Dhs 4691 Eng Form PDF Details

Within the realm of personal care assistance, documentation serves as a cornerstone, ensuring that services provided are thoroughly tracked and accurately billed. The DHS-4691-ENG form is a critical tool in this process, designed to document the time and activities spent by a Personal Care Assistant (PCA) with a recipient. This form records dates of service, types of activities performed, and time spent on each activity, including dressing, grooming, bathing, and more, in a structured manner. It demands meticulous input of dates in consecutive order, with a requirement for activities to be initialed only once per day regardless of the frequency, underscoring the importance of precision in reporting. Furthermore, it accommodates documentation of up to two visits per day, specifying the staff-to-recipient ratio for each visit—an essential metric for shared services. Additionally, it includes sections for recording hospital stays, care facility stays, or periods of incarceration, providing a comprehensive view of the recipient's care continuity. The form culminates with a mandatory acknowledgment and signature section for both the recipient (or responsible party) and the PCA, emphasizing the legal obligation to report accurately and truthfully. This mandatory verification process underpins the form's role in mitigating fraud within the personal care assistance system. Beyond its primary function, the DHS-4691-ENG form also serves as a testament to the commitment to uphold the integrity of personal care services, ensuring recipients receive the care prescribed in their PCA Care Plan.

QuestionAnswer
Form NameDhs 4691 Eng Form
Form Length3 pages
Fillable?No
Fillable fields0
Avg. time to fill out45 sec
Other namesdhs 4691 eng, time activity documentation, pca activity documentation, mn pca time activity

Form Preview Example

*DHS-4691-ENG*

DHS-4691-ENG

8-16

PCA Time and Activity Documentation

PCA AGENCY NAME

DATES/LOCATION OF RECIPIENT STAY IN HOSPITAL/CARE FACILITY/INCARCERATION

PHONE NUMBER

Dates of Service

(in consecutive order)

Activities

MM/DD/YY

MM/DD/YY

MM/DD/YY

MM/DD/YY

MM/DD/YY

MM/DD/YY

MM/DD/YY

Dressing

Grooming

Bathing

Eating

Transfers

Mobility

Positioning

Toileting

Health Related

Behavior

IADLs

Visit One

Ratio staff to recipient

1:1

1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shared services location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time in

 

AM

 

AM

 

AM

 

AM

 

AM

 

AM

 

AM

(circle AM/PM)

 

PM

 

PM

 

PM

 

PM

 

PM

 

PM

 

PM

Time out

 

AM

 

AM

 

AM

 

AM

 

AM

 

AM

 

AM

(circle AM/PM)

 

PM

 

PM

 

PM

 

PM

 

PM

 

PM

 

PM

Visit Two

Ratio staff to recipient

1:1 1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

1:1

1:2 1:3

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Shared services location

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Time in

AM

 

AM

 

AM

 

AM

 

AM

 

AM

 

AM

(circle AM/PM)

PM

 

PM

 

PM

 

PM

 

PM

 

PM

 

PM

Time out

AM

 

AM

 

AM

 

AM

 

AM

 

AM

 

AM

(circle AM/PM)

PM

 

PM

 

PM

 

PM

 

PM

 

PM

 

PM

Daily Total

(minutes)

Total Minutes This Time Sheet

MINUTES

 

MINUTES

MINUTES

MINUTES

MINUTES

 

MINUTES

 

MINUTES

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total 1:1

 

 

Total 1:2

 

 

 

Total 1:3

 

 

 

 

 

 

 

 

 

 

MINUTES

 

 

 

MINUTES

 

 

MINUTES

 

 

 

 

 

 

 

 

 

 

 

 

 

Acknowledgement and Required Signatures

After the PCA has documented his/her time and activity, the recipient must draw a line through any dates/times he/she did not receive services from the PCA. Review the completed time sheet for accuracy before signing. It is a crime to provide false information on PCA billings for Medical Assistance payment. By signing below you swear and verify the time and services entered above are accurate and that the services were performed by the PCA listed below as specified in the PCA Care Plan.

RECIPIENT NAME (FIRST, MI, LAST)

MA MEMBER # or DATE OF BIRTH RECIPIENT/RESPONSIBLE PARTY SIGNATURE DATE

I certify and swear under penalty of law that I have accurately reported on this time sheet the hours I actually worked, the services I provided, and the dates and times worked. I understand that misreporting my hours is fraud for which I could face criminal prosecution and civil proceedings.

PCA NAME (FIRST, MI, LAST)

PCA NPI/UMPI

PCA SIGNATURE

DATE

Review PCA Provider Time and Activity Documentation for additional policy information about timesheet requirements.

Page 1 of 3

Instructions for PCA Time and Activity Documentation

This form documents time and activity between one PCA and one recipient. Document up to two visits per day on this form. Employers may have additional instructions or documentation requirements. For shared care, you must use a separate form for each person for whom you are providing care.

Name of PCA Provider Agency

Mobility

Enter name of the PCA provider agency and its phone number.

Recipient Stays

Enter dates and location of recipient stays in a hospital, care facility or incarceration.

Dates of Service

Dates of service must be in consecutive order. Enter the date in mm/dd/yy format for each date you provide service. The recipient must draw a line through any dates and times PCA services were not provided.

Activities

For each date you provided care, write your initials next to all the activities you provided. Your initials indicate you provided the service as described in the PCA Care Plan. If you provide a service more than once in a day, initial only once. The following are general descriptions of activities of daily living and instrumental activities of daily living.

Dressing

Choosing appropriate clothing for the day, includes laying- out of clothing, actual applying and changing clothing, special appliances or wraps, transfers, mobility and positioning to complete this task.

Grooming

Personal hygiene, includes basic hair care, oral care, nail care (except recipients who are diabetic or have poor circulation), shaving hair, applying cosmetics and deodorant, care of eyeglasses, contact lenses, hearing aids.

Bathing

Starting and finishing a bath or shower, transfers, mobility, positioning, using soap, rinsing, drying, inspecting skin and applying lotion.

Eating

Getting food into the body, transfers, mobility, positioning, hand washing, applying of orthotics needed for eating, feeding, preparing meals and grocery shopping.

Transfers

Moving from one seating/reclining area or position to another.

Moving including assistance with ambulation, including use of a wheelchair. Mobility does not include providing transportation for a recipient.

Positioning

Including assistance with positioning or turning a recipient for necessary care and comfort.

Toileting

Bowel/bladder elimination and care, transfers, mobility, positioning, feminine hygiene, use of toileting equipment or supplies, cleansing the perineal area and inspecting skin and adjusting clothing.

Health-related Procedures and Tasks

Health related procedures and tasks according to PCA policy. Examples include: range of motion and passive exercise, assistance with self-administered medication including bringing medication to the recipient, and assistance with opening medication under the direction of the recipient or responsible party, interventions, monitoring and observations for seizure disorders, and other activities listed on the care plan and considered within the scope of the PCA service meeting the definition of health-related procedures and tasks.

Behavior

Redirecting, intervening, observing, monitoring and documenting behavior.

IADLs (Instrumental Activities of Daily Living)

Covered service for recipients over age 18 years only, such as: meal planning and preparation, basic assistance with paying the bills, shopping for food, clothing, and other essential items, performing household tasks integral to the personal care assistance services; assisting with recipient’s communication by telephone, and other media, and accompanying the recipient with traveling to medical appointments and participation in the community.

Visit One

Documentation of the first visit of the day.

Ratio of PCA to Recipient

1:1 = One PCA to one recipient

1:2 = One PCA to two recipients (shared services) 1:3 = One PCA to three recipients (shared services)

Circle the appropriate ratio of PCA to recipients for this visit.

Page 2 of 3

DHS-4691-ENG 8-16

Visit Two

Documentation of the second visit of the day.

Ratio of PCA to Recipient

1:1 = One PCA to one recipient

1:2 = One PCA to two recipients (shared services) 1:3 = One PCA to three recipients (shared services)

Circle the appropriate ratio of PCA to recipients for this visit.

Shared Services Location

(Required for shared services only) Write a brief description of the location where you provided the shared services, examples include school, work, store and home.

Time in

Enter time in hours and minutes that you started providing care and circle AM or PM.

Time out

Enter time in the hours and minutes that you stopped providing care and circle AM or PM.

Daily Total

Add the total time in minutes that you spent with this recipient for the care documented in one column.

Total Minutes This Time Sheet

Add the time in minutes for all visits on this entire time sheet and enter the total in the appropriate ratio box.

Acknowledgement and Required Signatures

Recipient/responsible party prints the recipient’s first name, middle initial, last name, and MA Member (MHCPID) Number or birth date (for identifying purposes). Recipient/ responsible party signs and dates form. PCA prints his/ her first name, middle initial, last name, individual

PCA Unique Minnesota Provider Identifier (UMPI) (for identifying purposes). PCA signs and dates form.

PCA AGENCY PHONE NUMBER

Attention. If you need free help interpreting this document, call the above number.

.هلاعأ مقرلا ىلع لصتا ،ةقيثولا هذه ةمجرتل ةيناجم ةدعاسم تدرأ اذإ :ةظحلام

kMNt’sMKal’ . ebIG~k¨tUvkarCMnYyk~¬gkarbkE¨bäksarenHeday²tKit«f sUmehATUrs&BÍtamelxxagelI .

Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, nazovite gore naveden broj.

Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb, ces hu rau tus najnpawb xov tooj saum toj no.

ໂປຣດຊາບ. ຖາຫາກ້ ທານຕ່ ອງການການຊ້ ວຍເຫ່ ຼືອໃນການແປເອກະສານນຟຣ້ີ ,ີຈງໂທຣໄປທ່ົ່ີໝາຍເລກຂາງເທ້ ີງນ.້ີ

Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili.

Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по указанному выше телефону.

Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.

Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado arriba.

Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.

LB3-0001 (3-13)

ADA3 (9-15)

For accessible formats of this publication, ask your PCA. For assistance with additional equal access to human services, contact your PCA agency’s ADA coordinator.

Page 3 of 3

DHS-4691-ENG 8-16

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Writing part 1 in dhs 4691 eng

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It's very easy to get it wrong while filling out your MA MEMBER or DATE OF BIRTH, thus ensure that you take a second look prior to when you submit it.

3. Through this stage, look at PCA AGENCY PHONE NUMBER, Attention If you need free help, gkarbkEbäksarenHedaytKitfÂ, kMNtsMKal ebIGktUvkarCMnYyk, Atención Si desea recibir, and L B. Every one of these are required to be filled in with utmost accuracy.

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