Community Living Homes

Date*

Date

Person Completing Data*

First NameLast Name

Select Home Name *

(if your home is not in the drop down menu please close out and use the Community Living Form Instead)

Please list the initials of the consumers in the home this week

C1C2C3C4C5C6

HCBS COMPLIANCE STATEMENT:All HCB Settings where people live receive Medicaid HCBS must have the following characteristics to the same extent as those individuals not receiving Medicaid HCBS?CCH strives to support full access to the greater community, including opportunities to seek family or guardian involvement, friendships and social integration. Assure that the client will also have access or control of personal resources, and access to community services. CCH monitors all training and indicators conducted by our staff to assure they are supportive and assist in seeking new opportunities for the people we serve to have healthy, happy and productive lives.

Maintained Supported living Home Environment*

Number of consumers who remained in the home independantly

Did Your staff Provide daily meals on time, substantial quantity and enjoyable to the people you serve? If a consumer refused a meal please reduce your daily count by the number of days refused. ( Example if Consumer 1 refused to eat on Tuesday your answer should be 5-6 Days)*

Rows	Extremely Satisfied	Satisfied	Not Very Satisfied	Reason for any Meal Refusals	Consumer Initial
C1
C2
C3
C4
C5
C6

All consumers received medication according to Dr. Orders

Following the The 7 R's Of Medications. Right client; Right time – ½ hour before scheduled dose to ½ hour after; if a specific time is stated on the order; Right medication; Right dose; Right route; Right documentation; Right to refuse.

Consumer Executed Personal Task as described in IPOS

IPOS*

Rows	Consumer Met All Weekly Expectations	Met 25% of This weeks goals	Met 50% of this weeks goals	Met 75% of this weeks goals	Consumer was not in the home this week	Consumer Refused to Work on IPOS Goals
C1
C2
C3
C4
C5
C6

HOW MANY CONSUMER DAILY PROGRESS NOTES ARE COMPLETED AND UP TO DATE FOR THE WEEK . *

PERSONAL FUNDS*

Rows	Cunsumer handles their own money completely	Consumer makes own personal Home assisted choices regarding spending and has access to facility monitored funds and	Consumer Gets No monthly Personal Funds	All Funds are available to consumer: The Home staff makes reasonable choices on the consumers behalf	consumers payee makes all financial choices
C1
C2
C3
C4
C5
C6

COMMUNITY INTERGRATIONS*

Rows	Consumer moves freely through the community with out assistance	Consumer makes own personal Home assisted choices regarding when and where integration takes place	Consumer Follows the scheduled home outing and events with input and choices considered	All Funds are available to consumer: The Home staff makes reasonable choices on the consumers behalf	consumers payee or guradian makes all integration decisions
C1
C2
C3
C4
C5
C6

MEDICAL SERVICES*

Rows	Consumer had NO medical appointments this week	Consumer Medical Appointments WE MET AS SCHEDULED	Consumer After Care Directions were returned to the Manager promptly or manager notified immediately	a Followup appointment or Aftercare recomendations are required	This Consumer has new Urgent Information regarding their medical care
C1
C2
C3
C4
C5
C6

Community Living Homes

EFFECTIVENESS

EFFICIENCY