negotiated service agreement - kahsa. following negotiated service agreement is entered into by and...

Download 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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  • Negotiated Service Agreement

    Resident Name: _____________________________ Apartment # ______

    Date of this Agreement: _______________________

    The following Negotiated Service Agreement is entered into by and between

    Kenneth Caldwell Assisted Living Manor and _______________________ for services

    provided to ________________________.

    The purpose of this Agreement is to outline the care and/or services necessary for

    Resident, which services addresses Residents cognitive issues and are developed with

    consideration for Residents preferences as to how services are to be delivered. When a

    service is provided by an outside resource, this Agreement will indicate the outside

    resource and source of payment.

    Services Provided by Kenneth Caldwell Assisted Living Manor:

    1. Nutrition Services: ___ 3 meals daily ___Room Tray ___Reminders

    Needs/Preferences:

    __________________________________________________________________

    __________________________________________________________________

    2. Nursing Services: Licensed Nurse responsible for nursing plan: ____________________________

    ___Diabetic Management ___Treatment Management

    ___Medication Management ___Behavior Management ___Education/Teaching

    Needs/Preferences: ________________________________________________

    __________________________________________________________________

    3. Personal Care: ___Ambulation/Transfer ___AM Dressing Assist ___Fall Prevention

    ___Toileting Assist ___PM Dressing Assist ___Personal Hygiene

    ___Bathing ___Neck Alarm

    Needs/Preferences: _________________________________________________

    __________________________________________________________________

    4. Housekeeping/Laundry Services: ___Linens Weekly ___Personal Laundry

    ___Weekly Cleaning ___Daily Bed making

    Needs/Preferences: __________________________________________________

    5. Transportation: __Medical/Dental Appointments ___Social Transportation Needs/Preferences: __________________________________________________

  • 6. Activity/Socialization: Needs/Preferences___________________________________________________

    __________________________________________________________________

    7. Personal Shopping: ___Resident ___Family ___Facility ___Other

    Needs/Preferences:

    __________________________________________________________________

    8. Money Management: ___Resident ___Family ___Legal Representative ___Other

    Needs/Preferences:

    __________________________________________________________________

    9. Refusal of Services:________________________________________________ 10. Consequences of refusal:____________________________________________ 11. HCBS Services____________________________________________________

    Services Provided by Outside Agency:

    Service: Podiatry Service: Lab

    Provider: Christopher Surtman Provider: AMS

    Billed to: _________________ Billed to: ___________

    Service: Therapy____________ Service: Home Health/Hospice

    Provider: Select Rehab_______ Provider: _________________

    Billed to: ___________________ Billed to: _________________

    Service: Oxygen Service: Pacemaker check

    Provider: __________________ Provider: ______________

    Billed to: __________________ Billed to: ______________

    Service: ___________________ Service: Social Serv/Psych Consult

    Provider: __________________ Provider: _____________________

    Billed to: ___________________ Billed to: _____________________

    _____________________________________ _________________________________

    Residents Signature Date Legal Representative Date

    _____________________________________ _________________________________

    Licensed Nurse Date Family Member Date

    Mailed for signature: Date sent__________ Date returned__________

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