Oaas Pf 11 015 Form – Fill Out and Use This PDF

Instructions for OAAS Service Logs for Long Term – Personal Care Services (LT-PCS) and

Community Choices Waiver (CCW) Personal Assistance Services (PAS)

Service Logs must be used to document services provided to OAAS participants receiving Long Term-Personal Care Services (LT-PCS) or Community Choices Waiver (CCW) Personal Assistance Services (PAS). Each Direct Service Worker (DSW) must complete his/her own Service Log for the participant being served. If providing Shared PAS or Shared LT-PCS (under the ADHC Waiver), each participant must have his/her own Service Log reflecting services provided by a single DSW.

When an error is made, only the individual who made the entry is allowed to correct the error. Corrections must be made by drawing a single line through the incorrect entry, writing “error” above the entry, initialing the

correction, and placing the correct information on the form.

This form can be printed two-sided or printed as a carbon copy.

This entire form, including the progress notes section, can be completed, signed, initialed and/or dated electronically, as long as the provider and participant follows the specific instructions stated below.

PAGE 1 OF THE SERVICE LOG

Items 1-7 may be completed and typed/entered by the provider.

1	2
3	4
5	6

7

1)Enter the name of the provider.

2)Print the name of the Direct Service Worker (DSW).

3)Enter the participant’s name.

4)Enter the participant’s date of birth.

5)Enter the beginning date of the prior authorization week (Example: 11/12/17).

6)Enter the ending date of the prior authorization week (Example: 11/18/17).

7)Enter the date for each day of the week on which services are scheduled to be performed. (Example: If services are scheduled to be delivered Monday through Friday, begin by placing the correct date of the prior authorization week on Monday, 11/13. Continue filling in the dates as applicable for the remainder of the week.).

The prior authorization week begins on Sunday at 12:00 a.m. (midnight) and ends on the following Saturday at 11:59 p.m.

Reissued August 10, 2021	OAAS-P-18-005
Replaces March 12, 2018 Issuance	Page 1 of 4

Service Log Instructions

NOTE: The DSW will be utilizing the Electronic Visit Verification (EVV) system to record the actual beginning and end times of service delivery, as well as the location at check in/out.

Items in 8 MUST be completed EACH DAY (by hand or electronically) by the Direct Service Worker (DSW).

8

Additional possible tasks under PAS:

8)The DSW must enter their signed initials (write initials with an ink pen or enter their electronic initials) next to each task actually performed. A DSW’s initials in the appropriate block will indicate that the task was completed on that day. Only those tasks that were performed that day should be indicated with signed initials. If the task was NOT performed for that particular day, the box should be left blank.

NOTE: All entries must be entered/completed on the Service Log by the DSW on the day that the task(s) are performed.

Items 9 and 10 are to be completed ONLY AFTER the form has been fully completed for the given week.

9

10

9)The signature of the participant or the participant’s Responsible Representative or the participant’s legal representative and the date of that signature must appear on this line. This signature should be obtained at the end of the prior authorized week.*

10)The DSW must also sign and date the form at the end of the prior authorized week. The DSW should

NOT complete this section until the work for that prior authorized week has been completed.*

*These signatures/dates may be handwritten with an ink pen or entered electronically.
Reissued August 10, 2021	OAAS-P-18-005
Replaces March 12, 2018 Issuance	Page 2 of 4

Service Log Instructions

Items 21 and 22 are to indicate the total number of pages for a given prior authorized week’s documentation. This is important since page 2 of the service log may be duplicated as needed.

2122

Example: Page _1__ of __5__, Page _2___ of __5__, Page _3___ of __5__, etc.

Reissued August 10, 2021	OAAS-P-18-005
Replaces March 12, 2018 Issuance	Page 4 of 4

COMMUNITY CHOICES WAIVER (CCW) PERSONAL ASSISTANCE SERVICES (PAS) LOG

	PROVIDER’S NAME:				DIRECT SERVICE WORKER’S NAME (PRINT):
	PARTICIPANT’S NAME:						PARTICIPANT’S DOB:
	Week Of:	Through:
	Day Of Week:		Sunday	Monday	Tuesday	Wednesday			Thursday	Friday	Saturday
	Date→
	Tasks:		Indicate Tasks Completed Each		Day by Signing with Worker’s Initials.
	Eating
	Bathing
	Dressing
	Grooming
	Transferring
	Ambulation
	Toileting
	Light Housekeeping
	Food Preparation & Storage
	Shopping
	Laundry
	Medication Reminders
	Assist To Scheduled Medical Appointment
	Assist To Arrange Medical Transportation
	Accompany To Medical Appointments
	Protective Supervision
	Supervision/Assistance with Health Tasks
	Escort for Assistance with Community Tasks
	Extension of Therapy Services

PARTICIPANT/RESPONSIBLE REPRESENTATIVE/LEGAL REPRESENTATIVE’S SIGNATURE: ______________________________________________ DATE: ___________

DIRECT SERVICE WORKER’S SIGNATURE: ______________________________________________________________________________________ DATE: __________

NOTE: TIMES OF SERVICE DELIVERY, AS WELL AS LOCATION AT TIME OF CHECK IN/OUT, ARE DOCUMENTED THROUGH THE ELECTRONIC VISIT
VERIFICATION (EVV) SYSTEM.
	Page _____ of _____
Reissued August 10, 2021	OAAS-PF-11-015
Replaces March 12, 2018 Issuance	Page 1 of 2