Casmir Care Services, Inc

Time and Activity Sheet

July 1, 20___ - June 30th, 20___

Client: Week: From: To:

Service Provided By: Number of weekly hours approved: _____

***This form is for Personal Assistance Services (PAS)/OLTL Program ONLY. DO NOT use for other services provided.

Personal Assistance Services (PAS/OLTL) (W1793)

Respite (OLTL) (T1005)

Client signature is required for every day of service

Day / Date / Time In / AM/
PM / Time out / AM/
PM / Total
Hours / Client or Representative Signature
Sunday (Week 1)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Sunday (Week 2)
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday

Please check the appropriate box where assistance and or cuing the consumer

to perform a task was provided/performed.

(Week 1) Health Maintenance / Routine Wellness / S / M / T / W / T / F / S / (Week 1) General Household / Chore Activities / S / M / T / W / T / F / S
Bowel and bladder routine / Grocery shopping
Ostomy, catheter, wound care / Laundry
Range of motion care, if applicable / Washing floors, windows and walls
Adequate nutrition, meal preparation, eating, / Minor house repairs
Exercise; healthy living activities/regimens / Respite: This may include bathing, dressing, eating, housekeeping, and participating in community activities.
Keeping of medical appointments / Other:
Personal Hygiene: bathing, dress etc. / Other:
Other / Other:
(Week 2) Health Maintenance / Routine Wellness / S / M / T / W / T / F / S / (Week 2) General Household / Chore Activities / S / M / T / W / T / F / S
Bowel and bladder routine / Grocery shopping
Ostomy, catheter, wound care / Laundry
Range of motion care, if applicable / Washing floors, windows and walls
Adequate nutrition, meal preparation, eating, / Minor house repairs
Exercise; healthy living activities/regimens / Respite: This may include bathing, dressing, eating, housekeeping, and participating in community activities.
Keeping of medical appointments / Other:
Personal Hygiene: bathing, dress etc. / Other:

July 1, 20___ - June 30th, 20___

Casmir Care Services, Inc

Time and Activity Sheet

Client Name:

Week: From: To:

Service Provided By:

What is Personal Assistance Services? Personal Assistance Services are aimed at assisting the individual to complete tasks of daily living that would be performed independently if they had no disability. These services include: Non-medical personal care (eating, bathing, dressing, personal hygiene), general household activities/chores (light housekeeping tasks, preparing meals, grocery shopping, laundry), cueing to prompt the participant to perform a task, and assisting a functionally impaired individual who cannot be safely left alone;• Health maintenance activities provided for the participant, such as bowel and bladder routines, ostomy care, catheter, wound care and range of motion as indicated in the individual’s service plan;• Routine wellness services to enable adequate nutrition, exercise, keeping of medical appointments and all other health regimens related to healthy living activities; Overnight Personal Assistance Services provide intermittent or ongoing, awake, overnight assistance to a participant in their home for up to eight hours. Overnight Personal Assistance services require awake-staff; and Chore services needed to maintain the home in a clean, sanitary and safe environment, such as washing floors, windows and walls, and tacking down loose rugs and tiles.

In summary, please explain what you have done to assist or cue the client over the past two weeks as it reflects in the outcome goals indicated in the ISP.

Were there any health and safety issues or concerns to providing service for the consumer? If yes, please explain and notify the service coordinator. YES NO

Staff signature & title:______Date:______