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PERSONAL CARE SERVICES PROVIDER LOG

Michigan Department of Human Services

1. Client Name															Client ID Number										Client Case Number								Log #

4. Provider Name															Provider ID Number												Printed Date

The approved tasks are prefilled with an”X.”															County					District					Section				Unit					Specialist
The approved tasks are prefilled with an”X.”
Mark an X to show on which days of the month you assisted this client with
															Specialist’s Initials												Date Received at DHS Office
any of the approved personal care tasks.

Month		Year															Days of the month
Month		Year	1	2	3	4	5	6	7	8	9	10	11	12		13	14	15	16		17	18	19	20		21	22	23	24	25	26	27		28	29	30	31
			1	2	3	4	5	6	7	8	9	10	11	12		13	14	15	16		17	18	19	20		21	22	23	24	25	26	27		28	29	30	31

	01.	Eating/Feeding
	02.	Toileting
	03.	Bathing
	04.	Grooming
	05.	Dressing
	06.	Transferring
	07.	Mobility
	08.	Medication
	09.	Meal Preparation
	10.	Shopping
	11.	Laundry
	12.	Light Housework
	13.	Complex Eat/Feed
	14.	Catheter/Leg Bags
	15.	Colostomy Care
	16.	Bowel Program
	17.	Suctioning
	18.	Special Skin Care
	19.	Range of Motion
	20.	Dialysis
	21. Wound Care
DHS-721 (Rev. 12/11) Previous edition obsolete. MS Word														Page 1 of 2																	12/05/2011 1:04 PM

1. Client Name															Client ID Number										Client Case Number								Log #

4. Provider Name															Provider ID Number												Printed Date

The approved tasks are prefilled with an”X.”															County					District					Section				Unit					Specialist
The approved tasks are prefilled with an”X.”

Mark an X to show on which days of the month you assisted this client with															Specialist’s Initials												Date Received at DHS Office
any of the approved personal care tasks.

Month		Year															Days of the month
Month		Year	1	2	3	4	5	6	7	8	9	10	11	12		13	14	15	16		17	18	19	20		21	22	23	24	25	26	27		28	29	30	31
			1	2	3	4	5	6	7	8	9	10	11	12		13	14	15	16		17	18	19	20		21	22	23	24	25	26	27		28	29	30	31

	01.	Eating/Feeding
	02.	Toileting
	03.	Bathing
	04.	Grooming
	05.	Dressing
	06.	Transferring
	07.	Mobility
	08.	Medication
	09.	Meal Preparation
	10.	Shopping
	11.	Laundry
	12.	Light Housework
	13.	Complex Eat/Feed
	14.	Catheter/Leg Bags
	15.	Colostomy Care
	16.	Bowel Program
	17.	Suctioning
	18.	Special Skin Care
	19.	Range of Motion
	20.	Dialysis
	21. Wound Care
Month		Year															Days of the month
Month		Year	1	2	3	4	5	6	7	8	9	10	11	12		13	14	15	16		17	18	19	20		21	22	23	24	25	26	27		28	29	30	31
			1	2	3	4	5	6	7	8	9	10	11	12		13	14	15	16		17	18	19	20		21	22	23	24	25	26	27		28	29	30	31

	01.	Eating/Feeding
	02.	Toileting
	03.	Bathing
	04.	Grooming
	05.	Dressing
	06.	Transferring
	07.	Mobility
	08.	Medication
	09.	Meal Preparation
	10.	Shopping
	11.	Laundry
	12.	Light Housework
	13.	Complex Eat/Feed
	14.	Catheter/Leg Bags
	15.	Colostomy Care
	16.	Bowel Program
	17.	Suctioning
	18.	Special Skin Care
	19.	Range of Motion
	20.	Dialysis
	21. Wound Care
Client/employer: Are you satisfied with the services provided to you?																YES						NO Why not?:
Provider/employee: I certify that I have provided all the services named above on the days indicated.
NOTE: Return signed copy of form to the adult services specialist within ten business days after the last service date on this log. Failure to return form
timely will result in delay or termination of payment.
Client’s Signature										Date					Provider’s Signature																	Date

Department of Human Services (DHS) will not discriminate against any individual or group because of race, religion, age, national origin, color, height, weight, marital status, sex, sexual orientation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., under the Americans with Disabilities Act, you are invited to make your needs known to a DHS office in your area.

DHS-721 (Rev. 12/11) Previous edition obsolete. MS Word

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12/05/2011 1:04 PM

INSTRUCTIONS FOR COMPLETION OF THE DHS-721, PERSONAL CARE SERVICES PROVIDER LOG

The provider log is prefilled with an “X” to indicate the services approved by the specialist. The provider completes this form to document the provision of personal care services for each day in the time period(s) indicated.

ADULT SERVICES SPECIALIST

1.Prints the provider log from ASCAP which indicates the approved tasks.

2.Gives or mails the form to the client (or client’s representative) referencing the instructions below.

3.When the completed form is returned, initials/dates it in the boxes provided at the top of the form and file in the case record.

NOTE: The DHS-721 is used in lieu of the paper invoices (DHS-2353) for AFC/HA providers and can remain in the resident’s file at the facility. The specialist must initial/date the form at the time of the client’s review.

PROVIDER

1.Check (X) each day on which an approved task was provided for each month in the service time period(s).

2.Sign/date the form at the end of service time period to certify provision of the approved tasks.

3.Have the client/employer review the form and sign/date it to verify the services were delivered as agreed.

4.Return the signed/dated form to the adult services specialist at the end of the service time period.

NOTE: Failure to return the form within 10 business days after the last service date on the log will result in delay or termination of payments to the client/employer for these services.

CLIENT/EMPLOYER

1.Review the completed form to be sure all the approved tasks were done as certified by the provider.

2.Indicate if you are satisfied with the services.

3.Sign/date the form and direct the provider to return it to the adult services specialist.

NOTE: Failure to return the form within 10 business days after the last service date on the log will result in delay or termination of payments to the client/employer for these services.

APPROVED PERSONAL CARE TASKS

1.Eating/Feeding – helping with use of utensils, cup/glass, getting food/drink to mouth, cutting up/manipulating food on plate, cleaning face and hands, as needed after a meal.

2.Toileting – helping on/off toilet, commode/bed pan, emptying commode/bed pan, managing clothing, wiping and cleaning body after toileting, cleaning ostomy and/or catheter tubes/receptacles, applying diapers and disposable pads; may include doing catheter, ostomy or bowel programs.

3.Bathing – helping with cleaning the body or parts of the body, shampooing hair, using tub or shower, sponge bathing, including getting a basin of water, managing faucets, soaping, rinsing and drying.

4.Grooming – helping to maintain personal hygiene and neat appearance, including hair combing, brushing, oral hygiene, shaving, fingernail and toe nail care (unless a physician advises no to do so).

5.Dressing – helping with putting on/taking off, fastening/unfastening garments/undergarments, special devices such as back/leg braces, corsets, artificial limbs or splints.

6.Transferring – helping to move from one position to another, such as from bed to or from a wheelchair or sofa, to come to a standing position and/or repositioning to prevent skin breakdown.

7.Mobility – helping with walking or moving around inside the living area, changing locations in a room, moving from room to room or climbing stairs.

8.Medication – helping with administering prescribed or over-the-counter medication.

9.Meal Preparation – helping with planning menus, washing, peeling, slicing, opening packages, cans and bags, mixing ingredients, lifting pots/pans, reheating food, cooking, operating stove/microwave, setting the table, serving the meal, washing/drying dishes and putting them away.

10.Shopping – helping to compile a list identifying needed items, picking up items at the store, managing cart/baskets, transferring items to home and storing them away.

11.Laundry – helping by getting laundry to machines, sorting, handling soap containers, placing laundry into machines, operating machine controls, handling wet laundry, drying, folding and storing laundry.

12.Light Housework – helping with sweeping, vacuuming, washing floors, washing kitchen counters and sinks, cleaning the bathroom, changing bed linen, taking out garbage/trash, dusting and picking up, bringing in fuel for heating/cooking

purposes if necessary.

13-21. Complex Care tasks – require special techniques/knowledge; replace most/all 1-9 tasks when approved by specialist.

DHS-721 (Rev. 12/11) Previous edition obsolete. MS Word

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12/05/2011 1:04 PM

Question	Answer
Form Name	Dhs 721 Form
Form Length	3 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	45 sec
Other names	services provider log online, personal care services provider log, mi dhs 721 log pdf, michigan services log

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