BH NEGOTIATED SERVICE AGREEMENT

NAME: / NICKNAME:
Age: / Birthdate: / Place of birth: / Gender: 5 M 5 F
Assessment Location: / Living arrangements:
Marital Status: / Spouse’s name: / Maiden name:
Children’s names:
Primary Contact Person: / Relation:
Address: / Phone #:
Social Security #: / Medicare #:
Medicaid #: / Veteran: 5 Y 5 N / Branch of Service:
Primary Health insurance: / Policy #:
Pre-authorization required: 5 Y 5 N / Phone #:
Other insurance coverage: / Policy #:
SUBSTITUTE DECISION MAKER: 5 Y 5 N (If yes, provide a copy to the facility)
Name: / Phone:
Scope of decision-making capabilities:
Primary Care Provider:
Clinic Address: / Phone: / Fax:
SPECIALIST: / Phone: / Fax:
SPECIALIST: / Phone: / Fax:
DENTIST: / Phone: / Fax:
PHARMACY: / Phone: / Fax:
Preferred Hospital: / Phone:
ADVANCE DIRECTIVES: 5 Y 5 N (If yes, provide a copy to the facility)
Funeral Arrangements? 5 Y 5 N / Funeral Home: / Phone #:
Current Height (ft/in): / Current Weight (lb):
r Recent change? Explain:
Blood Pressure: / Pulse: / Resp: / Temp:

Resident Name: ______Page 1

BH NEGOTIATED SERVICE AGREEMENT

CARE AND SERVICES / RESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLY / WHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOW
COMMUNICATION: SPEECH/HEARING/VISION / Yes / No
Problems with speech
Describe:
Hearing problems
Describe/aid:
Visual problems
Describe/aid:
Telephone Use
Independent Assistance Dependent
Language:
Describe
MEDICATION MANAGEMENT:
Self Administration (Check all that apply)
Oral
Topical
Eye drops/ointments
Inhalers / Sprays
Injections
Allergy Kits
Keep Own Meds
SELF MEDICATION W/ASSISTANCE
Oral
Topical
Eye drops/ointments
Inhalers / Sprays
Allergy Kits
Meds Organizer
Equipment:
CARE AND SERVICES / RESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLY / WHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOW
ADMINISTRATION
Nurse Delegated? / Yes / No
Oral
Topical
Eye drops/ointments
Inhalers / Sprays
Allergy Kits
Meds Organizer
Equipment:
Injections Yes No / If yes:
By family
Licensed professional
Medication plans when resident not in home:
TREATMENT/PROGRAMS/THERAPIES
Health issues to monitor: / Yes / No
Oxygen Use
Pain
Weight Loss/Gain
Programs the resident attends, such as adult day health
Nursing Consultation/Treatments / Yes / No
RN Delegation
What tasks:
Consent
Physical Enablers:

Resident Name: ______Page 2

BH NEGOTIATED SERVICE AGREEMENT

CARE AND SERVICES / RESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLY / WHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOW
PSYCH/SOCIAL/COGNITIVE STATUS / Yes / No / What resident does
Describe behaviors – be specific: / Describe specific non-medication (behavioral/environmental) interventions to address the symptoms
Sleep disturbance
Memory impairment (Short-term)
Memory impairment (Long-term)
Decision making
Disruptive behavior
Assaultive
Resistive
Depression
Anxiety
Disorientation
Wandering in home
Exit seeking
Hallucinations
Delusions
If yes, describe:
Requires psychopharmacological medications
If yes, describe symptoms for each medication
STANDARD PRECAUTIONS / Caregiver will use latex/plastic gloves when in contact with any secretions to prevent spread of infection. Thorough hand washing with soap will be done before and after gloving. Gloves will be put on and discarded at the end of each task.

Resident Name: ______Page 4

BH NEGOTIATED SERVICE AGREEMENT

CARE AND SERVICES / RESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLY / WHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOW
MOBILITY
In room & immediate living environment:
Independent Assistance Dependent
Outside of immediate living environment (to include outdoors):
Independent Assistance Dependent
Equipment:
Preferences/Choices:
BED MOBILITY/TRANSFER
Independent Assistance Dependent
Skin care due to inability to position self:
Equipment/supplies:
Risk for falls:
Preferences:
Enablers:
Safety assessment, alternatives explored; how to keep resident safe:
Night time care needs:
EATING
Independent Assistance Dependent
Special diet/supplements:
Eating habits
Food allergies
Preferences/equipment
CARE AND SERVICES / RESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLY / WHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOW
TOILETING/CONTINENCE ISSUES
Independent Assistance Dependent
Bladder incontinence Yes No Occasional
Bowel incontinence Yes No Occasional
Skin care due to bowel/bladder incontinence:
Equipment:
Preferences:
DRESSING
Independent Assistance Dependent
Equipment:
Preferences:
PERSONAL HYGIENE
Independent Assistance Dependent
Oral hygiene, including dentures:
When and how often:
Preferences:
BATHING
Independent Assistance Dependent
How often:
When:
Equipment:
Preferences:

Resident Name: ______Page 6

BH NEGOTIATED SERVICE AGREEMENT

CARE AND SERVICES / RESIDENT STRENGTHS/WHAT RESIDENT PREFERS TO DO INDEPENDENTLY / WHAT PROVIDER/CAREGIVER/SUPPORT PERSON DOES/WHEN & HOW
BODY CARE (Foot care, skin care, nail care, range of motion, dressing changes)
Independent Assistance Dependent
Foot care: Yes No
Skin care:
How often:
Skin problems: Yes No
Describe:
Dressing changes: Yes No
Nurse delegated: Yes No
Preferences:
MANAGING FINANCES
Independent Assistance Dependent
Who manages finances:
Financial records:
Preferences:
SHOPPING
Independent Assistance Dependent
Special transportation needs:
How often:
Preferences:
TRANSPORTATION
Independent Assistance Dependent
Medical services:
Special transportation needs:
Equipment:
How often:
Preferences:
ACTIVITIES/SOCIAL NEEDS
Independent Assistance Dependent
Interests/Activities/Religious Activities:
Social/Cultural Traditions/Preferences:
Family/Friends/Relationships:
Employment Support:
Clubs/Groups/Day Health:
Emergency Numbers Provided:
Special Arrangements:
Participation Issues
SMOKING
Yes No
Safety Concerns:
Preferences:
CASE MANAGEMENT / Contact the case manager when:
·  The resident needs assistive device or other services to meet the needs
·  Significant changes with the condition/needs that necessitate changes with this service agreement
OTHER ISSUES/CONCERNS/PROBLEMS

WAC 388-78A-2130 - 2160 Negotiated Service Agreement: Brief instructions based on WAC

(1)  Developed within 30 days of admission based on the Assessment and the Initial Resident Service Plan.

(2)  Describes/identifies: (a) The services to be provided; (b) Who will provide the services; and (c) When and How the services will be provided.

(3)  Designed to meet the Resident’s Needs, Preferences, and Choices.

(4)  Developed with input from the Resident and/or the Resident’s Representative / Surrogate Decision Maker, appropriate professionals, and the case manager, if applicable

(5)  Agreed to, Signed and Dated by the Resident and/or the Resident’s Representative / Surrogate Decision Maker, appropriate professionals, and the provider.

(6)  The signed copy of the plan must be given to the Case Manager if Resident is receiving services paid for fully or partially by the department.

(7)  Reviewed and Revised: (a) at least every 12 months; (b) upon any significant change in Resident’s physical, mental, or emotional condition; and when the negotiated service agreement no longer describes the resident’s needs and/or services.

Resident Name: ______Page 10

BH NEGOTIATED SERVICE AGREEMENT

DATE OF ORIGINAL SERVICE AGREEMENT:
TITLE/TYPE / SIGNATURE /

DATE

/ REVIEW/REVISE DATE / REVIEW/REVISE DATE
PROVIDER /

RESIDENT

RESIDENT REPRESENTATIVE
RESIDENT REPRESENTATIVE
SURROGATE DECISION MAKER
CASE MANAGER
SOCIAL WORKER
HEALTH PROFESSIONAL
OTHER:
OTHER:

The person signing writes the date s/he actually read and agreed to the plan. If the participant has verbally agreed to the plan, the provider should note below: (a) the name and role of the participant; (b) the date the participant had the plan to read to them; and (c) what if any changes the participant recommended for the plan.

______

Resident Name: ______Page 10