PCA Timesheet

PCA Timesheet

Time and Activity Documentation
If you are unable to successfully submit your visit using the HHA Mobile App, you must submit this backup timesheet within 24 hours so your time can be entered for the current pay period.

Complete and submit this Timesheet and fill in all areas per the client's care plan. Both you and the Client or Responsible Party must sign the form in order for it to be valid.

Agency Name: A Chance To Grow, Inc.
Agency Phone Number: (612) 789-1236
Brief explanation of why you were unable to submit your shift through EVV:*
Has the recipient been hospitalized or incarcerated overnight in the past month?*

YesNo
If yes, please provide date(s) and location(s):
Date of Service (Visit/Shift Date):*

MonthDayYear
Date

Activities:*

	Completed	Not Completed	Client Refused
Behavior, Observation, and Monitoring (*activity cannot be marked "refused")
Bathing - Tub
Bathing - Shower
Bathing - Bed
Mouth / Oral Care / Denture Care
Hair Care / Comb / Style
Shampoo Hair
Shaved
Non-Diabetic Nail Care (*activity not allowed if client is diabetic)
Dressing / Undressing
Skin Care
Toileting - Brief / Diaper
Toileting - Commode
Toileting - Bedpan / Urinal
Toileting - Toilet
Monitor / Assist with Feeding / Eating
Transfers - Transfer Belt & Standby
Transfers - Transfer Belt & Board
Transfers - Transfer Belt & Manual Lift
Transfers - Hoyer
Walking - Staff Assistance
Walking - Use of Devices
Walking - Device & Staff Assistance
Home Exercise Program / ROM
Position Change Minimum of Every 2 Hours
Complex Health Related Tasks (*Only if identified in client's care plan)
Behavioral Support & Intervention
Diversional Activities
1:1 Supervision / Monitoring of Client Safety (*Always Required, must be marked "Completed")
IADL's (*Only if Client is over 18 years old)
Meal Planning
Meal Preparation
Assist with Paperwork / Phone Calls / Bill Paying
Community Outing / Participation
Light Housekeeping
Essential Shopping (*Client must be present)
Laundry
Assist with Communication
Wash Dishes
Assist with Transportation (*Must have agency authorization to transport)
Clean Client's Medical Equipment
Accompany Client to Appointments

Was this shared care?*

YesNo
Where was the share care provided? (Select all the apply)

HomeCommunity
What was the ratio of PCA to Clients?

1:21:3
Time In:*

Hour Minutes

AM/PM Option
Time Out:*

Hour Minutes

AM/PM Option
Total Time (in Minutes):*
Enter the amount of time in minutes
Acknowledgement and Required Signatures
After the employee has documented his/her time and activity, the Client/Responsible Party must review the completed time sheet for accuracy before signing.
Name of Staff / Caregiver:*

First NameLast Name
Staff ID:*
Fraud statement:

I declare under penalty of perjury that all hours worked and descriptions of work performed contained in the submitted shifts are true and correct with full knowledge that all of this information may be subject to investigation and that any false or dishonest information contained on these shifts may be grounds for denial of payment and/or reporting of findings to the investigation unit of the Department of Human Services.
Staff / Caregiver Signature:*

Clear
Date:*

MonthDayYear
Date
Caregiver Title:*

PCADSW (Respite Care, Homemaking and/or Companion Care)
Name of Client / Care Receiver:*

First NameLast Name
Birth Date of Client:*

MonthDayYear
Date
Fraud statement:

I declare under penalty of perjury that all hours worked and descriptions of work performed contained in the submitted shifts are true and correct with full knowledge that all of this information may be subject to investigation and that any false or dishonest information contained on these shifts may be grounds for denial of payment and/or reporting of findings to the investigation unit of the Department of Human Services.
Client / Responsible Party Signature:*

Clear
Date:*

MonthDayYear
Date
Should be Empty:

PCA Timesheet

Fraud statement:

Fraud statement: