Supportive Living Homes
Weekly PMM Data Management
Date
*
-
Month
-
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Person Completing Data
*
First Name
Last Name
Select Home Name
*
Adams
Blackstone
Deyo
Elm I
Elm II
Herkimer Apt
Hill Place
Homecrest 1
Homecrest 2
Homecrest 3
Madison
Monroe
Pleasant I
Pleasant II
Sixth
Spring Arbor
Westbrook
W. Washington
(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
C1
C2
C3
C4
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.
Yes
No
Did any Medication Errors occur in your home this week
Yes - an incident report was filed.
No - no errors occured
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.
Yes
No
N/A
*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
Submit
Should be Empty: