CYANJEL HOME CARE LLC
TIMESHEET
Pittsburgh, PA EIN: 87-1342372 Provider # 103936386
DCW Name
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First Name
Last Name
DCW Last 4 SSN
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Participant Name
*
First Name
Last Name
Participant Medicaid Id
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Service Location
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Service Date
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-
Month
-
Day
Year
Date
Total Hrs
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Punch In Time
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Hour Minutes
AM
PM
AM/PM Option
Punch Out Time
*
Hour Minutes
AM
PM
AM/PM Option
Reason for Missing In and Out
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Fail to call in and out.
Forgot to clock in.
Forgot to call out.
The HHAexchange data system was slow/didn't work at the time of punching in or out.
The service is conducted outside the residence.
Address did not link to the member (GPS).
Other Reason
Daily CARE Plan Activity (Select All that applies)*
*
Rows
YES
NO
Meal Preparation
Housework/Chore
Managing Finance
Managing Medications
Shopping
Transportation
Hygiene
Dressing Upper
Dressing Lower
Locomotion
Transfer
Toilet Use
Bed Mobility
Eating
Bladder Incontinence
Bowel Incontinence
Personal Care T1019
Bathing
Lotion/Ointment
Laundry
Reading/Writing
Supervision/Coaching/Cueing
Incontinence Care
Catheter Care
Wound Care
GnTube Feeding
Stairs
In Person
Via Telephone
Tub Bath
Shower Bath
Phone Use
Hair Care
Nail Care
Skin Care
Assist With Feeding
Assist With Walking
Range of Motion Exercise
Light House Keeping
Participant Signature
*
Participant signature date box
*
-
Month
-
Day
Year
Date
Direct Care Worker Signature
*
Direct Care Worker Signature Date
*
-
Month
-
Day
Year
Date
Submit Timesheet
Submit Timesheet
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