Personal Care Agency – Functional Assessment

PERSONAL CARE AGENCY - FUNCTIONAL ASSESSMENT


A Functional Assessment is completed for each client prior to admission to the agency and annually thereafter, or at earlier intervals when a significant change in condition occurs.

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FUNCTIONAL STATUS & ASSISTANCE NEEDED: ADL=Activities of Daily Living

BOWEL & BLADDER MANAGEMENT LEVEL
  1. Independent. No accidents.
  2. Does with some help.
  3. Requires supervision, set-up, cueing, and/or coaxing. Needs assistance with equipment. Has infrequent accidents.
  4. Does with maximum help and/or daily accidents.
ADL/MOBILITY FUNCTIONING LEVEL
  1. Independent, safely without assistance.
  2. Does with some help
  3. Uses an assistive device, takes a long time or does with great difficulty. Personal Care Aide does more than half of the activity.
  4. Does with maximum help or cannot do at all.

MEDICATION MANAGEMENT

2. Requires reminders.
3. Open container and remind.

PERSONAL CARE SERVICES

LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED

MOBILITY

Is client at risk of falling?
Has client fallen recently?
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LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
LEVEL 1-4
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED

COGNITIVE | COGNITIVE FUNCTIONING

DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
DESCRIBE HOW CLIENT FUNCTIONS & ASSISTANCE NEEDED
If cognitively impaired, has the client been medically evaluated to rule out reversible conditions?
Source of cognitive status information:
The Personal Care Services, as described above, can be provided safely to this client.

Note: If the Functional Assessment reveals that the client’s needs exceed the personal care services, the health care professional must make a referral to a home health agency or other alternative service.

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