A SSESSMENT P L A N FOR A FC RESIDENTS Michigan …

1 ASSESSMENT PLAN FOR AFC RESIDENTSM ichigan Department of Licensing and Regulatory AffairsBureau of Community and Health written assessment plan is required. The licensee is responsible for assuring that a written assessment plan form has been approved by the Department of Licensing and Regulatory Affairs and contains the informationrequired by administrative rule and Section 3 (9) form is to be completed by the licensee and resident, or the resident s designated representative. The responsibleagency, if any, may assist in this additional sheets if necessary and PRINT of ResidentName of Designated Representative (if applicable)Date of BirthSexMFI. SOCIAL/BEHAVIORAL ASSESSMENTPLAN OF ACTION (Check Yes or No and Complete Where Appropriate)YesNoIF NO, Describe Needs and How They Will Be MetA. Moves Independently inCommunityB. Communicates NeedsC.

2 Understands VerbalCommunicationD. Alert to SurroundingsE. Reads and WritesF. Tells TimeG. Manages MoneyH. Follows Sexual BehaviorK. Gets Along With Self InjuriousBehaviorM. Participants in SocialActivitiesN. SmokesO. Appropriately UsesAlcohol/DrugsSee Page 4 for Non-discrimination and ADA statementContinued on Next PageBCAL-3265 (Rev. 1-16) Previous editions may be used. MS WordPage 1 of 4II. SELF CARE SKILL ASSESSMENTPLAN OF ACTION (Check Yes or No and Complete Where Appropriate)Needs HelpYesNoIF YES, Describe Needs and How The Will Be MetA. Eating/FeedingB. ToiletingC. BathingD. Grooming (hair care,teeth, nails, etc.)E. DressingF. Personal HygieneG. Walking/MobilityH. Stair of Prosthesis(Dentures, Artificial limbs,etc.) of Assistive Devices(explain)K. Other (explain)III. HEALTH CARE ASSESSMENTPLAN OF ACTION (Check Yes or No and Complete Where Appropriate)YesNoIF YES, Describe Needs and How They Will Be MetA.

3 Taking medicationB. Special DietsC. Physical LimitationsD. Special Equipment Used(Wheel chair, Walker,Cane, etc.)E. Other Difficulties (Vision,Weight, Allergies, etc.)F. Susceptible toHypothermia orHyperthermiaContinued on Next PageBCAL-3265 (Rev. 1-16) Previous editions may be used. MS WordPage 2 of 4IV. SOCIAL AND PROGRAM ACTIVITIESPLAN OF ACTION (Check Yes or No and Complete Where Appropriate)YesNoExplain How These Activities Will Be Provided or EncouragedA. Participates in ReligiousPracticeB. Participates in HouseholdChoresC. Adult Activity ProgramD. Senior CenterE. Workshop or jobF. SchoolG. Hobbies/Special InterestH. (PleaseAddress Any ApplicableVisitation Prohibitions and/orOther ConsiderationsK. Other (explain)V. MEDICAL INFORMATIONName of Primary Physician/ClinicTelephone Number()Primary Physician s Complete Address (Street Number and Name)CityStateZip CodeV.)

4 MEDICATIONS TAKEN AT TIME OF ASSESSMENTName of MedicationWho PrescribedDosageContinued on Next PageBCAL-3265 (Rev. 1-16) Previous editions may be used. MS Word Page 3 of 4 MEDICAL OR DENTAL FOLLOW-UPS NEEDED ( , check-ups, regular appointments, etc.)VI. RELEASE OF INFORMATION RESIDENT OR LEGAL GUARDIAN SIGNATURE ONLY By signing this form, I understand that I am authorizing the release of medical information concerning me, includinginformationregardingAcquiredImm uneDeficiencySyndrome(AIDS),AIDSR elatedComplex(ARC)orHumanImmunodeficienc y Virus (HIV), if applicable, to the licensee and licensee s staff, the responsible agency and the MichiganDepartment of Licensing and Regulatory Affairs, Bureau of Community and Health Systems, for the purpose of providingappropriate care to me and determining compliance with licensing rules. Signature of Resident or Legal GuardianDateVII.

5 OTHER INFORMATIONC omments/Special InstructionsVIII. ASSESSMENT PLAN COMPLETIONDate Assessment Plan Was CompletedName(s) and Position(s) of Person(s) Who Completed AssessmentIX. PLACEMENT deterioration and movement to a more restrictive movement to a less restrictive SIGNATURESS ignature of Resident or Designated RepresentativeDateSignature of LicenseeDateSignature of Responsible Agency (if applicable)Date AUTHORITY:1979 218 LARA is an equal opportunity :VoluntaryPENALTY:Violation of Administrative Rule and 1979 218 BCAL-3265 (Rev. 1-16) Previous editions may be used. MS WordPage 4 of 4