Doh 4397 Form PDF Details

The New York State Department of Health's Division of Assisted Living has developed a comprehensive form known as DOH-4397, designed for the evaluation of residents in assisted living facilities. This form covers various aspects of a resident's health and daily living capabilities, aiming to provide a thorough assessment to ensure that individuals receive the appropriate level of care and support they need. It begins with assessing the resident's ability to communicate effectively in English, whether they can speak, read, write, and understand instructions, considering any speech impairments, dental, vision, and hearing issues they may have. Further, it delves into the resident's customary routine, including their sleeping, bathing, and eating habits, as well as their social activities and continence management. The form is detailed in its approach to evaluating physical functions, requiring information on the level of assistance needed for various tasks such as eating, ambulation, transferring, toileting, bathing, and dressing. Prosthetic needs, any podiatric concerns, and the resident’s ability to engage in housekeeping, shopping, and the use of a telephone are also examined. Additionally, the form screens for cognitive impairment, inquiring about the individual’s orientation, comprehension, concentration, memory, and any notable behaviors that could indicate cognitive decline. This evaluation instrument is critical for the tailored care planning and successful integration of residents into the assisted living community, ensuring their health, safety, and well-being are adequately addressed.

QuestionAnswer
Form NameDoh 4397 Form
Form Length6 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 30 sec
Other names4397 b form, doh 4397, residence resident 1, nys doh 4397 form

Form Preview Example

New York State Department of Health Division of Assisted Living

ASSISTED LIVING RESIDENCE RESIDENT EVALUATION

 

Resident’s Name: _________________________________________________________________________________

 

Facility Name: ________________________________________

Date of Evaluation: __________________________

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 1: COMMUNICATION/DENTAL/VISION/HEARING

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Can the individual Speak English? Yes No

Read English? Yes No

Write in English? Yes No

 

 

 

Can the individual understand instructions in English?

Yes

No

 

 

 

 

 

 

 

If no to any of the above, indicate dominant language: Speak:______________ Read:______________

Write:______________

 

 

 

Verbal Expression/Speech (check all that apply):

 

 

 

 

 

 

 

 

 

 

 

Easily Understood

 

Yes

No

Difficulty finding words or expressing self

Yes

No

 

 

 

Slurred or mumbled speech

Yes

No

Understands directions

 

 

Yes

No

 

 

 

SPEECH: Does the resident have a speech defect / impairment? Yes

No

 

 

 

 

 

 

If yes, describe:___________________________________________________________________________________________

 

 

 

DENTAL Prosthetics: _____________________________________________________________________________________

 

 

 

VISION: Glasses:

Yes No Glaucoma: L R

 

Legally Blind: L R Contact Lenses: Yes No

 

 

 

Comments:______________________________________________________________________________________________

 

 

 

HEARING: Does the patient have a hearing deficit?

Yes

No

Hearing Aid: L R

 

 

 

 

 

Comment(s): _____________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

SECTION 2: CUSTOMARY ROUTINE

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Sleeping routine:

Preferred wake up time: __________

Napping routine:

___________________

 

 

 

 

Preferred bedtime: ______________

Nighttime sleep pattern: ___________________

 

 

Comments: ______________________________________________________________________________________________

 

 

_________________________________________________________________________________________________________

 

 

 

Bathing routine:

Prefers

Bath

Shower

 

Frequency: ____________________________________________

 

 

Comments: ______________________________________________________________________________________________

 

 

_________________________________________________________________________________________________________

 

 

 

Eating routine: Food preferences (religious, cultural, other): _________________

_________________ ________________

 

 

 

Food dislikes: ___________________

___________________

___________________

 

 

 

Comments: ______________________________________________________________________________________________

 

 

_________________________________________________________________________________________________________

 

 

 

_________________________________________________________________________________________________________

 

 

 

Daily Events:

Goes out __________days a week

 

Stays busy with hobbies, reading, fixed daily routine

 

 

(check all that apply)

 

(Specify 1 – 7)

 

 

 

 

 

 

 

 

 

 

 

 

 

Spends most time alone

 

 

 

 

Contact with relatives/close friends ________days per week

 

 

 

 

 

 

 

 

 

 

 

 

 

 

(Specify 1 – 7)

 

 

 

Spends most time watching TV

 

 

Usually attends church, synagogue, mosque, etc.

 

 

 

Prefers small group activities

 

 

Prefers large group activities

 

 

 

 

Comments: ______________________________________________________________________________________________

 

 

_________________________________________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOH-4397 Part B (03/08) Rev. 09/12

 

 

 

 

 

 

 

 

 

Page 1 of 6

New York State Department of Health Division of Assisted Living

ASSISTED LIVING RESIDENCE RESIDENT EVALUATION

Resident’s Name: _________________________________________________________________________________

Facility Name: ________________________________________ Date of Evaluation: __________________________

SECTION 3: CONTINENCE STATUS/MANAGEMENT

 

 

 

 

 

 

 

 

Is the resident continent of urinary function?

Yes

No

 

 

 

 

 

 

 

 

Is the resident continent of bowel function?

Yes

No

 

 

 

 

 

 

 

 

IF ANSWER IS “NO” TO EITHER QUESTION, COMPLETE THIS SECTION, AS APPROPRIATE.

 

 

 

 

Urinary Incontinence

 

 

 

 

Bowel Incontinence

 

 

 

Several times a week

Day Only

 

 

 

Several times a week

 

Day only

 

 

 

Daily

 

 

Night only

 

 

Daily

 

 

 

Night only

 

 

 

 

 

 

Day and night

 

 

 

 

 

 

Day and night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Current management techniques

 

 

Current management techniques

 

 

Prompting/reminding defers incontinence

 

 

Uses incontinence pads/adult diapers:

 

 

 

 

Timed voiding defers incontinence

 

 

 

Day only

 

 

 

 

 

 

 

 

Uses incontinence pads/adult diapers:

 

 

 

Night only

 

 

 

 

 

 

 

 

Day only

 

 

 

 

 

 

Day and night

 

 

 

 

 

 

 

 

Night only

 

 

 

 

 

 

Comments:

 

 

 

 

 

 

 

 

Day and night

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

__________________________________________________________

 

Catheter (specify type) ____________________________

 

__________________________________________________________

 

Comments: _____________________________________

 

__________________________________________________________

_______________________________________________

 

 

 

 

 

 

 

 

 

 

Self-manage continence? Yes No

 

 

 

Self-manage continence?

Yes No

 

 

SECTION 4: PHYSICAL FUNCTION

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TASK

 

LEVEL OF ASSISTANCE

 

 

 

 

COMMENTS

 

 

 

 

Eating:

 

Independent: Able to feed self independently with or

Dentures

Upper

Yes

No

 

(Ability to feed self

 

without assistive device.

 

 

 

 

 

 

 

Lower

Yes

No

 

meals and snacks)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Intermittent Assistance: Requires minimal,

 

Chewing difficulties

Yes

No

 

 

 

intermittent supervision and/or assistance.

 

 

 

 

 

 

 

 

 

 

Continual Assistance: Requires constant assistance

 

Difficulty swallowing

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

and/or supervision throughout meal.

 

 

Modified consistency

Yes

No

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Assistance: Unable to feed self, needs to be fed.

 

Specify ______________

 

 

 

 

 

Comments:

 

 

 

 

 

 

Unable to take nutrients orally, requires enteral nutrition.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Ambulation:

 

Independent: Walks and climbs and descends stairs

 

Wheelchair

Walker

 

 

(Ability to safely walk

 

independently with or without assistive device.

 

 

 

 

 

 

 

 

and move about once

 

 

 

 

 

 

 

 

Quad cane

Cane

 

 

in a standing position)

 

Intermittent Assistance: Walks and climbs and

 

 

 

 

 

 

 

 

 

 

 

 

 

 

descends stairs with minimal, intermittent assistance

 

Other: ____________________

 

 

 

and/or supervision.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Continual Assistance: Walks and climbs and

 

Falls within the last 3 months?

 

 

 

 

 

 

 

Yes No

 

 

 

 

descends stairs with constant supervision and/or

 

Frequency #: _______________________

 

 

 

assistance.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Total Assistance: Chairfast or bedfast. Requires total

 

Injury: ____________________________

 

 

 

 

Comments:

 

 

 

 

 

 

assistance for mobility.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

DOH-4397 Part B (03/08) Rev. 09/12

 

 

 

 

 

 

 

 

 

Page 2 of 6

New York State Department of Health Division of Assisted Living

ASSISTED LIVING RESIDENCE RESIDENT EVALUATION

Resident’s Name: _________________________________________________________________________________

Facility Name: ________________________________________ Date of Evaluation: __________________________

 

TASK

 

 

LEVEL OF ASSISTANCE

 

 

COMMENTS

 

Transferring:

 

 

Independent: Able to transfer independently with or

 

 

Comments:

 

(Moving from bed to

 

 

without assistive device.

 

 

 

 

chair, on/off toilet,

 

 

 

 

 

 

 

in/out of shower or

 

 

Intermittent Assistance: Transfers with minimal

 

 

 

 

tub)

 

 

 

 

 

 

 

 

human assistance and/or supervision.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Continual Assistance: Unable to transfer but can bear

 

 

 

 

 

 

 

weight and pivot when transferred by at least one other

 

 

 

 

 

 

 

person.

 

 

 

 

 

 

 

Total Assistance: Chairfast or bedfast, unable to

 

 

 

 

 

 

 

transfer, pivot, bear weight or turn self in bed.

 

 

 

PROSTHESIS: No Yes (describe)__________________________________________________________________________

AMPUTATION: No Yes (describe)___________________________________________________________________________

PODIATRIC: Does the resident have podiatric concerns requiring treatment or which impair ability to ambulate or transfer? No Yes (describe)_______________________________________________________________________________

 

 

 

 

 

 

 

 

 

 

TASK

 

 

LEVEL OF ASSISTANCE

 

 

COMMENTS

 

 

Toileting: (Getting to/from

 

 

Independent: Able to toilet independently with or without

 

 

Ostomy

Yes No

 

and on/off the toilet,

 

 

assistive device.

 

 

Comments:

 

 

cleansing self after

 

 

Intermittent Assistance: Able to toilet with minimal

 

 

 

 

 

 

 

 

 

 

 

elimination and adjusting

 

 

intermittent assistance and/or supervision.

 

 

 

 

 

clothing)

 

 

 

 

 

 

 

 

 

Continual Assistance: Able to toilet with constant

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

assistance and/or supervision.

 

 

 

 

 

 

 

 

Total Assistance: Unable to toilet. Requires total

 

 

 

 

 

 

 

 

assistance with toileting.

 

 

 

 

 

Bathing: (Getting in and

 

 

Independent: Able to bathe or shower independently with

 

 

Comments:

 

 

out of tub or shower,

 

 

or without assistive device.

 

 

 

 

 

washing and drying entire

 

 

 

 

 

 

 

 

 

Intermittent Assistance: Able to bathe or shower

 

 

 

 

 

body)

 

 

w/minimal intermittent assistance and/or supervision.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Continual Assistance: Able to bathe or shower with

 

 

 

 

 

 

 

 

constant assistance and/or supervision.

 

 

 

 

 

 

 

 

Total Assistance: Unable to use shower or tub. Bathed

 

 

 

 

 

 

 

 

in bed or at bedside.

 

 

 

 

 

Dressing: (Getting clothes

 

 

Independent: Able to dress and undress independently

 

 

Comments:

 

 

from closets and drawers,

 

 

with or without assistive device.

 

 

 

 

 

dressing and undressing

 

 

 

 

 

 

 

 

 

Intermittent Assistance: Able to dress and undress with

 

 

 

 

 

upper/lower body including

 

 

 

 

 

 

 

buttons, snaps, zippers,

 

 

minimal, intermittent assistance and/or supervision.

 

 

 

 

 

 

 

Continual Assistance: Requires assistance throughout

 

 

 

 

 

socks and shoes)

 

 

 

 

 

 

 

 

 

 

the dressing and undressing process.

 

 

 

 

 

 

 

 

Total Assistance: Requires another person to dress and

 

 

 

 

 

 

 

 

undress upper and lower body.

 

 

 

 

 

DOH-4397 Part B (03/08) Rev. 09/12

 

 

 

Page 3 of 6

New York State Department of Health Division of Assisted Living

ASSISTED LIVING RESIDENCE RESIDENT EVALUATION

Resident’s Name: _________________________________________________________________________________

Facility Name: ________________________________________ Date of Evaluation: __________________________

 

SECTION 4: PHYSICAL FUNCTION Cont.

 

 

 

 

 

 

 

 

 

 

 

 

 

 

TASK

 

 

LEVEL OF ASSISTANCE

COMMENTS

 

Grooming: (Washing face,

 

 

Independent: Able to groom self independently with or

Comments:

 

hair care, shaving,

 

 

without assistive device.

 

 

teeth/denture, fingernail

 

 

 

 

 

 

Intermittent Assistance: Requires grooming utensils to

 

 

care, eyeglasses care)

 

 

 

 

 

 

be set up and placed within reach.

 

 

 

 

 

 

 

 

 

 

Continual Assistance: Requires assistance throughout

 

 

 

 

 

the grooming process.

 

 

 

 

 

Total Assistance: Depends entirely upon someone else

 

 

 

 

 

for grooming.

 

 

Transportation: (Physical

 

 

Independent: Able to independently drive a regular or

Comments:

 

and mental ability to safely

 

 

adapted car; OR uses a regular or handicap accessible public

 

 

use a car, taxi, or public

 

 

 

 

 

bus, train or subway.

 

 

transportation [bus, train,

 

 

 

 

 

Independent: But requests facility perform task.

 

 

subway)

 

 

 

 

 

 

Intermittent Assistance: Able to ride in a car only when

 

 

 

 

 

 

 

 

 

 

driven by another person; AND/OR due to physical, cognitive

 

 

 

 

 

or mental limitations occasionally requires another person to

 

 

 

 

 

accompany him/her when using a bus, train or subway.

 

 

 

 

 

Continual Assistance: Able to ride in a car only when

 

 

 

 

 

driven by another person; OR able to use a bus or handicap

 

 

 

 

 

van, train or subway only when assisted or accompanied by

 

 

 

 

 

another person.

 

 

 

 

 

Total Assistance: Unable to ride in a car, taxi, bus or

 

 

 

 

 

van, and requires transportation by ambulance.

 

 

Laundry: (Ability to do own

 

 

Independent: Able to independently take care of all

Comments:

 

laundry – to carry laundry

 

 

laundry tasks.

 

 

to and from washing

 

 

 

 

 

 

Independent: But requests facility perform task.

 

 

machine, to use washer

 

 

 

 

 

 

Intermittent Assistance: Able to do only light laundry,

 

 

and dryer, to wash small

 

 

 

 

items by hand)

 

 

such as minor hand wash or light washer loads. Needs

 

 

 

 

 

assistance with heavy laundry, such as carrying large loads

 

 

 

 

 

of laundry.

 

 

 

 

 

Continual Assistance: Due to physical, cognitive or

 

 

 

 

 

mental limitations, needs continual supervision and

 

 

 

 

 

assistance to do any laundry.

 

 

 

 

 

Total Assistance: Unable to do any laundry.

 

 

 

 

 

 

 

 

Housekeeping: (Ability to

 

 

Independent: Able to independently perform all

Comments:

 

safely and effectively

 

 

housekeeping tasks.

 

 

perform light housekeeping

 

 

 

 

 

 

Independent: But requests facility perform task.

 

 

and heavier cleaning tasks)

 

 

Intermittent Assistance: Able to perform only light

 

 

 

 

 

housekeeping (e.g., dusting, wiping kitchen counters) tasks

 

 

 

 

 

independently; AND/OR able to perform housekeeping tasks

 

 

 

 

 

with intermittent assistance or supervision from another

 

 

 

 

 

person.

 

 

 

 

 

Continual Assistance: Unable to consistently perform

 

 

 

 

 

any housekeeping tasks unless assisted by another person

 

 

 

 

 

throughout the process.

 

 

 

 

 

Total Assistance: Unable to effectively participate in any

 

 

 

 

 

housekeeping tasks.

 

DOH-4397 Part B (03/08) Rev. 09/12

Page 4 of 6

New York State Department of Health Division of Assisted Living

ASSISTED LIVING RESIDENCE RESIDENT EVALUATION

Resident’s Name: _________________________________________________________________________________

Facility Name: ________________________________________ Date of Evaluation: __________________________

SECTION 4: PHYSICAL FUNCTION cont.

 

TASK

 

 

LEVEL OF ASSISTANCE

 

 

COMMENTS

 

 

 

 

 

 

 

 

 

Shopping: (Ability to

 

 

Independent: Able to plan for shopping needs and independently

 

 

Comments:

 

plan form, select and

 

 

perform shopping tasks, including carrying package.

 

 

 

 

purchase items in a

 

 

 

 

 

 

 

 

Independent: But requests facility perform task.

 

 

 

 

store and to carry them

 

 

 

 

 

 

home or arrange

 

 

Intermittent Assistance: Able to do only light shopping and carry

 

 

 

 

delivery)

 

 

small packages, but needs someone to do occasional major shopping.

 

 

 

 

 

 

 

Continual Assistance: Unable to go shopping alone, but can go

 

 

 

 

 

 

 

with someone to assist; OR unable to go shopping but is able to

 

 

 

 

 

 

 

identify items needed, place orders, and arrange for home delivery.

 

 

 

 

 

 

 

Total Assistance: Needs someone to do all shopping and

 

 

 

 

 

 

 

errands.

 

 

 

 

Ability to use a

 

 

Independent: Able to dial numbers and answers calls

 

 

Comments:

 

Telephone: (Ability to

 

 

appropriately and as desired.

 

 

 

 

 

 

 

 

 

 

 

answer the telephone,

 

 

Independent: But requests facility perform task.

 

 

 

 

dial numbers, and

 

 

Intermittent Assistance: Able to use a specially adapted

 

 

 

 

effectively use the

 

 

 

 

 

 

 

 

telephone (i.e., large numbers on the dial pad, teletype phone for the

 

 

 

 

telephone to

 

 

 

 

 

 

 

 

deaf) and call essential numbers; able to answer the telephone and

 

 

 

 

communicate)

 

 

 

 

 

 

 

 

carry on a normal conversation but has difficulty with placing calls;

 

 

 

 

 

 

 

 

 

 

 

 

 

 

able to answer the telephone only some of the time or is able to carry

 

 

 

 

 

 

 

on only a limited conversation.

 

 

 

 

 

 

 

Continual Assistance: Unable to make calls or answer the

 

 

 

 

 

 

 

telephone at all, but can listen if assisted with equipment.

 

 

 

 

 

 

 

Total Assistance: Totally unable to use the telephone. Requires

 

 

 

 

 

 

 

someone else to make calls.

 

 

 

 

 

 

 

 

 

 

 

SECTION 5: COGNITIVE IMPAIRMENT SCREEN

Cognitive Functioning: Individual’s current level of alertness, orientation, comprehension, concentration and immediate memory.

Response: What is today’s date?

Correct

Incorrect

What day of the week is today:

(correct, if within 2 days)

 

 

How old are you?

Correct

Incorrect

When were you born?

Correct

Correct

Incorrect

Incorrect

Behaviors of Note: (check all that apply):

 

Wanders Day/Night Sleep disturbance Confused Depressive Feelings Anxious

Withdrawn/Refuses to Socialize

Agitated (repeated vocalizations, screaming, shouting, moaning, cursing, fidgeting, etc.)

Other:____________________

Overall Cognitive Functioning:(check all that apply):

Is alert and oriented, comprehends verbal questions and commands and has accurate recall

Requires prompting and redirection, on occasion, to complete tasks

Has occasional fluctuation in orientation, memory/alertness

Has significant memory loss and is disoriented to person, place and/or time

This screen includes indicators, which are often related to cognitive impairment. This is a screen ONLY and is intended to assist the residence in determining if an individual is appropriate for care in an ALR and/or if the individual should be referred to his/her physician for consultation and/or further evaluation or treatment.

Comments: _______________________________________________________________________________________________

_________________________________________________________________________________________________________

_________________________________________________________________________________________________________

DOH-4397 Part B (03/08) Rev. 09/12

Page 5 of 6

New York State Department of Health Division of Assisted Living

ASSISTED LIVING RESIDENCE RESIDENT EVALUATION

Resident’s Name: _________________________________________________________________________________

Facility Name: ________________________________________ Date of Evaluation: __________________________

SECTION 6: ADMISSION DECISION

ACCEPTED TO: ALR/AH/EHP Enhanced ALR Special Needs ALR

Upon admission, the following documents were provided to the applicant at, or prior to, the admissions interview:

Consumer Information Guide

Copy of the Residency Agreement

Copy of the statement of resident rights

Copy of any facility regulations relating to resident activities, office and visiting hours and like information

If made available to the operator by the Long-Term Care Ombudsman Program, a fact sheet about the program and the listing of legal services or advocacy agencies.

Personal Allowance Protections (SSI and Temporary Assistance (TA) recipients only)

Most recent Statement of Deficiencies (shown to applicant)

Signature(s) of ALR staff participating in this evaluation.

 

 

Name: _________________________________________

Title: ____________________

Date: ___________

Name: _________________________________________

Title: ____________________

Date: ___________

Name: _________________________________________

Title: ____________________

Date: ___________

Signature of Administrator/Case Manager/or ISP Planner: _________________________________ Date: ________

Signature of Individual/Resident: ______________________________________________________ Date: ________

Signature of Resident Representative: _________________________________________________ Date: ________

Name(s) of others participating in this evaluation.

 

 

Name: ___________________________________________

Relationship: ______________

Date: ___________

Name: ___________________________________________

Relationship: ______________

Date: ___________

DOH-4397 Part B (03/08) Rev. 09/12

Page 6 of 6