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ADULT CARE HOME

PERSONAL CARE PHYSICIAN AUTHORIZATION AND CARE PLAN

Assessment Date ___/___/___

Reassessment Date ___/___/___

Significant Change___/___/___

RESIDENT INFORMATION

(Please Print or Type)

RESIDENT _________________________________________ SEX (M/F) ____ DOB ____/____/____ MEDICAID ID NO. __________________________

FACILITY ____________________________________________________________________________________________________________________________

ADDRESS ___________________________________________________________________________________________________________________________

___________________________________________________________________PHONE ___________________ PROVIDER NUMBER __________________

DATE OF MOST RECENT EXAMINATION BY RESIDENT’S PRIMARY CARE PHYSICIAN ______/______/______

ASSESSMENT

1. MEDICATIONS – Identify and report all medications, including non-prescription meds, that will continue upon admission:

Name

Dose

Frequency

Route

() If Self-Administered

2.MENTAL HEALTH AND SOCIAL HISTORY: (If checked, explain in “Social/Mental Health History” section)

Wandering	Injurious to:			Is the resident currently receiving Mental Health, DD, or
Wandering	Injurious to:			Substance Abuse Services (SAS)?	YES	NO
				Substance Abuse Services (SAS)?	YES	NO
Verbally Abusive	Self	Others	Property
Physically Abusive				Has a referral been made?	YES	NO
Physically Abusive	Is the resident currently receiving
	Is the resident currently receiving
Resists care	medication(s) for mental illness/behavior?			If YES:
Suicidal	YES	NO
Suicidal				Date of Referral _________________
				Date of Referral _________________
Homicidal	Is there a history of:			Name of Contact Person _____________________________
Disruptive Behavior/	Substance Abuse			Name of Contact Person _____________________________
Disruptive Behavior/	Developmental Disabilities (DD)
	Developmental Disabilities (DD)			Agency ______________________________________________
Socially Inappropriate	Mental Illness			Agency ______________________________________________
Socially Inappropriate	Mental Illness

Social/Mental Health History: ________________________________________________________________________________________________

______________________________________________________________________________________________________________________________

DMA-3050-R

Resident __________________________________

3.AMBULATION/LOCOMOTION: No Problems Limited Ability Ambulatory w/ Aide or Device(s) Non-Ambulatory Device(s) Needed _______________________________________________________________________________________________________________


	Has device(s):	Does not use		Needs repair or replacement
4.	UPPER EXTREMITIES:		No Problems		Limited Range of Motion	Limited Strength		Limited Eye-Hand Coordination
	Specify affected joint(s) _________________________________________________________________							Right	Left	Bilateral
	Other impairment, specify __________________________________________________________________________________________________
	_______________________________________________________________________________________________________________________________
	Device(s) Needed ____________________________________________ Has device(s):						Does not use	Needs repair or replacement
5.	NUTRITION:	Oral	Tube (Type) ______________________________________ Height __________________ Weight __________________
	Dietary Restrictions: ___________________________________________________________________________________________________________
	________________________________________________________________________________________________________________________________
	________________________________________________________________________________________________________________________________
	________________________________________________________________________________________________________________________________
	Device(s) Needed _______________________________________________________________________________________________________________
	Has device(s):	Does not use		Needs repair or replacement

6. RESPIRATION:

Normal

Well Established Tracheostomy

Oxygen

Device(s) Needed _____________________________________________ Has device(s):

Shortness of Breath

Does not use

Needs repair or replacement

7.SKIN: Normal Pressure Areas Decubiti Other _______________________________________________________________

Skin Care Needs ______________________________________________________________________________________________________________

_______________________________________________________________________________________________________________________________


8.	BOWEL:	Normal		Occasional Incontinence (less than daily)			Daily Incontinence
	Ostomy: Type ______________________________________________________________ Self-care:
9.	BLADDER:		Normal	Occasional Incontinence (less than daily)			Daily Incontinence
	Catheter: Type _________________________________________________________________ Self-care:
10.	ORIENTATION:		Oriented		Sometimes Disoriented	Always Disoriented

YES


11.	MEMORY:	Adequate	Forgetful – Needs Reminders			Significant Loss – Must Be Directed
12.	VISION:	Adequate for Daily Activities			Limited (Sees Large Objects)		Very Limited (Blind); Explain___________________
	Uses:	Glasses	Contact Lens	Needs repair or replacement
	Comments ___________________________________________________________________________________________________________________
	______________________________________________________________________________________________________________________________
13.	HEARING:	Adequate for Daily Activities			Hears Loud Sounds/Voices		Very Limited (Deaf); Explain _________________
	Uses Hearing Aid(s)		Needs repair or replacement
	Comments ___________________________________________________________________________________________________________________


14. SPEECH/COMMUNICATION METHOD:			Normal		Slurred	Weak	Other Impediment
Gestures	Sign Language	Writing		Foreign Language Only ________________________
Assistive Device(s) (Type _____________________________________)						Has device(s): Does not use

No Speech

Other None

Needs repair or replacement

Resident _______________________________________

DMA-3050-R

CARE PLAN

15.IF THE ASSESSMENT INDICATES THE RESIDENT HAS MEDICALLY RELATED PERSONAL CARE NEEDS REQUIRING ASSISTANCE, SHOW THE PLAN FOR PROVIDING CARE. CHECK OFF THE DAYS OF THE WEEK EACH ADL TASK IS PERFORMED AND RATE EACH ADL TASK BASED ON THE FOLLOWING PERFORMANCE CODES: 0 - INDEPENDENT,

1 - SUPERVISION, 2 - LIMITED ASSISTANCE, 3 - EXTENSIVE ASSISTANCE, 4 - TOTALLY DEPENDENT. (PLEASE REFER TO

YOUR ADULT CARE HOME PROGRAM MANUAL FOR MORE DETAIL ON EACH PERFORMANCE CODE.)

ACTIVITIES OF DAILY LIVING (ADL)				WEDNESDAY
DESCRIBE THE SPECIFIC TYPE OF ASSISTANCE NEEDED BY THE RESIDENT AND	SUNDAY	MONDAY	TUESDAY	WEDNESDAY	THURSDAY	FRIDAY	SATURDAY
PROVIDED BY STAFF, NEXT TO EACH ADL:

EATING

TOILETING

AMBULATION/LOCOMOTION

BATHING

DRESSING

GROOMING/PERSONAL HYGIENE

TRANSFERRING

OTHER: (Include Licensed Health Professional Support (LHPS) Personal Care Tasks, as listed in Rule 42C .3703, and any other special care needs)

PERFORMANCE CODE

ASSESSOR CERTIFICATION

I certify that I have completed the above assessment of the resident’s condition. I found the resident needs personal care services due to the resident’s medical condition. I have developed the care plan to meet those needs.

Resident/responsible party has received education on Medical Care Decisions and Advance Directives prior to admission.

__________________________________________	______________________________________________	____________________
Name	Signature	Date

PHYSICIAN AUTHORIZATION

I certify that the resident is under my care and has a medical diagnosis with associated physical/mental limitations warranting the provision of the personal care services in the above care plan.

The resident may take therapeutic leave as needed.

_________________________________________	_____________________________________________	_____________________
Name	Signature	Date

DMA-3050-R

INSTRUCTIONS FOR COMPLETING THE REVISED ADULT CARE HOME PERSONAL CARE PHYSICIAN AUTHORIZATION AND CARE PLAN (DMA-3050-R)

The block in the upper right hand corner of the form denotes the type of assessment that is completed: Include Assessment date, Reassessment date, or Significant Change. Refer to the glossary in the Adult Care Home Services manual for the definition of significant change.

RESIDENT INFORMATION: In the Resident Information area include the resident’s name as it appears on the blue Medicaid ID card. Complete all information.

DATE OF MOST RECENT EXAMINATION: Includes a yearly physical by the resident’s attending physician.

ASSESSMENT:

1.MEDICATIONS: List the name of each medication, include non-prescription meds that the resident will continue upon admission. Check appropriate box for self-administered.

2.MENTAL HEALTH AND SOCIAL HISTORY: Identify by checking the appropriate box. Review records from discharging facility to monitor if there was any indication about history of injury to self, property, or others. Include meds for mental illness/behavior, and include if there is a history of Mental Illness, Developmental Disabilities, or Substance Abuse.

•Is the resident currently receiving Mental Health (MH), Developmental Disabilities (DD), or Substance Abuse Services (SAS)? If a referral has been made for an evaluation, indicate the date of referral, name of contact person at the agency, and the agency name.

•Social/Mental Health History: Include any history that can be gathered from assessment by the resident, family, friends, etc. that provide information about the resident’s preferences, activities and living status. This is also an area that needs to identify any Mental Health history such as institutionalization, out patient, compliance history, police record, etc.

TOP OF SECOND PAGE: RESIDENT_________________: Place name as on Medicaid ID card in this blank.

3.AMBULATION/LOCOMOTION: Check applicable block and list devices needed.

4.UPPER EXTREMITIES: Check applicable box and list devices needed.

5.NUTRITION: Check appropriate box. Indicate height and weight. Include any restrictions to diet, i.e. NAS, soft, etc.

6.RESPIRATION: Check appropriate box. Indicate any devices needed.

7.SKIN: Check appropriate box. Explain in detail treatment necessary and include any MD orders for skin care.

8.BOWEL: Check appropriate box. Indicate if the resident is independent of activity. Explain what resident needs from staff.

9.BLADDER: Check appropriate box. Indicate if the resident is independent of activity. Explain what residents need from staff.

10.ORIENTATION: Check appropriate box.

11.MEMORY: Check appropriate box.

12.VISION: Check appropriate box. Expand on concerns in comments area.

13.HEARING: Check appropriate box. Expand on concerns in comments area.

14.SPEECH/COMMUNICATION METHOD: Check appropriate box.

TOP OF THIRD PAGE: RESIDENT__________________: Place name as on Medicaid ID card in this

blank.

CARE PLAN:

15.Refer to the Adult Care Home Services manual for more detail on Performance Codes.

ACTIVITIES OF DAILY LIVING: Include a description of the specific type of assistance provided by staff next to each ADL and code the activity in the Performance Code area. In Other, list any Licensed Health Professional Support tasks as well as any special care needs in this area.

ASSESSOR CERTIFICATION: Check box for Medical Care Decisions and Advance Directives education. Signature of assessor certifies that the care plan is developed based on assessment findings.

PHYSICIAN AUTHORIZATION: The form is forwarded to the attending physician. The physician’s authorization certifies that the individual is under the physician’s care and has a medical diagnosis that warrants the provision of personal care services as indicated in the care plan. The physician prints his/her name, signs, and dates the form. The physician also may indicate and provide standing orders for an individual to take therapeutic leave by checking the block.

Question	Answer
Form Name	Form Personal Care
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	personal physician authorization, printable inservices for caregivers, care physician authorization, form personal care

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