Assisted Living Full Assessment & Service Agreement

ASSISTED LIVING FULL ASSESSMENT & SERVICE AGREEMENT

NAME: / DATE:
ASSESSMENT TYPE:  Initial  Re-Assessment
DIAGNOSES:
ALLERGIES:
MEDICATIONS: Identify if independent (I), assist (A), or administer(Ad)
PRESCRIPTION / OTC, HERBAL, VITAMINS, ETC.
DESCRIBE METHODS TO OBTAIN RESIDENT’S MEDICATIONS: / DESCRIBE FAMILY INVOLVEMENT IN MEDICATIONS, IF ANY:
DESCRIBE METHODS TO STORE RESIDENT’S MEDICATIONS:
PAINif any, DESCRIPTION & PAIN MANAGEMENT / STAFF INTERVENTIONS
SENSORY ABILITIES / STAFF INTERVENTIONS
HEARING:
VISION:
MODES OF EXPRESSION
 Can/cannot make self understood / Explain:
 Can/ cannot understand others
KNOWN BEHAVIORS (if any checked, please explain):
 History of substance abuse
 History of harming self, others, or property
 Conditions requiring behavioral interventions
 Other:
DETAILS OF BEHAVIORS: / STAFF INTERVENTIONS:
PLEASE CHECK IF THE RESIDENT HAS ANY OF THE FOLLOWING:
 Mental illness /  Developmental Disabilities
 Dementia /  TBI or other cognitive impairment
NURSING NEEDS, IF ANY (please describe): / STAFF INTERVENTIONS:
SKIN CONDITIONS – past, present, potential: / STAFF INTERVENTIONS:
SMOKING: Does resident smoke?  Yes  No
If yes, please describe safety needs, if any:
 Resident smokes safely without need for direct supervision; manages own paraphernalia
ACTIVITIES OF DAILY LIVING
BATHING:
 Independent  Assistance  Dependent
DESCRIBE: / PREFERENCES, HABITS, ROLES:
TOILETING:
 Independent  Assistance  Dependent
DESCRIBE: / PREFERENCES, HABITS, ROLES:
PERSONAL HYGIENE:
 Independent  Assistance  Dependent
DESCRIBE: / PREFERENCES, HABITS, ROLES:
GROOMING:
 Independent  Assistance  Dependent
DESCRIBE: / PREFERENCES, HABITS, ROLES:
TRANSFERRING:
 Independent  Assistance  Dependent
DESCRIBE: / PREFERENCES, HABITS, ROLES:
MEALTIMES:
 Independent  Assistance  Dependent
DESCRIBE: / PREFERENCES, HABITS, ROLES:
SAFETY/MOBILITY:
 Independent  Assistance  Dependent
DESCRIBE: / PREFERENCES, HABITS, ROLES:
HEALTH MAINTENANCE: / STAFF INTERVENTIONS:
Health maintenance monitoring:
Laundry:
Housekeeping:
Transportation:
SUPERVISION: Can resident safely leave home alone?  Yes  No
If no, please describe methods to ensure resident’s safety when away from the home:
TYPICAL DAY
12 AM / NOON
1 AM / 1 PM
2 AM / 2 PM
3 AM / 3 PM
4 AM / 4 PM
5 AM / 5 PM
6 AM / 6 PM
7 AM / 7 PM
8 AM / 8 PM
9 AM / 9 PM
10 AM / 10 PM
11 AM / 11 PM

NOTES:

PERSONAL BIOGRAPHY / STAFF RESPONSIBILITIES:
Spiritual/Religious:
Hobbies/Activities enjoyed:
Family/close friends/community contacts:
Past occupation or daily habits:
Sources of pleasure and comfort:
DECISION MAKING AUTHORITY
 Advance Directive (please describe):
If an advance directive is present, who is the designated decision maker if/when the advance directive is put into action?
Scope of decision-making authority:
SIGNATURES
______
Qualified Assessor Date
______
Resident Date
______
Representative Date
______
Facility Representative Date
______
Nurse (if applicable) Date
UPDATE: SIGNATURES
______
Qualified Assessor Date
______
Resident Date
______
Representative Date
______
Facility Representative Date
______
Nurse (if applicable) Date

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