locomotion indoors (e.g., Hoyer lift, push manual wheelchair, etc.)	10 minutes	8 minutes	5 minutes	NA
Locomotion to & from vehicle (includes transfer)	10 min/trip	8 min/trip	5 min/trip	NA
Assistance with doctor ordered ROM, per day	15 mins max/ day	10 minutes	5 minutes	5 minutes
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Dressing
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Dressing (60 min. max/day)	30 minutes	15 minutes	10 minutes	5 minutes
Setting out clothes ( 5 min. max per day)	NA	5 minutes	5 minutes	5 minutes
If total assistance to dress is needed, then this does not apply.
Clothing Appropriateness (including matching)	5 minutes	5 minutes	5 minutes	5 minutes
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Prosthetic / Orthotic / Medical Device(s)
Examples of such devices include: limbs, shoes, lifts, braces, wheelchairs, walkers, canes, helmets, splints, CPAP, hearing aids, glucose meter, communication/tech devices, and other devices that assist an individual to perform ADLs.
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Putting on and removing devices	15 minutes	10 minutes	5 minutes	5 minutes
Maintenance and cleaning of devices (Time may vary depending on type of device)	15 minutes	10 minutes	5 minutes	5 minutes
Name/Type of Medical Device: Please describe.
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Are any hours of support needed?	☐Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Toileting
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Bed pan/Commode/Toilet (includes transfer)	15-30 minutes	10-15 minutes	5-10 minutes	5 minutes
Bowel program (includes digital/ suppository, time to take effect, clean up)	30-60 minutes	15-30 minutes	15 minutes	NA
Clean self after toileting (includes clothing change)	15 minutes	10 minutes	5 minutes	5 minutes
Empty ostomy/urine bag	15 minutes	10 minutes	5 minutes	5 minutes
Changing of incontinence products	15 minutes	10 minutes	5 minutes	5 minutes
Menstrual hygiene & related needs	10 minutes	10 minutes	5 minutes	5 minutes
Establish/maintain toileting schedule	5 minutes	5 minutes	5 minutes	5 minutes
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Eating
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Remind/Coax to begin and/or cease eating or drinking	NA	NA	NA	5 minutes
Cutting or blending food	10 minutes	8 minutes	5 minutes	NA
Direct feeding by mouth	15 minutes	10 minutes	5 minutes	NA
Nourishment by other means (e.g. tube feeding, parenteral nutrition)	30-60 minutes	15-30 minutes	10-15 mins	NA
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Instrumental Activities of Daily Living

Medication Management
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Ordering medication(s) (10 min/week max)	5-10 minutes	5 minutes	5 minutes	5 minutes
Taking medications	15 minutes	10 minutes	5 minutes	5 minutes
Setting up medications	15 minutes	10 minutes	5 minutes	5 minutes
Check compliance (only if there is no time given for taking meds)	5 minutes	5 minutes	5 minutes	5 minutes
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Will/is automated medication management equipment be(ing) used? *If yes, see supplemental services section.	☐ Yes	☐ No
Informal support policy considered?	☐ Yes	☐ No
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Meal Preparation
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Development of healthy menu (includes special diet, specify below)	20 min/wk	15 min/wk	10 min/wk	5 min/wk
Safe preparation of foods
Meals	30 min/meal	15 min/meal	10 min/meal	5 min/meal
Snacks	10 min/snack	8 min/snack	5 min/snack	5 min/snack
Future meals (prepare & freeze)	30 min/wk	20 min/wk	10-15 min/wk	5-10 min/wk
Clean up after meals	15 min/meal	10 min/meal	8 min/meal	5 min/meal
Clean up after snacks	5 min/snack	5 min/snack	5 min/snack	5 min/snack
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Informal support policy considered?	☐ Yes	☐ No
Home delivered meals considered?	☐ Yes	☐ No
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Shopping
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Medication Pick-up	15-30 min/wk	10-15 min/wk	5-10 min/wk	5 min/wk
Making shopping list	15 min/wk	10 min/wk	5 min/wk	5 min/wk
Shopping for personal items	30 min/wk	20 min/wk	15 min/wk	5 min/wk
Shopping for groceries	1-2 hours/wk	1 hour/wk	30 min/wk	5 min/wk
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Informal support policy considered?	☐ Yes	☐ No
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Housekeeping
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
HOUSEKEEPING MAX OF 2 TOTAL HOURS PER WEEK TOTAL
Clean bathroom and/or kitchen	20-30 minutes	10-20 minutes	5-10 minutes	5 minutes
Clean floors, carpets, rugs, dusting	30-45 minutes	20-35 minutes	10-25 minutes	5 minutes
Make bed and/or change linens	15 minutes	10 minutes	5 minutes	5 minutes
Remove trash	10 minutes	8 minutes	5 minutes	5 minutes
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Informal support policy considered?	☐ Yes	☐ No
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Laundry
Note: Reviews of time for laundry tasks above what is specified here can be requested on a case by case basis with thorough justification. For example, if incontinence issues exist more time can be granted for laundry
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
IN-RESIDENCE LAUNDRY MAX OF 2 HOURS TOTAL PER WEEK
OUTSIDE OF RESIDENCE LAUNDRY MAX of 3 HOURS TOTAL PER WEEK
Sorting	10 minutes	8 minutes	5 minutes	5 minutes
Folding and putting away	15 minutes	10 minutes	5 minutes	5 minutes
Washing/dryer outside of residence, per load	15-30 minutes	15-20 minutes	10-15 minutes	5 minutes
Washer/dryer in residence, per load	10-15 minutes	5-10 minutes	5-10 minutes	5 minutes
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Informal support policy considered?	☐ Yes	☐ No
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Money Management
Time per Task Guide:	Total Assist	Medium Assist	Light Assist	Cue/Prompt
Opening mail	8 min/day	7 min/day	5 min/day	5 min/day
Developing, reviewing and maintaining a budget	20 min/week	15 min/week	10 min/week	5 min/week
Paying bills	30 min/week	20 min/week	15 min/week	5 min/week
Assistance with bank accounts	30 min/week	20 min/week	15 min/week	5 min/week
Can you perform this task without any support?	☐ Yes	☐ No
In the last 3 days how did you get this done?
Please Describe
How much or what aspects of this task are you able to do safely on your own?
Please Describe
Informal support policy considered?	☐ Yes	☐ No
Are any hours of support needed?	☐ Yes	☐ No
If support is needed, list each task and describe the amount and frequency of support needed. Include an estimate of the weekly hours of support needed. (Thorough justification of time greater than examples above is required.)
Please Describe
Recommend independent living skills training?	☐ Yes	☐ No

Total weekly hours needed (Round to nearest 15-minutes)	hours	Total:
Total Monthly hours needed	(weekly hours X 4.33 = monthly hours)	Hours Total: 0 (Rounded)	0.0

Time conversion chart
15 min = .25 hr.	30 min = .5 hr.	45 min = .75 hr.	60 min = 1.0 hr.

Supplemental Services
Do not complete any of the Supplemental Services sections unless the consumer qualifies for PAS and only if there is a justified need for the service.
Enhanced Services
Assistance for participants who require hands-on care during the night, including re-positioning, tracheotomy care, and care for chronic incontinence; need must be documented by a physician.
Limitations: ES cannot be provided by a participant’s spouse, parent, or any individual residing in the home with the participant; however, exceptions may be authorized under the following conditions: The participant lives in a rural area in which access to a provider is beyond a 50-mile radius from the participant’s home and the family member is the only provider available to meet the participant’s needs. The participant lives alone and has severe cognitive impairment, physical disability, or intellectual disability.
Do you have a medical condition documented by a physician that requires hands-on support during the night? *The STEPS Program Manager requires a copy of this documentation	☐ Yes	☐ No
In the last 3 days how did this get done?
Please Describe
What tasks need to be performed to ensure health and safety?
Please Describe
How many nights per week are services needed? (Up to 7)	# per week

Total nights per week
Total nights per month	Nights per week x 4.33 = Total nights per month	Total: 0 (Rounded)	0.0
Monthly Cost	Number of nights per month x $85 = Total monthly cost	Total: $ 0.00

Home delivered meals
Maximum of 62 meals per month
Were there hours approved under “meal prep”? *If yes, Home Delivered Meals cannot be authorized	☐ Yes	☐ No
Informal supports policy applicable? *If policy is applicable, Home Delivered Meals cannot be authorized	☐ Yes	☐ No
If support is needed, please describe how this is more cost effective.
Please Describe
Number of meals per day (up to 2)
Number of days per week meals needed
Total weekly meals needed	0	Total Monthly Meals (up to 62):	0	0.00
Monthly meals x $6.04 = Monthly cost	Total cost: $ 0.00

PERS
Personal Emergency Response Systems (PERS) allowing participants to seek help when alone.
Were there hours approved under “Enhanced services”? *If yes, PERS cannot be authorized	☐ Yes	☐ No
If support is needed, please describe how this is more cost effective.
Please Describe
Services providers name	If known
PERS installation fee	If known: $0.00
PERS monthly fee	If known: $0.00

Medication Management Equipment
Do you already have a medication management system in place? *Standard med box doesn’t count	☐ Yes	☐ No
Were there hours approved under Medication Management? *If yes, Medication Management Equipment cannot be authorized	☐ Yes	☐ No
If support is needed, please describe how this is more cost effective.
Please Describe
Services providers name	If known
Medication monitoring installation fee	If known: $0.00
Medication monitoring monthly fee	If known: $0.00

Personal Assistance Services Summary

Activity of Daily Living	Independent Skills Training Recommended?	Monthly Hours	Monthly Service Cost
Bathing and Personal Hygiene	☐	0
Mobility	☐	0
Dressing	☐	0
Prosthetic/Orthotic/Medical Devices	☐	0
Toileting	☐	0
Eating	☐	0
ADL Total:	0	$ 0.00
Instrumental Activities of Daily Living	Independent Skills Training Recommended?	Monthly Hours	Monthly Service Cost
Medication Management	☐	0
Meal Preparation	☐	0
Shopping	☐	0
Housekeeping	☐	0
Laundry	☐	0
Money Management	☐	0
IADL Total:	0	$ 0.00
ADLs/IADLs Combined Total:	0	$ 0.00
Supplemental Services	Total Monthly	Monthly Service Cost
Enhanced Services	0	$ 0.00
Home Delivered Meals	0	$ 0.00
PERS	$ 0.00
Medication Management System	$ 0.00
Supplemental Service Total:	$ 0.00
Grand Total Monthly Cost:	$ 0.00

Installation and Equipment one time cost

Service	Description	One time cost
PERS	Describe service	$ 0.00
Medication Management	Describe service	$ 0.00

STEPS Services Summary Page

♦Use this page to provide a narrative summary of each section of the assessment. The CSC will use this page to complete the Individualized Service Plan. Please ensure that any units are whole units (no partial units accepted) and that all hours have been rounded to the nearest 15-minute increment.♦

Service Assessment	Request or Qualify?	Summary of assessment
Pre-Vocational Assessment	☐ Yes	☐ No	Provide summary.
Independent Living Skills Assessment	☐ Yes	☐ No	Provide summary.
Were any ADLs or IADLs recommended for IL Skills Training? ☐	Provide summary.
Hours or Units
Supported Employment	0.00	Provide summary.
Transportation Assessment *Enter manually from Transportation section	Cost or hours	Provide summary.
PAS Assessment	0	Provide summary.
Only with PAS	Enhanced Services	0	Provide summary.
Home meals	0	Provide summary.
PERS	1 unit, if applicable	Provide summary.
Med Minder	1 unit, if applicable	Provide summary.
Assistive Service	In your opinion, would this consumer benefit from Assistive Services

STEPS Services Assessment Signature Page

Date of STEPS Services Assessment:	Enter a date

I participated in the development of this STEPS Services Assessment and agree that it reasonably reflects my need for support.

I am responsible for complying with STEPS program policies and procedures as laid out in the STEPS Program Policy Manual, including those that apply to the STEPS Services Assessment. NOTE: Participants unwilling to follow the program policies and procedures will not be able to remain in the program.

I understand that I am responsible for accurately reporting my need for assistance during the STEPS assessment. NOTE: Falsifying the need for services will result in removal from the program and may be reported to the Office of the Attorney General Medicaid Fraud Control Unit (MFCU).

I understand that the time currently reflected in my STEPS Services Assessment is subject to review by the State and my Managed Care Organization (MCO), and that this review may result in a change.

Assessor’s signature	Date
Participant’s signature	Date