|
|
Provider *
|
|
Please complete one form per residential facility.
|
|
Facility Name *
|
|
|
Facility Address *
|
|
|
Facility Contact Person(s) *
|
|
|
Title *
|
|
|
Contact Phone Number *
|
|
|
Email *
|
|
|
Site Phone Number *
|
|
|
Site Fax Number *
|
|
|
Live-in Staff *
|
Yes
No
|
|
Owner-occupied *
|
Yes
No
|
|
Corporate *
|
Yes
No
|
|
List Class if CBRF
|
|
|
Number of beds *
|
|
|
Number of years in operation *
|
|
Facility Licensed/Certified to Serve
Check as appropriate:
|
|
Gender *
|
Male
Female
Either
|
|
Advanced Age *
|
Yes
No
|
|
Traumatic Brain Injury *
|
Yes
No
|
|
Developmental Disabilities *
|
Yes
No
|
|
Physically Disabled *
|
Yes
No
|
|
Alzheimer's/Dementia *
|
Yes
No
|
|
Serious & Persistent Mental Illness *
|
Yes
No
|
Facility Capabilities
Behavioral Needs: check one box in each category to indicate the capability of your facility to serve members displaying the described behavior
|
|
Verbal Aggression *
|
None
Mild: Occasional use of profanity or inappropriate comments. Behavior is easily redirected with verbal cues.
Moderate: A moderate use of profanity, inappropriate comments and/or screaming and/or yelling. Behaviors can be redirected with
verbal cues.
Severe: Frequent screaming and/or yelling that is not easily redirected and/or verbal threats
to harm others that are no acted upon.
|
|
Physical Aggression *
|
None
Mild: Self injuries and/or self stimulating behavior that is mild and easily redirected verbally.
Moderate: Self injurious and/or self stimulating behaviors that may cause injury to self or
others such as hair pulling, kicking, slapping, and punching that is able to be verbally redirected with one or multiple cues.
Severe: Self injurious and/or self stimulating behaviors that may cause serious injury to self
or others such as hair pulling, kicking, slapping, and punching that is not easily/not redirected verbally.
|
|
Property Destruction *
|
None
Mild: Easily verbally-redirected behavior such as fist pounding, tearing clothes, and door slamming.
Moderate: Verbally redirected behavior that destroys property such as punching walls, throwing and/or breaking objects without
causing harm to others.
Severe: Property destruction that requires modification to the environment to avoid injury to
self or others such as recessed lighting, unbreakable windows, and/or special furniture not easily destroyed.
|
|
Sexual Behaviors *
|
None
Mild: Inappropriate sexual comments that are easily redirected verbally and/or masturbation
that requires verbal redirection to be done in privacy (this does not include public masturbation).
Moderate: Flashing, stripping, and/or frequent inappropriate sexual comments that can be verbally redirected and occurs within
the home and not in public.
Severe: Flashing, stripping and/or masturbation that may occur within the home and may not be
easily redirected verbally. Acts of flashing, stripping and/or masturbation that occur in public that may or may not be easily verbally redirected.
|
|
|
|
Do you have a nurse on staff? *
|
Yes
No
|
|
If yes to previous question, is your nurse an RN or LPN?
|
RN
LPN
|
|
If you do have a nurse on staff, how many hours per week is your nurse on site?
|
|
|
If you do have a nurse on staff, how many of your facilities are serviced by your nurse?
|
|
|
If you do have a nurse on staff, what are the responsibilities of that nurse?
|
|
|
Medical Needs: (please check all boxes that apply to indicate your facility's capability to serve members with the listed medical
need) *
|
Diabetic Blood Sugar Monitoring
Insulin-Dependent Diabetic
Sliding-scale Insulin-Dependent Diabetic
Tracheotomy
Care
Tube-Feeding
Incontinence
Bariatric
None
|
|
|
|
Wheelchair accessible entrances? (two entrances to grade) *
|
Yes
No
|
|
Hoyer lift? *
|
Yes
No
It is the responsibility of the provider to own and/or purchase a hoyer.
|
|
Transfer Status (check one)
|
Independent
Assist of One
Assist of Two
|
|
Number of bedrooms: *
|
|
|
Number of wheelchair accessible bedrooms: *
|
|
|
Number of shared bedrooms: *
|
|
|
Number of wheelchair accessible shared bedrooms: *
|
|
|
Number of bathrooms: *
|
|
|
Number of wheelchair accessible shared bathrooms: *
|
|
|
Is the facility alarmed? *
|
Yes
No
|
|
Does the facility have pets? *
|
Yes
No
|
|
List types of pet(s)
|
|
|
Are members allowed to smoke? *
|
Yes
No
|
Consumer Transportation Options
|
|
Agency vehicle(s) *
|
Agency Van
Agency Car
Staff
Vehicle
Public
Transit
Lift
Equipped
|
Consumer Resources
|
|
Please provide the available community resources to members residing in the home *
|
|
|
|
|
Owner/Operator Name *
|
|
|
Academic preparation *
|
|
|
Relevant experience or training *
|
|
|
Has the owner/operator ever been convicted of a crime? *
|
Yes
No
|
|
If yes, please explain
|
|
|
On-site Manager Name *
|
|
|
Academic preparation *
|
|
|
Relevant experience or training *
|
|
|
Has the on-site manager ever been convicted of a crime? *
|
Yes
No
|
|
If yes, please explain
|
|
|
Please list required staff trainings *
|
|
|
|
|
Additional facility expertise/experience not identified above
|
|
Attestation Statement
I certify that the information completed on this long-term care program summary is true and accurate as of its completion. If the long-term program summary
information changes at any time, I will submit a new long-term care program summary.
|
|
Name of Person Completing Form *
|
|
|
Date Completed *
|
|
|
|
EMF Forms Online