New AFL 60-Day Visit Summary

CONNECTICUT HOME CARE PROGRAM COMMUNITY OPTIONS SERVICE PROVIDER MANDATORY REPORT
Admission ID
For use with MONDAY.COM link column
PERIOD COVERED
WAS THERE A CHANGE IN THE CLIENT'S CONDITION DURING THIS TIME PERIOD?
WAS THIS CHANGE REPORTED TO THE ACCESS AGENCY?
Reported to:
Please type the name of the person at the access agency to whom this information of a change in client's condition was reported to.
Date/Time

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate
NOTE: You are required to immediately report to the Access Agency any significant change in the client's health, functioning, safety issue, hospitalization. You are required to report to the Access Agency immediately any change in your ability to provide services to the client, such as your unexpected absence, client refuses services, client not home.
Provider Agency
Contact Person
PROVIDER AGENCY:
NAME OF CARE MANAGER
If you do not know the name of the care manager please write "Unknown"
Participant First Name
Particpant's First Name
Participant Last Name
Participant's Last Name
Participant's Address

Street Address (Include Apt or Unit#)

Apt or Unit #

CityState

Zip Code
Type of Service:

Other
AFL Level of Participant
Number of Hours per Week
Number of Visits per Week
Form Completed by
Emerest Representative' Full Name
Your Work Email Address
To receive your copy of this form.
Nurse’s Signature
*Per the Connecticut General Statutes: 17b 450- 461, your agency and your staff are mandated reporters of alleged elder abuse, neglect, exploitation or abandonment. Department of Social Services Protective Services For The Elderly Central Intake Line: (888)385-4225
AFL HOME VISIT SUMMARY
PARTICIPANT INFORMATION:
Phone Number
Please enter a valid phone number.Format: +1 (000) 000-0000.
Primary Language
Date of Birth

MonthDayYear
2 digit month, 2 digit day, 4 digit yearClient's Date of Birth
Living Status (It is the responsibility of the agency to verify that the DCP and participant live in the same home)
Food or Environment Allergies
DIRECT CARE PROVIDER INFORMATION

Primary AFL Caregiver
Direct Care Provider Name
Primary Caregiver Name
Relationship to Participant
DCP Phone#
Format: +1 (000) 000-0000.
RN Visit Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate

Meal Consumption Percentages

Rows	Percentage%
Breakfast
Lunch
Dinner
Snack

Purpose of Visit (chose other and state visit type if the visit is not part of the ongoing 60 day visit ex: post hospital visit or pop up visit)

Other

Is Home Environment Checklist

Rows	Yes	No
Is the home clean and in good repair?
Does the home reflect regular maintenance?
Is the lighting/heating/cooling/ventilation working?
Is the home equipped with fire extinguisher and first aid kit?
Is the home clutter free?
Is the home safe?

Other Home Environment Finding or Note:

DIRECT CARE PROVIDER OBSERVATIONS

Rows	EXCEEDS	MEETS	DOES NOT MEET	NOT OBSERVED
Care Plan has been implemented and is being followed?
DCP is meeting the health and safety needs of the partcipant
DCP promptly reports to Emerest any changes in participant's condition
DCP demonstrates overall competency in their responsibilities
DCP has completed the required training?
DCP continues to provide nutritionally balanced meals and healthy snacks

PARTICIPANT OBSERVATIONS

Rows	YES	NO	EXPLAIN
Since the last visit, has the participant had any changes in condition?
Has the participant reported any dissatisfaction or concerns regarding the DCP?
Has the participant requested or required any additional services?

SPECIAL PRECAUTIONS

Other
Special Instructions and Additional Comments
Provide a brief summary of your findings. Include information regarding the caregiver's ability to care for the client.
Today's Date

MonthDayYear
2 digit month, 2 digit day, 4 digit yearDate should match the date of the home visit.
DCP Agreement and Signature.
Direct Care Provider Signature
Direct Care Provider Email
They will get a copy of this visit summary
Participant Agreement and Signature.
Participant Signature

CONNECTICUT HOME CARE PROGRAM COMMUNITY OPTIONS SERVICE PROVIDER MANDATORY REPORT

AFL HOME VISIT SUMMARY

PARTICIPANT INFORMATION:

DIRECT CARE PROVIDER INFORMATION

Photo for add-ons