Free Form 02AG041E (AG-24) Instructions - Oklahoma

Documentation of Qualifications to Provide Personal Care Services

02AG041I (AG-24)

Purpose of Form Form 02AG041E is used to document the requirements and abilities of an individual selected to perform specific personal care tasks as identified on the plan of care. Instructions for Preparation of Form Enter the name, Social Security number, address, and county of the Personal Care Assistant (PCA). The evaluator indicates whether the PCA or the evaluator has provided or obtained the information required before the PCA can begin work. Any written comments are entered in the comments section. The date the information is received is entered in the date column. The evaluator signs and enters the date all requirements are received. The name of the PCA is entered where indicated for the client to approve the individual as PCA and the client signs and dates the form. The evaluator completes the identifying information at the top of the second page to deliver Medicaid personal care services. The evaluator observes the demonstration of each task and provides any additional instruction to assure the PCA performs the task safely and according to the needs of the client as identified on the plan of care. The PCA and evaluator initial the box beside each task indicating the task was performed satisfactorily. The date of the successful competency demonstration of each task is entered. Other tasks not on the list may be added within the realm of personal care services. The PCA and evaluator sign and date the form. Routing of Form Original Copy PCA file Client file

OKDHS REVISED 3-1-2003

1