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Comments:Communication:Is client able to speak and verbally express him/herself?YesNoComments:Name devices the client uses to communicate/understand others:BEHAVIORAL HEALTH(Check all that uptive @ timesForgetfulPleasant & cooperativeResistant to careVerbally Abusive & threateningOther:Other:ETOH Use: How often: Meetings:Mini Mental/BIMS Score:DateComments:Information provided by:FALL RISKDoes the client have a history of falls?YesNoComments:HEARING & VISIONHearing impairedAssistive devicesMDComments:Vision impairedGlasses or deviceMDIndicate client’s current vision quality (w/ glasses if used regularly):1)Adequate – sees fine print2)Impaired – sees larger print20

3)Mod Impaired – limited vision4)Highly Impaired – sees only light/shadowsComments:DIETDiet:NPO: Parental:Special instructions/preparations:Comments:Able to chewAble to swallowAspiration precautionsOwn teethDenturesPartial plateComments:DENTALName of dentist: Date of last visit:HEIGHT/WEIGHTWeight:Recent gain:YesHeight:No Recent loss:Yes21No

HEALTH CARE PROVIDERS / SPECIALISTSType (PCP/ .5.6.7.8.Behavioral HealthProvidersDentistOther:Other:PCP appointment after discharge: Date TimeOTHER APPOINTMENTS:22

SLEEPIs client satisfied w/ sleep quality?YesnightNo # of hours perComments:MEDICAL ISSUESDiagnosis:ArthritisCHFGI issuesMSSeizure d/oAsthmaCOPDHead InjuryParkinsonsSkin une disorderChemo/radiationUrinary problemsCardiacRenalDialysisComments:Surgical HistoryDates23

Smoking:YesNoQuit:YesNoCessation Classes:YesNoIf yes, how long?MEDICATIONSDescriptionDoseFrequencyRouteWhy takenMethod of preparation:Who administers medications?Allergies:Reaction:Pharmacy:24

Is client compliant/following schedule with taking medications?YesNoComments:SKIN INTEGRITYIntactOpenRashIncisionActive Infection(s) ttoiletcommodebedpanurinalIncontinentbriefstexas catheterindwelling catheterintermittent catheterizationOstomyDialysisType:Treatment on:Intensity:verbalfacial 01(none)Does pain interfere with ADLs?Yes23456(moderate)78910(Severe)NoFrequency: Duration:25

Relieved w/:Outcome:DIABETESGlucometer:Frequency:B.S. range: Hgb A1C: CheckedeveryPodiatrist:Diabetic shoes: Diabetic teaching:LABSTests:Location:FrequencyIMMUNIZATIONS RECEIVEDFlu vaccineH1N1PneumovaxTetanusOtherGoals for Client:1.2.3.26

Summary:Signature of Nurse Case ManagerDate27

TRANSITION RECOMMENDATIONSReferral OptionsPlanned NH Discharge Date:Case Management referred to:(for NHTP client only)DEACAP agencyMHRHPreventive LOCOther:Client referred to:DEA CoreDHS CoreDEAMHRHPreventivePersonal ChoiceHABPACERecommended Home Based ServiceServices Client ReceivesHomemakerCNASkilled ServicesMOWHospice CareMental Health ServicesSenior CenterAdult Day CenterMed Reminding/CueingTransportationDMEProvider Name# hours/days per wkMedically Necessary Equipment1)2)3)4)5)6)7)8)28OCP

Skilled Services RequiredTreatment or ServiceFrequencyProviderRecommendations for Transition:29

Rhode Department of Human ServicesPart 2: Transition Challenges & Risk AssessmentPhysical healthoCurrent, new, or undisclosed physical health problem or illnessioMedical testing issues or delaysiioInability to manage physical health or illness in communityiiioMissing or waiting for physical health related documents or recordsoOther physical health issues (describe)Mental health or mental illnessoCurrent, new, or undisclosed mental health problem or illnessivoCurrent or history of substance/alcohol abuse with risk of relapsevoDementia or cognitive issuesvioInability to manage mental health/illness in communityviioOther mental health/illness issues (describe)Financial or insurance benefitsoLack of or insufficient financial resourcesviiioConsumer credit or unpaid billsixoSSDI, SSI, SAGA, SSA, VA, or other cash benefitsxoOther financial benefits or issuesxioInsurance issuesxiiiiiiiiivvviviiviiiixxxiIncl. hospitalization due to physical healthInc. waiting for neuro-psych examinationInc. taking medications correctly; following up with treatment or care; self-monitoring of blood sugar, etc.Incl. emotional issues such as depression or anxiety, or behavioral issues related to mental health. Incl.hospitalization due to mental health issuesIncludes abuse of legal drugs such as abuse of prescription medicationsIncl. impaired judgment due to cognitive issuesInc. taking medications correctly; following up with treatment or care.Inc. lack of financial resources to pay security deposit, or for services or supports. Incl. Medicaid spend down;anticipated denial of Medicaid services once in community.Incl. lack of/poor credit; unpaid balance or money owed to utilities, etc.Incl. denial, delay, loss, or lack of State or Federal financial benefits; rejection or delay in application forfinancial benefits; over or under payment of benefitsIncl. related to individual’s or spousal finances; missing documents/records; denial, loss of, or waiting forapproval of other benefits, including benefits such as food stamps or energy assistance. Excludes cash benefitsfrom SSDI, SSI, SSD.30

oOther financial issues (describe)Consumer engagement, awareness, and skillsoDisengagement or lack/loss of motivationxiiioLack of awareness or unrealistic expectations regarding disability or needed supportsxivoLack of independent living skillsxvoLanguage or communication skillsxvioOther consumer related issues (describe)Services and supportsoLack of transportationxviioLack of PCA, home health, or other paid support staffxviiioLack of mental health services or supports (in facility or in community)xixoLack of alcohol, substance abuse, or addiction services (in facility or in community)xxoLack of assistive technology or durable medical equipment (excluding home modifications)xxioLack of any other services or supportsxxiioOther issues related to services or supports (describe)oLack of informal supports (family/friends)Waiver programoTargeted waiver fulloIneligible for or denial of waiver servicesoCurrent waivers do not meet consumer needsxxiiioWaiting for evaluation, application review, or response from waiver agency/contactoOther waiver program issues (describe)oClient ixxiiiIncl. issues with prescription insurance coverage, Medicare Part D, Medicaid, SAGA medical insurance, etc.Incl. lack of follow through on responsibilities; decision to remain in facility and withdraw fromprogramIncl. resistance to or inflexibility regarding need or options for supportIncl. if self-directing, consumer cannot manage PCA’s or other support staffIncl. language differences, no interpreter (incl. sign language interpreter), lack of communication device, etc.Incl. insufficient, denial, wait for, or loss of transportation. Includes transportation to receive treatment, seeapartments, get documents necessary to transition, or live in community.Incl. insufficient, denial, wait for, difficulty obtaining, or loss of paid support staffIncl. insufficient, denial, wait for, or loss of mental health services or supports, either in the facility or in thecommunity.Incl. insufficient, denial, wait for, or loss of alcohol, substance abuse, or addiction services or supports, either inthe facility or in the community.Incl. insufficient, denial, wait for, or loss of, or need for training for AT or DME; excludes home modificationsor affordability issuesIncl. insufficient, denial of, wait for, or loss of any other types of services or supports (excludes PCA/directsupport staff; mental health services, AT/DME, or home modifications)Incl. if no existing waiver for level of care, such as no 24 hour care waiver31

ooooooLack of or insufficient housingxxivIneligible for or waiting for approval from RAP or other housing programsHousing modification issuesxxvDelays related to housing authority, agency, or housing coordinatorDelays related to lease, landlord, apartment manager, etc.Other housing related issues (describe)Legal or criminaloConsumer criminal historyxxvioProbate court issuesxxviioMissing or waiting for identity, birth certificate, or other related recordsoLegal representative issuesxxviiioOther court or legal issues (describe)Facility relatedoFacility staff or administration issuesxxixoWaiting for, loss of, or absence of discharge planningoEvaluation of consumer by facility issuesxxxoOther facility related issues (describe)Other involved individualsoIssues with spouse/partner, family, or friendsxxxioPhysical health provider/doctor opposed, unsupportive, or unresponsiveoMental health provider/doctor opposed, unsupportive, or unresponsiveoOther provider or state agency opposed, unsupportive, or unresponsivexxxiioOther issues related to involved individuals (describe)MFP Office or Transition coordinatoroTransition plan not approvedoWaiting for response, approval, etc. from MFP OfficeoLack of time for transition coordinator to follow upoOther transition coordinator issues (describe)oOther MFP Office issues (describe)Other topical area creating xiiIncl. denial of, wait for, or loss of accessible or committed housing; consumer dissatisfaction with orinflexibility available residence or living arrangementIncl. modifications not completed or not yet authorizedIncl. current criminal issues, such as incarcerationIncl. probate judge issuesIncl. lack of legal representative if applicable; legal representative opposed, unsupportive,unresponsive; Incl. all legal representatives, such as conservator, guardian, etc.Incl. opposed, unsupportive, unresponsive, etc.Incl. delay in, wait for, or lack of any type of evaluation for which the facility/facility staff is responsibleIncl. opposed, unsupportive, unresponsive, etc. Includes financial exploitation.Incl. opposed, unsupportive, unresponsive, or absence of provider/state agency or their staff; Incl. care manageror care planner from provider or state agency (excludes staff from current facility);32

Describe:oPrevious DEA Protective Services issues:Date:Describe:FOOTNOTES:NOTE: These will be used to clarify and further describe subcategories.oxxxiiiMultiple additional areas can be created33

APPENDIX FHOUSING ASSESSMENT TOOL(Contains two parts; (1) Qualified Resident Assessment, and (2) Home Safety Checklist)34

Part 1: QUALIFIED RESIDENCE ASSESSMENTLiving ArrangementYesHOMEIs the home owned or leased by the individual or the individual'sfamily member?If leased, the lease must be the participant or family member.If participant share the home they own or lease, they either may subletor rent with a granting the other person exclusion possession to thespace or enter into a co-ownership or co-leasing arrangement.In either case, both parties must retain independent and equal rights toenforcement of the lease and/or ownership responsibilities.APARTMENTDoes the apartment have and individual lease with lockable accessand egress to the unit?Does the apartment have living, sleeping, bathing and cooking areasover which the individual or the individual's family has domain andcontrol?The lease must be in participant’s name or a family representative.The apartment must comport with federal fair housing requirements.The lease should not include: (1) rules and/or regulation from aservice agency as conditions of tenancy or include a requirement toreceive services from a specified company, (2) required notification ofabsence periods, (3) include provision for being admitted , dischargedor transferred out of or into a facility, and (4) reserve the right toassign apartments and change apartment assignmentsCOMMUNITY BASED RESIDENTIAL SETTINGNo more than 4 unrelated individual reside there.Is not part of a larger congregate care setting (Campus) separatedfrom typical community dwelling.The resident must be owned and operated by a person or organizationother than the individual.Care givers such as personal attendants are not counted in the formaximum unrelated individuals.ASSISTED LIVINGOccupancy is governed by a lease.A contract or agreement is consistent with the provision of a standardlease.35NoComments

Living ArrangementYesUnit has lockable access and egress.Occupancy of the unit does not require that services must be providedas a condition of tenancy or from a specific company.The facility may not require notifications of absences.Aging in place provisions are required for qualified residences,Lease may not reserve the right to assign apartments or changeapartment assignments.36NoComments

Part 2: HOME SAFETY CHECKLISTName:ü Living Room – Family RoomCheck the box that applies:1. Can you turn on a light without having to walk into a dark room?2. Are lamp, extension or phone cords out of the flow of foot traffic in this room?3. Are passageways in this room free from objects and clutter (papers, furniture)?4. Are curtains and furniture at least 12 inches from baseboard or portable heaters?5. Do your carpets lie flat?6. Do your small rugs and runners stay put (don’t slide or roll up) when you push them with your foot?ü Kitchen7. Are your stove controls easy to see and use?8. Do you keep loose fitting clothing, towels, and curtains that may catch fire, away from the burnersand oven?9. Is there a working fire extinguisher available?10. Are all appliances in working order?11. Are counter tops free from clutter?12. Can you reach regularly used items without climbing to reach them?13. Do you have a step stool that is sturdy and in good repair?ü Bedrooms14. Do you have a working smoke detector on the ceiling outside your bedroom door?15. Can you turn on a light without having to walk into a dark room?16. If available, are pull cords visible and accessible?17. Do you have a lamp or light switch within easy reach of your bed?18. Is there enough room to maneuver around the bed?19. Are there safety rails on the bed?20. If there is a commode, is it placed close to the bed and against a wall?21. Is a phone within easy reach of your bed?22. Is a light left on at night between your bed and the toilet?23. Are the curtains and furniture at least 12 inches from your baseboard or portable heater?ü Bathroom24. Does your shower or tub have a non-skid surface: mat, decals, or abrasive strips?25. If available, are pull cords visible and accessible?26. Is there a shower or transfer bench in place?27. Does the tub/shower have a sturdy grab-bar (not a towel rack)?28. Is your hot water temperature 120º or lower?29. Does your floor have a non-slip surface or does the rug have a non-skid backing?30. Are you able to get off and on the toilet easily?ü Stairways31. Is there a light switch at both the top and bottom of inside stairs?32. With the light on, can you clearly see the outline of each step as you go down the stairs?33. Do all of your stairways have sturdy handrails on both sides?34. Do the handrails run the full length of the stairs, slightly beyond the stairs?35. Are all steps in good repair (not loose, broken, missing or worn in places)?37Y NN/A

36. Are stair coverings (rugs, treads) in good repair, without holes and not loose, torn or worn?ü Hallways and Passageways37. Do all small rugs or runners stay put (don’t slide or roll up) when you push them with your foot?38. Do your carpets lie flat?39. Are all lamp, extension and/or phone cords out of the flow of foot traffic?ü Front and Back Entrances40. Do all entrances to your home have outdoor lights?41. Are the locks on the doors in proper working condition?42. Are walkways to your entry free from cracks and holes?ü Throughout Your House43. Do you have an emergency exit plan in case of fire?44. Are the floors and living areas free from clutter?45. Are there any chairs on wheels that could pose as a hazard?46. Is there a working flashlight in case of a power outage?47. Are the doorways and walk spaces wide enough for a wheelchair and/or walker?48. Do you have emergency phone numbers listed by your phone?49. Are there telephones located in at least 2 rooms?50. Are there other hazards or unsafe areas in your home not mentioned in this checklist that you areconcerned about? If s

Apple Rehab Watch Hill Watch Hill Avalon Nursing Home Warwick Ballou Home for the Aged Woonsocket Bannister House Providence Bayberry Commons Pascoag Berkshire Place Providence Bethany Home of RI Providence Brentwood Nursing Home Warwick Briarcliffe Manor J