Assistive Care Services and Assisted Living for the Elderly Waiver

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Assistive Care Services and Assisted Living for the Elderly Waiver Services Coverage and Limitations Handbook PART I APPENDIX E ASSISTIVE CARE SERVICES RESIDENT SERVICE LOG The following page contains an optional resident service log for assistive care services. The form may be copied and used by providers to document the resident service log. INSTRUCTIONS Set Up the Form • Fill in the name of the provider and the month and year. • Fill in the names and Medicaid numbers of current residents. • If there are less than 31 days in the month, cross out extra days. How to Code Your Census Each day, code who was or was not in the facility on the previous day. For example: On the second day of the month, enter "Y" for residents who were in the facility and "N" for residents who were not in the facility on the first day of the month. As new residents are admitted during the month, add them to the form and code as appropriate. Admission and Discharge You can bill Medicaid for the day the person is admitted to the facility, but you cannot bill Medicaid for the day the person is discharged from the facility. • Code the day the person was admitted as "Y." • Code the day the person was discharged as "N." Temporary Absences You cannot bill Medicaid for temporary absences of more than 24 hours. Such absences might be for hospitalization, home visits, etc. • Code the day the person left the facility as "N." • Code the day the person returned to the facility as "Y." Completing the Form At the end of the month, total the number of days (Y) each resident was in the facility and enter in the Days column at the right. Total the number of residents in the facility each day at the bottom. Add both sets of figures--you should have the same total each way. July 2001 E-1
RESIDENT SERVICE LOG (Optional Form for Medicaid Assistive Care Services) FACILITY NAME ____________________________________________ MONTH & YEAR _____________________________________ Resident Name Medicaid # 1 2 3 4 5 6 7 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 30 31 Days (AHCA Form 5000-3100A July 2001)
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Assistive Care Services and Assisted Living for the Elderly Waiver

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