Assistive Care Services and Assisted Living for the Elderly Waiver
Assistive Care Services and Assisted Living for the Elderly Waiver
Assistive Care Services and Assisted Living for the Elderly Waiver
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RESIDENT SERVICE PLAN FOR ASSISTIVE CARE SERVICES<br />
(Optional Form)<br />
FACILITY:<br />
DATE:<br />
RESIDENT NAME: MEDICAID #:<br />
Beginning Date of Service Plan ____________________<br />
Ending Date of Service Plan_________________<br />
ASSISTANCE WITH ACTIVITIES OF DAILY LIVING (ADLs)<br />
ACTIVITY SERVICE NEED PROVIDER<br />
AMBULATION<br />
o Independent<br />
o Provide Assistance<br />
o Assist with Ambulatory Device<br />
o Wheelchair o Walker o Cane<br />
o Facility Staff<br />
O<strong>the</strong>r ________________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
BATHING<br />
o Independent<br />
o Provide Supervision<br />
o Provide Assistance<br />
o Provide Total Help<br />
o Tub<br />
o Shower<br />
o Morning<br />
o Evening<br />
o Facility Staff<br />
O<strong>the</strong>r _______________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
DRESSING<br />
Choose<br />
attire<br />
o<br />
o<br />
o<br />
o<br />
Put on<br />
shoes<br />
o<br />
o<br />
o<br />
o<br />
Dress/<br />
Undress<br />
o<br />
o<br />
o<br />
o<br />
Independent<br />
Provide Supervision<br />
Provide Assistance<br />
ProvideTotal Help<br />
o Facility Staff<br />
O<strong>the</strong>r _______________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
TOILETING<br />
o Independent<br />
o Supervision/Prompting<br />
o Provide Assistance<br />
o Incontinent:<br />
o Bladder o Bowel<br />
o Adult Brief<br />
o Ca<strong>the</strong>ter <strong>Care</strong><br />
o Ostomy<br />
Assistance<br />
o Facility Staff<br />
O<strong>the</strong>r _______________________<br />
Expected Outcome of Service: _______________________________________________________________________<br />
Comments: _______________________________________________________________________________________<br />
EATING<br />
Special diet:<br />
o Independent<br />
o Provide Supervision<br />
o Provide Assistance<br />
o Provide Total Help<br />
o H<strong>and</strong> Guidance<br />
o Cutting Food<br />
o Opening Packages<br />
o Facility Staff<br />
O<strong>the</strong>r _______________________<br />
o Regular o Diabetic o No added salt o Low fat/Low cholesterol O<strong>the</strong>r _________________<br />
Expected Outcome: _______________________________________________________________________________<br />
Comments: ______________________________________________________________________________________<br />
AHCA FORM 2900 (July 2001) Page 1 of 3