ࡱ> npklmq` |4bjbjqPqP ;q::)NNNd}}}~TBr~l^HHH'|íííííí$hNs#'ssHHs8HNHs:,6NyHr `ط;}j 0B'R_*yNy4sssssss^sssBssssovvdvv NAME:NICKNAME:Age:Birthdate:Place of birth:Gender: ( M ( FAssessment Location:Living arrangements:Marital Status:Spouses name:Maiden name:Childrens names: Primary Contact Person:Relation:Address:Phone #: Social Security #:Medicare #:Medicaid #:Veteran: ( Y ( NBranch of Service: Primary Health insurance:Policy #:Pre-authorization required: ( Y ( NPhone #:Other insurance coverage:Policy #: SUBSTITUTE DECISION MAKER: ( Y ( N (If yes, provide a copy to the facility)Name:Phone:Scope of decision-making capabilities: Primary Care Provider:Clinic Address:Phone:Fax:SPECIALIST:Phone:Fax:SPECIALIST:Phone:Fax:DENTIST:Phone:Fax:PHARMACY:Phone:Fax:Preferred Hospital:Phone: ADVANCE DIRECTIVES: ( Y ( N (If yes, provide a copy to the facility)Funeral Arrangements? ( Y ( N Funeral Home:Phone #: Current Height (ft/in):Current Weight (lb): ( Recent change? Explain: Blood Pressure:Pulse:Resp:Temp: CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWCOMMUNICATION: SPEECH/HEARING/VISION  Yes NoProblems with speech Describe:  FORMCHECKBOX  FORMCHECKBOX  Hearing problems Describe/aid:  FORMCHECKBOX  FORMCHECKBOX Visual problems Describe/aid:  FORMCHECKBOX  FORMCHECKBOX Telephone Use  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  DependentLanguage: DescribeMEDICATION MANAGEMENT: Self Administration (Check all that apply) FORMCHECKBOX  Oral  FORMCHECKBOX  Topical  FORMCHECKBOX  Eye drops/ointments  FORMCHECKBOX  Inhalers FORMCHECKBOX  Sprays  FORMCHECKBOX  Injections  FORMCHECKBOX  Allergy Kits  FORMCHECKBOX  Keep Own Meds SELF MEDICATION W/ASSISTANCE  FORMCHECKBOX  Oral  FORMCHECKBOX  Topical  FORMCHECKBOX  Eye drops/ointments  FORMCHECKBOX  Inhalers FORMCHECKBOX  Sprays  FORMCHECKBOX  Allergy Kits  FORMCHECKBOX  Meds Organizer  FORMCHECKBOX  Equipment:  CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWADMINISTRATIONNurse Delegated?  FORMCHECKBOX  Yes FORMCHECKBOX  No FORMCHECKBOX  Oral  FORMCHECKBOX  Topical  FORMCHECKBOX  Eye drops/ointments  FORMCHECKBOX  Inhalers  FORMCHECKBOX  Sprays  FORMCHECKBOX  Allergy Kits  FORMCHECKBOX  Meds Organizer  FORMCHECKBOX  Equipment:  Injections  FORMCHECKBOX  Yes  FORMCHECKBOX  NoIf yes:  FORMCHECKBOX  By family  FORMCHECKBOX  Licensed professionalMedication plans when resident not in home: TREATMENT/PROGRAMS/THERAPIES Health issues to monitor:YesNoOxygen UsePainWeight Loss/GainPrograms the resident attends, such as adult day health Nursing Consultation/TreatmentsYesNoRN DelegationWhat tasks: Consent Physical Enablers:  CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWPSYCH/SOCIAL/COGNITIVE STATUSYesNoWhat resident does Describe behaviors be specific:Describe specific non-medication (behavioral/environmental) interventions to address the symptoms Sleep disturbanceMemory impairment (Short-term)Memory impairment (Long-term)Decision makingDisruptive behaviorAssaultiveResistiveDepressionAnxietyDisorientationWandering in homeExit seekingHallucinationsDelusions If yes, describe:Requires psychopharmacological medications If yes, describe symptoms for each medicationSTANDARD PRECAUTIONSCaregiver will use latex/plastic gloves when in contact with any secretions to prevent spread of infection. Thorough hand washing with soap will be done before and after gloving. Gloves will be put on and discarded at the end of each task.  CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWMOBILITY In room & immediate living environment:  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  DependentOutside of immediate living environment (to include outdoors):  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Equipment: Preferences/Choices: BED MOBILITY/TRANSFER  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Skin care due to inability to position self:Equipment/supplies: Risk for falls:Preferences:Enablers: Safety assessment, alternatives explored; how to keep resident safe: Night time care needs: EATING  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent  Special diet/supplements: Eating habits Food allergiesPreferences/equipmentCARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWTOILETING/CONTINENCE ISSUES  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Bladder incontinence  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  Occasional Bowel incontinence  FORMCHECKBOX  Yes  FORMCHECKBOX  No  FORMCHECKBOX  OccasionalSkin care due to bowel/bladder incontinence:Equipment: Preferences: DRESSING  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Equipment: Preferences: PERSONAL HYGIENE  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Oral hygiene, including dentures: When and how often: Preferences: BATHING  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent  How often: When: Equipment: Preferences:  CARE AND SERVICESRESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLYWHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOWBODY CARE (Foot care, skin care, nail care, range of motion, dressing changes)  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent  Foot care:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Skin care: How often: Skin problems:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Describe: Dressing changes:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Nurse delegated:  FORMCHECKBOX  Yes  FORMCHECKBOX  No Preferences:MANAGING FINANCES  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Who manages finances: Financial records: Preferences:SHOPPING  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Special transportation needs: How often: Preferences: TRANSPORTATION  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Medical services: Special transportation needs: Equipment: How often: Preferences: ACTIVITIES/SOCIAL NEEDS  FORMCHECKBOX  Independent  FORMCHECKBOX  Assistance  FORMCHECKBOX  Dependent Interests/Activities/Religious Activities: Social/Cultural Traditions/Preferences: Family/Friends/Relationships: Employment Support: Clubs/Groups/Day Health: Emergency Numbers Provided: Special Arrangements: Participation Issues SMOKING  FORMCHECKBOX  Yes  FORMCHECKBOX  No Safety Concerns: Preferences: CASE MANAGEMENT Contact the case manager when: The resident needs assistive device or other services to meet the needs Significant changes with the condition/needs that necessitate changes with this service agreement OTHER ISSUES/CONCERNS/PROBLEMS  WAC 388-78A-2130 - 2160 Negotiated Service Agreement: Brief instructions based on WAC Developed within 30 days of admission based on the Assessment and the Initial Resident Service Plan. Describes/identifies: (a) The services to be provided; (b) Who will provide the services; and (c) When and How the services will be provided. Designed to meet the Residents Needs, Preferences, and Choices. Developed with input from the Resident and/or the Residents Representative / Surrogate Decision Maker, appropriate professionals, and the case manager, if applicable Agreed to, Signed and Dated by the Resident and/or the Residents Representative / Surrogate Decision Maker, appropriate professionals, and the provider. The signed copy of the plan must be given to the Case Manager if Resident is receiving services paid for fully or partially by the department. Reviewed and Revised: (a) at least every 12 months; (b) upon any significant change in Residents physical, mental, or emotional condition; and when the negotiated service agreement no longer describes the residents needs and/or services. DATE OF ORIGINAL SERVICE AGREEMENT: TITLE/TYPESIGNATUREDATEREVIEW/REVISE DATEREVIEW/REVISE DATEPROVIDER RESIDENT RESIDENT REPRESENTATIVE RESIDENT REPRESENTATIVE SURROGATE DECISION MAKER CASE MANAGER SOCIAL WORKER HEALTH PROFESSIONAL OTHER: OTHER:  The person signing writes the date s/he actually read and agreed to the plan. If the participant has verbally agreed to the plan, the provider should note below: (a) the name and role of the participant; (b) the date the participant had the plan to read to them; and (c) what if any changes the participant recommended for the plan. ______________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________     BH NEGOTIATED SERVICE AGREEMENT Resident Name: _______________________________________________ Page  PAGE 1 BH NEGOTIATED SERVICE AGREEMENT Resident Name: _______________________________________________________________________ Page  PAGE 2 Resident Name: ____________________________________________________________________ Page  PAGE 4 Resident Name: ______________________________________________________________________ Page  PAGE 6 Resident Name: ___________________________________________________________________ Page  PAGE 10 :;AB ! 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