Form Ddd-1431aforpf - Attendant Care/housekeeping Service Monitoring/supervision
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DDD-1431AFORPF (4-07)
ARIZONA DEPARTMENT OF ECONOMIC SECURITY
Division of Developmental Disabilities
ATTENDANT CARE/HOUSEKEEPING SERVICE MONITORING/SUPERVISION
This form should be used to evaluate Attendant Care/Housekeeping service provided by an Independent Provider or Qualified Vendor
employee. A Qualified Vendor may choose to use this form or one by their own agency.
INDIVIDUAL’S NAME (Last, First, M.I.)
I.D. NO.
SUPPORT COORDINATOR’S NAME
SERVICE START DATE
MONITORING VISIT DATE
SERVICE
1. OUTCOME (Objective)
Attendant Care (ANC)
Attendant Care Family (AFC)
Housekeeping
5 days
30 days (ANC/AFC/HSK in-home)
60 days (if required)
90 days
Check the appropriate box. If ‘NO’ is checked, please enter a comment.
YES
NO
N/A
1. Does the individual appear to have their ANC/AFC or HSK needs met?
2. Was activity observed or reported as consistent with the service agreement?
3. Is the provider respectful of the consumer/family choices?
4. If attendant care (non-family member) is being provided, is the individual/family satisfied with the
service provided?
5. Are other providers used for this service? If yes, are there any concerns with the other providers?
6. Are there skin integrity issues?
6a.
If there are skin integrity issues, is the provider following the ISP for resolution?
6b.
Has a nursing assessment been completed?
7. Does the family know who to call if a problem arises?
8. Does the individual/responsible person know who to call if there is a service gap or their provider does
not show up to provide a scheduled service?
MONITOR’S NAME
TITLE
SIGNATURE
DATE
CONSUMER OR FAMILY MEMBER’S NAME
SIGNATURE
DATE
PROVIDER’S NAME
TITLE
SIGNATURE
DATE
Routing: Original - Employee’s file; copy - Consumer case record; copy - Provider file.
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