Free Form 02AG040E (AG-22-A) - Oklahoma

*02AG040E-001*
OKLAHOMA DEPARTMENT OF HUMAN SERVICES Personal Care Aide (PCA) Supervisor Visit Date Client name Agency 1. How much help has the PCA been? a lot County Case number PCA present? Yes No some none Yes Yes No No

2. Do you know your PCA's name? Does your PCA have any legal authority over you? Name:

3. Is your PCA: Cooperative? Yes No Punctual? Yes No Does your PCA stay scheduled time? Yes No Days and times your PCA visits: When your regular PCA is unable to make your regular visit, does the agency send someone else? Yes No Is there anything that you need done that is not being done? Comments: 4. 5. Do you know the name of the agency your PCA works for? Can you locate the phone number? What does your PCA help you do? bath _____ times a week shopping/errands in home laundry 6. 7. shampoo housekeeping out of home cooking other Yes Yes No No

What does your PCA do that helps you the most? Do any other health care professionals visit you? Yes No Don't know Name of agency: Services provided: Generally, the client's health status has: remained unchanged improved: deteriorated:

8.

OKDHS revised 1-1-2005

02AG040E (AG-22-A)

02AG040E (AG-22-A) 9.

Personal Care Services (PCA) Supervisory Visit

Does the client's physical environment, personal appearance, and nutritional status reflect the number of units approved in the home? Yes No Comments: Yes No

10. Are there any concerns regarding client's medications? Current medications: 11. Does the client have adequate informal support? Informal support person or persons: What do they do and how often?

Yes

No

12. Mobility:

ambulatory

wheelchair Yes No

other

13. Changes in mental status?

Alert and oriented. Somewhat alert, continues to be able to function safely in home with current informal support. Not alert, unsafe to be left alone. Comments: 14. Has the client seen his or her physician in past six months, been to the E.R., or admitted to the hospital? Yes No Comments: 15. Are the services provided consistent with the care plan? Comments: 16. Care plan changes: Comments: 17. Visit frequency: Healthcare management nurse signature Copy sent to agency on date Mailed Faxed Yes No Increase Decrease Yes No

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OKDHS revised 1-1-2005