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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USING AVAILABLE<br />
TRANSPORTATION<br />
o Independent<br />
o Provide Supervision<br />
o Provide Assistance or Escort<br />
o Facility Staff<br />
O<strong>the</strong>r ___________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
HEALTH SUPPORT<br />
ACTIVITY SERVICE NEED PROVIDER<br />
REMINDING<br />
RESIDENT OF<br />
IMPORTANT TASKS<br />
o Independent<br />
o Appointments<br />
o Daily Tasks<br />
o O<strong>the</strong>r ____________________________<br />
o Facility Staff<br />
O<strong>the</strong>r ___________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
OBSERVING RESIDENT’S<br />
APPEARANCE AND WELL-BEING<br />
o Weekly or Less<br />
o Daily<br />
o O<strong>the</strong>r ____________________<br />
o Facility Staff<br />
O<strong>the</strong>r ___________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
OTHER SERVICES<br />
ACTIVITY SERVICE NEED PROVIDER<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
Expected Outcome of Service: _____________________________________________________________________<br />
Comments: _____________________________________________________________________________________<br />
CONSUMER COMMENTS:<br />
Facility Administrator or Designee DATE Resident or Representative DATE<br />
AHCA FORM 2900 (July 2001) Page 3 of 3
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