Negotiated Service Agreement - kahsa. following Negotiated Service Agreement is entered into by and between Kenneth Caldwell Assisted Living Manor and _____ for services provided to

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<ul><li><p>Negotiated Service Agreement </p><p>Resident Name: _____________________________ Apartment # ______ </p><p>Date of this Agreement: _______________________ </p><p> The following Negotiated Service Agreement is entered into by and between </p><p>Kenneth Caldwell Assisted Living Manor and _______________________ for services </p><p>provided to ________________________. </p><p> The purpose of this Agreement is to outline the care and/or services necessary for </p><p>Resident, which services addresses Residents cognitive issues and are developed with </p><p>consideration for Residents preferences as to how services are to be delivered. When a </p><p>service is provided by an outside resource, this Agreement will indicate the outside </p><p>resource and source of payment. </p><p>Services Provided by Kenneth Caldwell Assisted Living Manor: </p><p>1. Nutrition Services: ___ 3 meals daily ___Room Tray ___Reminders </p><p>Needs/Preferences: </p><p>__________________________________________________________________</p><p>__________________________________________________________________ </p><p>2. Nursing Services: Licensed Nurse responsible for nursing plan: ____________________________ </p><p>___Diabetic Management ___Treatment Management </p><p>___Medication Management ___Behavior Management ___Education/Teaching </p><p> Needs/Preferences: ________________________________________________ </p><p> __________________________________________________________________ </p><p>3. Personal Care: ___Ambulation/Transfer ___AM Dressing Assist ___Fall Prevention </p><p>___Toileting Assist ___PM Dressing Assist ___Personal Hygiene </p><p>___Bathing ___Neck Alarm </p><p>Needs/Preferences: _________________________________________________ </p><p>__________________________________________________________________ </p><p>4. Housekeeping/Laundry Services: ___Linens Weekly ___Personal Laundry </p><p>___Weekly Cleaning ___Daily Bed making </p><p>Needs/Preferences: __________________________________________________ </p><p>5. Transportation: __Medical/Dental Appointments ___Social Transportation Needs/Preferences: __________________________________________________ </p></li><li><p>6. Activity/Socialization: Needs/Preferences___________________________________________________</p><p>__________________________________________________________________ </p><p>7. Personal Shopping: ___Resident ___Family ___Facility ___Other </p><p>Needs/Preferences: </p><p>__________________________________________________________________ </p><p>8. Money Management: ___Resident ___Family ___Legal Representative ___Other </p><p>Needs/Preferences: </p><p>__________________________________________________________________ </p><p>9. Refusal of Services:________________________________________________ 10. Consequences of refusal:____________________________________________ 11. HCBS Services____________________________________________________ </p><p>Services Provided by Outside Agency: </p><p>Service: Podiatry Service: Lab </p><p>Provider: Christopher Surtman Provider: AMS </p><p>Billed to: _________________ Billed to: ___________ </p><p>Service: Therapy____________ Service: Home Health/Hospice </p><p>Provider: Select Rehab_______ Provider: _________________ </p><p>Billed to: ___________________ Billed to: _________________ </p><p>Service: Oxygen Service: Pacemaker check </p><p>Provider: __________________ Provider: ______________ </p><p>Billed to: __________________ Billed to: ______________ </p><p>Service: ___________________ Service: Social Serv/Psych Consult </p><p>Provider: __________________ Provider: _____________________ </p><p>Billed to: ___________________ Billed to: _____________________ </p><p>_____________________________________ _________________________________ </p><p>Residents Signature Date Legal Representative Date </p><p>_____________________________________ _________________________________ </p><p>Licensed Nurse Date Family Member Date </p><p> Mailed for signature: Date sent__________ Date returned__________ </p></li></ul>

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