ADULT RESIDENTIAL LICENSING PERSONAL CARE HOME ...

1 Completion of the Preadmission Screening is essential to ensure that the admitting home is aware of a resident s medical, psychological, and behavioral needs, and that the home can safely meet those needs. The Preadmission Screening MUST be completed PRIOR TO ADMITTING THE APPLICANT TO THE HOME AS A information captured on this document represents the most basic information homes must have to make an informed decision about admitting a resident. Homes may and are encouraged to include other information as part of their preadmission screening part of the screening is separated into different elements. Completion of the entire form is required for complete compliance; however, some elements will not result in a regulatory violation if they are not completed. The table below shows the primary benefit of each element, and regulatory response if the element is not completed: ADULT RESIDENTIAL LICENSING PERSONAL CARE HOME PREADMISSION SCREENING For Compliance with 55 and To be completed within 30 days prior to admission INSTRUCTIONS FOR USEE lementPrimary BenefitRegulatory Response if not CompletedI-A: Title of Person Completing ScreeningEnsures completion by qualified personViolationI-B: Printed Name of Person Completing ScreeningDocuments actual completion by qualified personViolationI-C: Signature of Person Completing ScreeningDocuments actual completion by qualified personViolationI-D: Name of Admitting PERSONAL Care HomeRecords home considering admission of residentTechnical AssistanceI-E: Date Screening CompletedEnsures completion prior to admissionViolationI-F.

2 Screening Information SourcesDocuments sources of information to ensure validity of informationViolationII-A: NameDocuments the name of the applicantViolationII-B: Date of BirthDocuments the age of the applicantViolationII-C: Primary Language Spoken / Means of CommunicationEnsures home can effectively communicate with applicant if admittedViolationII-D: Current ResidenceDocuments resident s social history; offers insight into social needsTechnical AssistanceII-E: Length of Time at Current ResidenceDocuments resident s social history; offers insight into social needsTechnical AssistanceII-F: Reason for Leaving Current ResidenceEstablishes the medical, psychological, behavioral, or social basis for seeking PCH admissionViolationII-G: Level of Supervision NeededEnsures that home is aware of resident s supervision needsViolationII-H: Mobility NeedsEnsures that home is aware of resident s mobility needsViolationII-I: Ability to Self-Administer MedicationsEnsures that home is aware of resident s medication needsViolationII-J: PERSONAL Care and Medical Needs (ALL)Ensures that home is aware of resident s PERSONAL care and medical needsViolationPART III: DETERMINATIONE stablishes that home can meet applicant s needsViolationPART IV: COGNITIVE SCREENINGE stablishes that resident requires secured careViolationPART I: SCREENER INFORMATIONI-A: Title of Person Completing Screening: (Check ONE)Human Services Agency Staff (List Agency).

3 Designated PERSONAL Care Home Staff PersonPersonal Care Home AdministratorI-B: Printed Name of Person Completing Screening:I-E: Date Screening Completed:I-C: Signature of Person Completing Screening: I-D: Name of Admitting PERSONAL Care Home:ApplicantApplicant's Informal SupportsMedical recordsOther (specify):I-F: Screening Information Sources:PART II: APPLICANT INFORMATIONII-A: Name:II-B: Date of Birth:II-C: Primary Language Spoken / Means of communication:5 or more years1 - 5 years3 months - 1year<3 monthsII-E: Length of Time at Current Residence:II-F: Reason for Leaving Current Residence:..formal support (home health, day services, etc)..informal support (family/friends)..no formal or informal formal and informal supportsII-D: Current Residence:II-G: Level of Supervision Needed: Independent Applicant has no mobility needs and can evacuate independently in an emergency Minimal (Mobile) Applicant requires limited physical or oral assistance to evacuate in an emergency Moderate (Immobile) Applicant requires moderate physical or oral assistance to evacuate in an emergency Total(Immobile) Applicant requires total physical or oral assistance to evacuate in an emergency from one or more staff persons None Applicant requires no supervision either in the home or when in the community Minimal Applicant requires no supervision in the home or when in familiar surroundings, but needs attendance in unfamiliar places Moderate Applicant requires some supervision in the home and needs attendance when outside the home, and/or tends to wander Extensive Applicant requires regular supervision in the home and cannot leave home unattended.

4 Unaware of unsafe areas Total Applicant requires 24-hour direct supervisionII-H: Mobility Needs:II-I: Ability to Self-Administer Medications:DPW-ARL- Preadmission Screening 7/1/11 Page 1 of 2 Applicant can self-administer without assistanceApplicant can self-administer with (check all that apply)..Applicant cannot self-administer in remembering in offering medications at prescribed in opening container or locked storage areaPrivate home or apartment PERSONAL care homeNursing facilityMH/ID Community settingHomelessOther (specify):Turning and positioning in bed/chairEatingDrinkingTransferring in/out of bed/chairToiletingBladder ManagementBowel ManagementAmbulatingPersonal HygieneManaging Health CareSecuring Health CareII-J: PERSONAL Care and Medical Needs Check all that Apply:Activities of Daily Living (ADLs): Instrumental Activities of Daily Living (IADLs):Obtaining clean, season clothingDoing laundryShoppingSecuring and using transportationManaging financesUsing the telephoneMaking and keeping appointmentsCaring for PERSONAL possessionsWritten correspondenceEngaging in social and leisure activitiesUsing a prosthetic deviceIf No is checked, specify local assessment agency to which applicant was referred.

5 Please be advised that this referral is required by (b):PART III: DETERMINATIONPART IV: COGNITIVE SCREENING Note: This section applies only if the applicant is seeking admission to a Secured Dementia Care Unit. This section must be completed by a physician or geriatric assessment team within 72 hours prior to admission to the Secured Dementia Care on this screening, I verify that the needs of this applicant require secured care due to Alzheimer's Disease or other dementia: YESNODPW-ARL- Preadmission Screening 7/1/11 Page 2 of 2 AnxietyPhysically violentDisorientationDelusionalAgitation LethargyHostilityWanderingConfusionHallu cinationsSadnessBehaviors Exhibited (Check all that Apply):Diagnosis:Date Screening Completed:Printed Name of Person Completing Screening:Signature of Person Completing Screening:Title of Person Completing Screening: (Check ONE)PhysicianGeriatric Assessment Team RepresentativeBased on this screening, I verify that the needs of this applicant can be met in this PERSONAL care home:YESNOYESNOThis resident CAN SAFELY USE AND AVOID POISONOUS MATERIALS.

6 Suicide attemptsFire-startingPhysical violence toward othersSexually abusive or inappropriate actsSubstance abuseOther (describe):History of Problematic Behavior (Check all that apply):Total hearing impairmentHears with device (specify):Total visual impairmentSees with device (specify):Sensory Needs:Medical, Psychological, and Behavioral Diagnoses (list).