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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GROOMING<br />
o Independent<br />
o Provide Supervision<br />
o Provide Assistance<br />
o Provide Total Help<br />
o Teeth<br />
o Hair<br />
o Nails<br />
O<strong>the</strong>r____________<br />
o Facility Staff<br />
O<strong>the</strong>r _______________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
TRANSFERRING<br />
o Independent<br />
o Provide Supervision<br />
o Provide Assistance<br />
o Facility Staff<br />
O<strong>the</strong>r _______________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
ASSISTANCE WITH SELF-ADMINISTERED MEDICATION<br />
ACTIVITY SERVICE NEED PROVIDER<br />
MEDICATIONS<br />
o Independent<br />
o Provide Daily Supervision or Assistance<br />
o Provide Administration<br />
o Facility Non-Nursing Staff<br />
o Facility Nursing Staff<br />
O<strong>the</strong>r ________________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
ASSISTANCE WITH INSTRUMENTAL ACTIVITIES OF DAILY LIVING (IADLs)<br />
ACTIVITY SERVICE NEED PROVIDER<br />
MAKING A<br />
TELEPHONE<br />
CALL<br />
o Independent<br />
o Supervision/ Prompting<br />
o Dial Number<br />
o Facility Staff<br />
O<strong>the</strong>r ___________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: ____________________________________________________________________________________<br />
MANAGING<br />
MONEY<br />
o Independent<br />
o Provide Assistance<br />
o Representative Payee or Power of Attorney<br />
o Facility Staff<br />
O<strong>the</strong>r ___________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
SHOPPING FOR<br />
PERSONAL ITEMS<br />
o Independent<br />
o Provide Supervision<br />
o Provide Total Help<br />
o Facility Staff<br />
O<strong>the</strong>r ___________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
AHCA FORM 2900 (July 2001) Page 2 of 3
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