Adult Day Health/Dementia Day

Adult Day Health/Dementia Day

I.General Policies and Procedures

A. List the date of your most recent certification (attach copy):

B. List total number of slots for program[1]:

C. Describe the time span between referral and assessment[2]:

D. Describe your procedure for action in case of the following emergencies[3]:

1. Fire:

2. Loss of power (lights and/or heat):

3. Hurricanes and snowstorms:

1. Client wandering away:

5. Client health crisis:

If emergency policies are written, attach a copy of policy(ies).

E. Attach a list of all staff training on emergency procedures during the past 18 months. Include dates and length of training, instructors, topics and attendees by names and staff positions[4].

F. List dates of fire drills conducted over past year[5]:

G. Describe your policy on any client admission and continuation requirements or restriction to your program[6]:

If written, attach the policy.

H. Describe your policy to notify ASAP agency when service is altered from that which was authorized[7]:

I. Describe how you achieve the staff to client ratio. Include information regarding the staffing requirements appropriate to both the basic and complex levels of care and, if applicable, the Dementia Day Program[8]:

J. List written agreements established with local emergency facilities and/or responders[9]:

K. Describe how transportation is provided to clients in the following areas[10]:

1. Outside trips:

2. To and from the program:

II.Personnel Procedure

A. Describe how you meet staffing requirements as specified in the ADH manual for the following[11]:

1. Program Director:

2. Assistant Program Director:

3. Registered Nurse:

4. Social Worker:

5. Activities Director:

6. Drivers:

7. Consulting Therapist:

8. Other:

B. List the staff who have had CPR and/or Basic First Aid training, include date with the expiration of certificate[12]:

C. Describe how you ensure that licenses and training certificates remain current[13]:

D. Describe how you document that each employee has had training on sensitivity to elders:

E. Describe the procedure for supervision of employees, by whom and frequency[14]:

III.Programs

A. In order to meet the needs of the participant, list who provides the following[15]:

Health care and supervision:

Counseling:

Restorative services:

Socialization:

Maintenance Therapy services:

B. Do clients have input in program/activity selections?[16] Yes No

Describe method:

C. Who is responsible for supervising the administration of medications[17]:

D. Describe how nutrition services are provided to day care participants[18]:

E. Who is responsible for seeing that meals meet 1/3 RDA?[19]

F. How are special diets accommodated?[20]

G. List AM & PM snacks served each day in past week[21]:

IV.Physical Plant

A. Describe how you achieve health, safety and comfort in the following areas[22]:

1. Dining area:

2. Project area:

3. Group Activity area:

4. Rest area:

5. Private enclosed space:

6. Food preparation area (including refrigeration, sink, and storage space):

7. Date of most recent inspection by fire department[23]:

V.For Dementia center only:

A. Admission[24]

1. List the requirements for admission:

2. Describe how your program ensures that only appropriate elders are accepted as participants into this program:

B. Program[25]

1. Describe how services and activities meet the needs of participants and their families:

2. Describe how activities are designed to meet the needs of high and low functioning groups:

3. Describe what training and support is offered to family and other caregivers:

4. If your program is combined with other programs, such as Adult Day Health or Social Day Care, describe how activities are provided in separate locations:

5. Describe a typical day at the center:

C. Staffing[26]

1. Describe how you ensure that the required participants to staff ratio is maintained:

2. Describe how you maintain the required number of staff as well as specific staff on a full day basis:

3. Describe how you have incorporated the multi-disciplinary team approach to services delivery:

D. Physical Plant[27]

Describe how your program meets physical plant specifications as listed in the Dementia Day Care Standards:

Name of Provider employee who completed this form:

Signature: Date:

Please note the documents and records which will be required for the Client files and/or Employee files to be reviewed at the time of On Site Evaluation.

Social Day/ Dementia Day
Adult Day Health
Employee Records Review
Provider:
Date:
Monitor:
Start and Termination Date[28]
Number of Reference Checks[29]
Physicals[30]: Date
TB[31]: Date
Orientation[32]: Date
Job Description(s)[33]
Ongoing training[34]: dates
Annual Performance Appraisal[35]: Date
CPR/ First Aid[36]: Dates
Licenses[37]
CORI Check[38]
Comments

Please note the documents and records which will be required for the Client files and/or Employee files to be reviewed at the time of On Site Evaluation.

Social Day/ Dementia Day
Adult Day Health
Client Records Review
Provider:
Date:
Monitor:
ID Info – name; address; phone; DOB
Emergency Contact(s) name and phone[39]
Physician(s) name and phone[40]
Hospital name and phone[41]
Medical/ social diagnosis[42]
current case managers/RN phone[43]
Service start date[44]
Termination date[45]
Service plan[46]
Comments

Page 1 of 9

Revised 2004

[1] Adult Day Health Regulations, 130 CMR 404.406 (E)(1)(b)

[2] Non-Homemaker Provider Agreement, Attachment A, Dementia Day Program

[3] 130 CMR 404.406 (E)(3)

[4] 130 CMR 404.406 (E)(3)(e), 130 CMR 404.406 (E)(3)(f)

[5] 130 CMR 404.406 (E)(3)(d)

[6] 130 CMR 404.406 (B)

[7] ASAP Provider Network Quality Assurance Manual

[8] 130 CMR 404.408 (A)

[9] 130 CMR 404.406 (E)(1)(b)(viii)

[10] 130 CMR 404.413

[11] 130 CMR 404.409

[12] 130 CMR 404.406 (E)(3)

[13] Non-Homemaker Provider Agreement, Section 23.0

[14] ASAP Provider Network Quality Assurance Manual

[15] Services required under 130 CMR 404.406 (D)

[16] 130 CMR 404.406 (D)(6)

[17] 130 CMR 404.406 (D)(1)(a)

[18] 130 CMR 404.406 (D)(4)

[19]ibid.

[20]ibid.

[21]ibid.

[22] 130 CMR 404.412 (C)

[23] 130 CMR 404.412 (B), 130 CMR 404.412 (D)

[24] Non-Homemaker Provider Agreement, Dementia Day Program Attachment A, Section I

[25] Non-Homemaker Provider Agreement, Dementia Day Program Attachment A, Sections II and III

[26] Non-Homemaker Provider Agreement, Dementia Day Program Attachment A, Section IV

[27] Non-Homemaker Provider Agreement, Dementia Day Program Attachment A, Section V

[28] M.G.L. c. 149 § 52C, 808 CMR 1.04

[29] M.G.L. c. 149 § 52C , 130 CMR 404.408 (B)(1)

[30] 130 CMR 404.408 (B)(2)

[31] 130 CMR 404.408 (B)(2)

[32] ASAP Provider Network Quality Assurance Manual, Non-Homemaker Provider Agreement, Dementia Day Program Attachment A, Section IV

[33] M.G.L. c. 149 § 52C , 808 CMR 1.04, 130 CMR 404.408 (C) (3)

[34] 130 CMR 404.408 (C) (2), Non-Homemaker Provider Agreement, Dementia Day Program Attachment A, Section IV

[35] M.G.L. c. 149 § 52C , 130 CMR 404.408 (C) (4), ASAP Provider Network Quality Assurance Manual

[36] 130 CMR 404.406 (E)(3)(e), 130 CMR 404.406 (E)(3)(f), Non-Homemaker Provider Agreement, Dementia Day Program Attachment A, Section IV

[37] Non-Homemaker Provider Agreement, Section 23.0

[38] M.G.L. c. 6 § 172C, Non-Homemaker Provider Agreement, Section 26.0

[39] 130 CMR 404.406 (E)(3)

[40]ibid.

[41] ASAP Provider Network Quality Assurance Manual

[42] 130 CMR 404.406 (F)(1)

[43]ibid.

[44] Non-Homemaker Provider Agreement, Section 6.0

[45]ibid.

[46]130 CMR 404.406 (F)(3), Non-Homemaker Provider Agreement, Dementia Day Program Attachment A, Section II