Participant Monthly Monitoring/Over Sight Form
Abundant Living Home Health Services
Home Visit
Telephone Call
Date
-
Month
-
Day
Year
Date
Time of Contact
Participant's Name
First Name
Last Name
Participant's DCN#
Phone Number
Please enter a valid phone number.
Format: (000) 000-0000.
Spoke Directly withConsumer:
Yes
No
If no, who did you speak with, and what is the relationship to the Consumer?
Why was Consumer not available to speak with the Monitor?
Any changes in Consumer's personal contact information (address, phone number) including back-up emergency plan?
Are there any changes in your health condition?
Yes
No
Were you admitted into the hospital this month?
Yes
No
If Yes, please explain:
How many days a week does your Attendant come?
How many hours is the Attendant there per day?
Are your services being delivered according to your care plan?
Yes
No
What are some of the services your Attendant performs for you?
Dietary
Dressing/Grooming
Bathing/Hygiene
Mobility/Transfer
Toileting
Meds
Meal/Dishes
Clean Kitchen
Clean Bath
Clean Living Area
Make Beds/Change Linen
Laundry
Trash
Wash Windows/Blinds
Shopping/Errands
Essential Correspondence
Housekeeping
Are there any problems between you and your Attendant?
Yes
No
If Yes, please explain:
Are you still able to self-direct your services?
Yes
No
If No, please explain:
Do you and the Attendant understand the program requirements?
Yes
No
If No, please explain:
Do you have any issues or concerns at this time that you need assistance with? (i.e. utilities, lack of food, ect?)
Yes
No
If Yes, please explain:
Home Visit Observation Only
Appearance of Consumer: Satisfactory
Yes
No
Appearance of home: Satisfactory
Yes
No
If No, please explain:
Additional Comments
Submitted By:
First Name
Last Name
Submit
Should be Empty: