2025-2026 Supportive 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 C1C2C3C4

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 an Independent Home Environment*

Number of consumers who remained in the home independantly

Were there any incident reports written for your home this week.

YesNo

Did any Medication Errors occur in your home this week

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.

*For Lifeways and Summit Point Only Was your Billing completed and turned in on time for your home this week? Due each Thursday by noon.

*For Lifeway an Summit Point Only If Billing was not ready by Thursday Noon, What were the issues experienced.

IPOS*

Rows	Which Consumer Met 75% of this weeks goals	Which Consumer was not in the home this week	Which Consumer Refused to Work on IPOS Goals
C1
C2
C3
C4

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

COMMUNITY INTERGRATIONS*

Rows	Consumer makes own personal Home assisted choices regarding when and where integration takes place (Yes or No)	Consumer Follows the scheduled home outing and events with input and choices considered (Yes or No)	How many Integration Outings were scheduled for this consumer ?(Please insert a Number)	How many Did the consumer participate in? (Please insert a number)
C1
C2
C3
C4