Home Care Service Plan

Individual:Date:Site:

Scope of Services [see Care Plan for instructions]:

Service Description / Service Requested / Frequency / Staff Responsible to Provide Service
Medication Management Assessment / Yes No / Intake, Annually, or as needed / RN
Medication Management / Yes No
Treatments and Exercises / Yes No
ADLs – dressing, grooming, bathing / Yes No
IADL’s- laundry, housekeeping, meal preparation, shopping, or other household chores / Yes No
Assistance with Mobility / Yes No
Financial Management / Yes No
Supervision / Yes No
RN Assessments / Yes No / Within 5 and 14 days of admission, every 90 days, or with a status/health change / RN

Supervision of Staff:

Supervision Description / Frequency / Staff Responsible
Registered Nurse / Director of Operations
Licensed Practical Nurse / N/A at this time. / Registered Nurse
Lead Counselor / Within 30 days of hire or for those who have not performed delegated tasks for one year or longer, and, then periodically/as needed. / Registered Nurse
Direct Support Professionals / Within 30 days of hire or for those who have not performed delegated tasks for one year or longer, and, then periodically/as needed. / Registered Nurse

Contingency and Emergency Plan:

If Service Cannot Be Provided or
in the Event of An Emergency / Plan of Action
Zumbro House / If a medical emergency arises when staff is present, staff will call 911, the physician and the Zumbro House Program Director.
Individual Receiving Services / If a medical emergency arises when staff is not present, the resident or responsible party should call the physician or 911.
Legal Representative

Important Zumbro House Contacts:

Program Director:

Director of Operations:

In Case of Emergency or Change in Condition,

Zumbro Houseshould contact:

Relationship:

Phone Number(s):

Address:

Authority to sign for the Individual Receiving Services in an Emergency:

In the event of an emergency, the party named below has the authority [responsible party] to sign for the Individualin an emergency.

Name:

Relationship: ______

Phone Number(s): ______

Address: ______

Health Care Directive:

Individual Receiving Services has a Health Care Directive

Copy on File: [type] ______

  • Does the above directive provide for any circumstances in which emergency medical services are not to be summoned?

No Yes, describe the circumstances:

Copy requested from Individual or Guardian/Conservator or Responsible Party

Individual Receiving Servicesdoes not havea Health Care Directive; however, information was provided by Zumbro House, Inc.

Assignment of Benefit & Fees:

I request payment of health insurance benefits for all services furnished me by Zumbro House, Inc. I assign to Zumbro House, Inc.benefits payable to me for home care services rendered.

MONTHLY SERVICE FEES: $425 rent

COUNTY FINANCIAL ASSISTANCE (if applicable): -$ applied to receive GA and food support – amounts unknown at this time

TOTAL MONTHLY CHARGES TO BE PAID BY INDIVIDUAL: $425 rent

Acceptance and Signature of Service Plan:

I have had the opportunity to participate in the development of the Service Plan. I have read this plan, understand the plan, and agree to abide by its terms.

Individual Signature: ______Date: ______

Guardian Signature: ______Date: ______

Responsible Party Signature: ______Date: ______

Provider Signature: ______Date: ______

Zumbro House, Inc. RN Signature: ______Date: ______

If Resident is not able to sign, provide reason:______

Print Name and Relationship of Responsible Party:______

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