Targeted Case Management Contact Monitoring Form Page 2
Download a blank fillable Targeted Case Management Contact Monitoring Form in PDF format just by clicking the "DOWNLOAD PDF" button.
Open the file in any PDF-viewing software. Adobe Reader or any alternative for Windows or MacOS are required to access and complete fillable content.
Complete Targeted Case Management Contact Monitoring Form with your personal data - all interactive fields are highlighted in places where you should type, access drop-down lists or select multiple-choice options.
Some fillable PDF-files have the option of saving the completed form that contains your own data for later use or sending it out straight away.
ADVERTISEMENT
1
2
3
4
5
6
75. Who do you call if you have a problem with an attendant(s)? ________________________________________________
□
□
6. Do you have a copy of your current person-centered service plan?
Yes
No
7. Who do you call if you want to make any changes to your person-centered service plan? __________________________
8. If you were dissatisfied with any of the services offered, have you reported this to your case manager or DAAS RN?
If yes, to whom did you report? ________________________________________________________________________
□
□
9. Do you have family who lives close to you?
Yes
No
If yes, who are they and what type of support do they provide to you?
________________________________________________________________________________________________
________________________________________________________________________________________________
□
□
If not, does anyone check on you?
Yes
No If yes, who and how often? __________________________________
□
□
10. Is there a pet(s) in the home?
Yes
No
If yes, what kind? ____________________________________________
□
□
□
□
Is the participant able to care for the pet?
Yes
No
Does it cause safety issues?
Yes
No
If yes, explain: ____________________________________________________________________________________
□
□
11. Overall are you pleased with the waiver services you receive?
Yes
No
If not, what changes/comments would you make to improve enrollment and service delivery?
________________________________________________________________________________________________
________________________________________________________________________________________________
12. Based on information from the participant and/or family, are services being delivered according to the waiver service plan
or provider service plan (as applicable/required)?
Services:
____________________________________________________________________________________
____________________________________________________________________________________
If no, document why: ______________________________________________________________________________
____________________________________________________________________________________
□
□
13. Do these services appear to remain appropriate to the waiver participant’s needs?
Yes
No
If no, document the date the copy of person-centered service plan was mailed to the participant.
Date ________________
14. Look at the residence. Is it neat, clean, foul odored, sanitary, or unsanitary? Document findings and observations.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
DMS-690 (1-1-16)
2
ADVERTISEMENT
0 votes
Related Articles
Related forms
Related Categories
Parent category: Business