Adult Foster Home Screening and Assessment and General Information

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1 Office of Licensing and Regulatory Oversight Resident information Resident s name: Resident s current address: Resident s current living situation: Resident s current primary caregiver: Adult Foster Home Screening and Assessment and General Information Date of screening: Date of admission: How long? Date of birth: Height: Weight: Medicare #: Medicaid #: VA #: Insurance: Case manager: Person responsible for payment: Claim number: Medical diagnosis (including illness and injury): Behavioral conditions (including distressing, disruptive or potentially harmful symptoms): Medications (including over-the-counter medications and supplements): Treatments and therapies: Advanced health care directive: No Yes, copies attached POLST (Physicians Orders for Life Supporting Treatment): No Yes, copies attached Mortuary/funeral plan: Resident representatives Responsible person: Other significant person: Emergency contact: Relationship: Relationship: Page 1 of 6 SDS 0902 (3/13)

2 Medical professional information Primary physician: Specialist: Dentist: Home health: Pharmacy information Preferred pharmacy: How will medications be delivered to the adult foster home? Who is responsible for paying for the medications? Registered nursing tasks Consultations needed: Tasks requiring teaching or delegation: Name of RN who will perform consultation/teaching/delegation: Medical equipment and supplies resident has and uses (H) or needs (N) Incontinence supplies Type: Pressure relief device Type: Bed pan Commode Urinal Crutches Walker Cane Quad cane Wheelchair Scooter Hoyer Prosthesis Brace Hospital bed Bed tray Geri chair Oxygen Oxygen concentrator CPAP/BiPAP Nebulizer Page 2 of 6 SDS 0902 (3/13)

3 Medical equipment supplier: How will supplies be delivered to the adult foster home? Who is responsible for paying for the supplies? Interviews The screening process must include interviews with multiple persons check which people were interviewed as part of this screening Yes No Resident Yes No Resident s family Yes No Resident s guardian Yes No Prior care provider Yes No Case manager Yes No Current physician Yes No Current pharmacist Yes No Current therapist Yes No Mental health professional Yes No Hospital staff Resident Assessment Mental status: Oriented... Yes No Memory lapses... Yes No Confused Short-term Long-term Aware of needs... Yes No Cooperative with care... Yes No History of mental illness... Yes No Danger to self or others... Yes No Wanders... Yes No Occasionally Frequently Behaviors... Yes No Verbal Physical Other Bathing: Needs assistance... Yes No Special equipment... Yes No Dressing: Needs assistance... Yes No Chooses own clothes... Yes No Special equipment... Yes No Page 3 of 6 SDS 0902 (3/13)

4 Toileting: Needs assistance... Yes No Incontinent bladder... Yes No Incontinent bladder... Yes No Incontinent bowel... Yes No Toileting plan... Yes No Incontinent supplies... Yes No Catheter... Yes No Does resident agree to wear.. Yes No Ostomy... Yes No Will resident leave on... Yes No Mobility, ambulation and transferring: Needs assistance in walking... Yes No Bed bound... Yes No Needs assistance propelling wheelchair... Yes No Needs assistance in transferring... Yes No Tires easily... Yes No Aware of needs... Yes No Special equipment... Yes No Personal grooming and hygiene: Skin conditions... Yes No Special equipment... Yes No Eating and dietary needs: Difficulty swallowing... Yes No Choking/aspiration risk... Yes No Special preparation... Yes No Special diet... Yes No Soft solids Pureed foods Food allergies... Yes No Thickened liquids Limited fluid intake Special equipment... Yes No Communication: Able to see... Yes No Able to hear... Yes No Glasses Hearing aid Able to speak... Yes No Special equipment... Yes No Impediment Gestures Sign language Foreign language Page 4 of 6 SDS 0902 (3/13)

5 Night needs: Difficulty sleeping... Yes No Special equipment... Yes No Emergency exiting: Special equipment... Yes No Strobe light Vibrating device Other: Activities, interests and preferences: Summary of Information (I) = Independent Resident requires no assistance or reminding to perform this task (A) = Assistance Resident is able to assist in the task but cannot perform the task alone and/or requires reminding (F) = Full Assistance Resident cannot assist with any part of the task Activities of daily living: (Check I, A or F next to each) Mental status & I A F Toileting I A F behaviors Bathing & personal I A F Mobility, ambulation & I A F hygiene transfer Dressing I A F Eating & nutrition I A F Summary of activities of daily living: # Independent in ADL s # Assistance in ADL s # Full assistance in ADL s Classification: Class 1 - may only admit residents who need assistance in no more than four activities of daily living Class 2 - may admit residents who require assistance in all activities of daily living, but require full assistance in no more than three activities of daily living Class 3 - may admit resident who require full assistance in four or more activities of daily living, but only one resident who requires bed-care or full assistance with all activities of daily living Page 5 of 6 SDS 0902 (3/13)

6 Other care needs: (Check I, A or F next to each) Communication I A F Night needs I A F Emergency exiting I A F Determination: If you answer no to even one of the following questions, you may not admit the resident to your adult foster home. Yes No The resident s needs can be met within the classification of the home. Yes No The licensee and all caregivers are able to meet the resident s needs. Yes No The resident s needs can be met without compromising the care of other residents. Yes No The resident and all other occupants can be evacuated within three minutes. Yes No A copy of the physician orders or verbal orders for the resident s medication, therapies and treatments has been obtained and is in the resident s file. Yes No Arrangements have been made to ensure RN consultation for teaching and delegation as appropriate to meet the resident s care needs. Signature of licensee: Date: Page 6 of 6 SDS 0902 (3/13)

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