Targeted Case Management Contact Monitoring Form Page 3
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715. Look at cabinets/refrigerator. Document food supply.
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16. Look in bathrooms. Document observations.
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17. Document waiver participant’s mobility, transferring, etc. based on what you are told and what you observe.
___________________________________________________________________________________________________
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18. Targeted Case Manager's observations since the last visit? (Document changes in functional abilities,
changes in residence and its condition, changes in attitude, behavior, appearance, progress or lack of progress, etc.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
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Complete if Home Delivered Meals is on the PCSP:
N/A
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19. Are you receiving HDM?
Yes
No
What types of meals do you receive?
Hot
Frozen
Both
20. How are the meals heated? __________________________________________________________________________
21. Who heats the meals? ___________________________________________________________________________
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22. Are you pleased with the meals?
Yes
No
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23. Do you see the person who brings your meal?
Yes
No
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24. Do they leave without seeing you?
Yes
No
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25. Does your meal provider ask you for a donation?
Yes
No
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26. Do you usually eat most of the meal they bring?
Yes
No
27. How many frozen meals do you get at one time?_____________________________________________
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28. Do you have room for that many meals?
Yes
No
29. Observe how many meals are in the freezer? __________________________________________
DMS-690 (1-1-16)
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