Form LIC 9172. Functional Capability Assessment
The LIC 9172 form is a Functional Capability Assessment required by Adult Residential and Social Rehabilitation Facilities, Adult Day Care Facilities, and Adult Day Support Centers. The goal of the form is to obtain information on an applicant's functional ability prior to placement in order to create a Needs and Services Plan for that individual.
The form consists of several sections that assess the applicant's physical, cognitive, and emotional abilities, such as their ability to dress themselves, use the restroom, prepare meals, and manage medications. It also includes fields for identifying any assistive devices or accommodations the applicant may require.
The important parties involved in filling out this form are the licensee and the applicant or their authorized representative. When filling out the form, it is important to gather accurate and detailed information about the applicant's abilities and limitations in order to create an effective plan for their care.
In addition to the form itself, supporting documentation such as medical records or assessments from healthcare providers may be attached to provide further context and detail about the applicant's capabilities.
Examples of situations where the LIC 9172 form may be used include placing an elderly individual in a residential care facility or assessing the functional capabilities of an individual with a disability in an adult day support program.
Strengths of the LIC 9172 form include its comprehensive assessment of an individual's abilities and the creation of a tailored care plan based on that assessment. However, weakness may include potential for subjective interpretation of the data gathered.
Alternative forms or analogues to the LIC 9172 form may include other functional assessments, such as the Katz Index of Independence in Activities of Daily Living or the Lawton Instrumental Activities of Daily Living Scale. These forms differ in the specific areas assessed and the level of detail provided.
Once completed, the form is typically submitted to the licensee who then stores it in the client’s file along with the Needs and Services Plan. This information is used to inform the care provided to the individual in the facility or program.