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www.eldersuite.com
Welcome! This informational packet and the enclosed disc will give you a peak at the new TDH Connect replacement software, ElderSuite. ElderSuite is used everyday by more than 100 facilities across Texas. We are proud to announce that ElderSuite is the only complete business management system that is designed specifically for Texas DAHS facilities, includes TDHS approved forms, and eliminates the need for TDH Connect. Some of ElderSuite’s features include:
• Integrated HIPAA Compliant E-Billing • Star+Plus Managed Care Billing
• Integrated Access to Weekly R&S Reports • Claim for Reimbursement–TDHS Form 1532 (Food Billing)
• Private Pay Billing Reports • Claim for Reimbursement Worksheet–TDHS Form 4502
• Title XIX/XX Certification–TDHS Form 4535 • Case Information–TDHS Form 2067
• Application for Meals–TDHS Form 1652/1662 • Daily Transportation Record–TDHS Form 3682
• Daily Attendance Record–TDHS Form 3683 • Daily Meal Count & Attendance–TDHS Form 1535
• Health Assessment–TDHS Form 3050 • Physician Orders–TDHS Form 3055
• Client Roster Reports • Monthly Attendance Calendars
• Client Birthday Reports • Daily, Weekly, Monthly & Yearly Financial Reports
• Physician’s Standing Orders • Medication Administration Sheets
• Medical Treatment Sheets • Social History Assessments
• Nurses Notes • Client Admission Agreements
• Monthly Nursing Assessments • Monthly Fire Drill Assessments
• Integration of Online Criminal History Checks • Monthly Activity Assessments
• Integration of Online Payment Status • Plus, much more!
ElderSuite eliminates unnecessary duplication and helps increase your productivity and revenue. ElderSuite is completely network ready, completely multi-center ready with centralized billing features, completely secure with integrated user level security features, and most of all completely user-friendly. If the need does arise, you have unlimited access to toll-free technical support. You just give us a call and a support engineer will assist you with any ElderSuite questions or problems. ElderSuite will increase your productivity and revenue; I guarantee it. So, call me toll free at 1-888-999-8055 ext. 63 to schedule your free onsite training and get your free trial started today. If you prefer, I can be reached on my mobile phone at 830-377-4169. Remember, there are absolutely no obligations and no contracts to sign. Sincerely, Vince Cotton President
P.S. Included in the back of this packet, is a fully functional copy of ElderSuite. After installing ElderSuite, you will need to login with the user name “ADMIN” and the password “PASSWORD”. Once you log in you can change the administrator’s password and add new users.
MicroSolutions 820 Main St.
Kerrville, Texas 78028
www.eldersuite.com
So, How Much Does it Cost?
It’s very cost effective because we don’t actually sell you a software package that becomes obsolete in six months. You pay for the rights to use ElderSuite on a monthly basis. The cost is based on the number of clients you need to enter into the ElderSuite database. Just look at the table below:
Number of Clients Cost Per Month Up to 40 Clients $100 Up to 50 Clients $125 Up to 60 Clients $150 Up to 70 Clients $175
Up to 80 Clients $200 Up to 90 Clients $225 Unlimited Clients $250
These rates are all-inclusive with no hidden fees whatsoever. There are no technical support fees, no upgrade fees, no transactions fees, and no additional workstation fees. Here at MicroSolutions, what you see is what you get.
So, What Do I Get?
Free Setup & Training
You get free setup and on-site training. We will visit your facility free of charge to setup and train your staff. We will install the software on as many computers as you need to operate your facility. You can even install it at your home office. Free Technical Support
When you need additional help using ElderSuite, we offer free technical support. We don’t think you should have to pay long distance fees either. So, you can call us via our toll-free line at 1-888-999-8055. Free Upgrades
Anytime we update ElderSuite you will receive the upgrade absolutely free. You will generally receive at least one update per month. Free Remote Backup Service A remote backup service for your ElderSuite database is provided free of charge. The backup service allows you to backup your ElderSuite database to a secured, remote location. No Contracts We are so confident in ElderSuite that we never require you to sign a contract and you’re never obligated in any way to continue using our service. You can stop at any time!
Contact Information Assessment
TDHS Case Worker MHMR Case Worker
Emergency Contact No. 2
Physician
Jill
Address: 123 Her Street
Kerrville, Texas 78028
(830)555-1212Home Phone:
Work Phone: (830)555-1212
Cell Phone: (830)555-1212
Name:
DaughterRelation:
Emergency Contact No. 1
Name:
Address:
Home Phone:
Work Phone:
Cell Phone: (830)555-1212
(830)555-1212
(830)555-1212
Kerrville, Texas 78028
123 His Street
Bob
SonRelation:
(830)555-1212Phone:
My TDHS Case WorkerName:
123 My Street
Kerrville, TX 78028
(830)555-1212Fax:
Address:
My MHMR Case Worker
(830)555-1212
Name:
Address: 123 My Street
Kerrville, TX 78028
(830)555-1212
Phone:
Fax:
Name: My Primary Physician
Address 123 My Street
Kerrville, TX 78028
Phone: (830)555-1212
Fax: (830)555-1212
Psychiatrist
Name: My Psychiatrist
Address 123 My Street
Kerrville, TX 78028
Phone: (830)555-1212
Fax: (830)555-1212
Client
Name: Lucy K Adams
Address 123 My Street
Kerrville, TX 78028
Phone: (830)555-1212
Date of Birth: 10/3/1960
Age: 43
Gender: F
Race: Other
Start Date: 6/5/2002
Inactive Date:
DHS Date: 5/24/2002
USDA Date: 6/5/2002
DHS Title: XIX
Payment Type: TDHS
Other Pay Rate: $0.00 Resources: $0.00
Social Security No.
Medicaid No.
Medicare No.
255-51-6364
555555555
255-51-6364-
Mon. Tue. Wed. Thur. Fri.
Scheduled Days of Attendance
Client Photo
DateSignature - Center Representative
Medical Notes
Allergies
Advanced Directives
Hospital
Name: Sid Peterson Memoria Hospital
Address 123 My Street
Kerrville, TX 78028
Phone: (830)555-1212
Fax: (830)555-1212
Pharmacy
Name: Walgreens
Address 123 My Street
Kerrville, TX 78028
Phone: (830)555-1212
Fax: (830)555-1212
NCS, Low Fat, NAS Diet. Client is diabetic.
Penicillin, Demerol
Living Will Do Not Resuscitate Order (DNR) Durable Power of Attorney for Healthcare
Special Notes
Client has had a skin graft on her left foot due to problems with healing. She is diabetic and requires awheelchair now for mobility. She has also been diagnosed with Parkinson's
X
1
Lucy K Adams (830)555-1212 (830)555-1212
123 My Street Kerrville, TX 78028
555555555
Lucy K Adams 43 $565.00
$565.00
X
X
255-51-6364
Kerrville Adult Day Care Center Vincent Cotton 8308968051
820 Main St. Suite 214 Kerrville, TX 78028
Lucy Adams
123 My Street
Kerrville, TX 78028
Texas Departmentof Human Services
Form 3050July 1996
DAY ACTIVITY AND HEALTH SERVICES
HEALTH ASSESSMENT/PLAN OF CARE
SECTION I - IDENTIFICATION AND BACKGROUND INFORMATION
1. Client Name - Last First M.I. 2. Current Date of Admission
3. Client No. 4. Date of Birth (month/day/year) 5. Sex 6. Lives Alone 7. Reason for Assessment
SECTION II - HEALTH ASSESSMENT (if completed by Licensed Nurse) / CLIENT SELF-REPORT (if completed by facility staff based on client input)
Disease Diagnosis/Health Problems: Check only those diseases present that have a relationship to current ADL status, cognitivestatus, behavior status. medical treatments, or risk of death. (Do not list inactive diagnosis.)
A.
1. Diseases (check all that apply)
Allergies
Alzheimer's Disease
Anemia
Aphasia
Arteriosclerotic HeartDisease (ASHD)
Arthritis
Asthma
Cancer-Type:
Cardiac Dysrhythmia
Cataracts
Cerebral Palsy
CerebrovascularAccident (stroke)
Congestive Heart Failure
Dementia Other Than Alzheimer's
Diabetes Mellitus
Emphysema, COPD
Glaucoma
HIV Infection
Hypotension
Hypertension
Multiple Sclerosis
Osteoporosis
Parkinson'sDisease
PeripheralVascular Disease
Pneumonia
Renal Disease(end stage)
Seizure Disorder
Tuberculosis
Urinary TractInfection (recurrent)
Type:
Frequency:
2. Other Current Diagnoses
CVA S/P 1990; S/P MI 1990
3. Problems/Conditions and Signs/Symptoms (Check al l problems that are present or that client has experienced in the last seven days.)
4. Edema (check all that apply)
Chest Pain
Constipation
Cough
Diarrhea
Dizziness, Vertigo
Fecal Impaction
Fever
Generalized Weakness
Headache
Joint Pain
Malnourished
Obese
Pain-Complains or showsevidence of pain daily oralmost daily.
Shortness of Breath
Syncope (fainting)
Tremors
Upset Stomach/Indigestion
Vomitting
Wheezing
Other (specify):
Other (specify):PittingLocalized (not pitting)GeneralizedNone
Adams Lucy K
555555555 10/3/1960
6/5/2002
Functional/Physical StatusB.COMMUNICATION/HEARING PATTERNS
1. Hearing (with hearing aid, if used)
Hears Adequately-Normal Talk, TV, PhoneMinimal Difficulty WhenNot in Quiet Setting
Hears in Special Situation Only-MustAdjust Tonal Qual./Speak Distinctly
Highly Impaired/No Useful Hearing
2. Communication Devices/Techniques (check all that apply)
Hearing Aid Present, and Used Hearing Aid, Present but not UsedOther Receptive CommunicationTechnique Used (e.g., lip read)
Other
3. Making Self Understood
UnderstoodUsually Understood-DifficultyFinding Words/Finishing Thoughts
Sometimes Understood-Ability isLimited to Making Concrete Requests
Rarely/NeverUnderstood
4. Ability to Understand Others
UnderstandsUsually Understands-May MissSome Part of Intent or Message
Sometimes Understands-Responds Adequatelyto Simple, Direct Communication
Rarely/NeverUnderstands
VISION PATTERNS
Vision (check all that apply)
Adequate-Sees Fine DetailIncluding Newsprint
Severely Impaired-No Vision or Appearsto See Only Light, Color, or Shapes
Impaired-Sees Large Print but NotRegular Print (newsprint)
Uses Glasses Uses Contacts Uses Magnifying Glass
Highly Impaired-Limited Vision; Not able to See News paperHeadlines (appears to follow objects with eyes)
PROBLEM BEHAVIOR
Problem Behavior (check all that apply)
NONE
Motor Agitation (pacing,handwringing, picking)
Wandering (moves with no rational purpose)
Physically Abusive (othersare hit, shoved, scratched)
Socially inappropriate or Disruptive Behavior (disruptive sounds, screams,self-abusive acts, sexual behavior or disrobing in public, throws food)
Failure to Eat orTake Medications
Verbally Abusive (others arethreatened, screamed at, cursed)
Initial Ongoing TransferMale Female NoYes
CONTINENCE
Form 3050Page 2
1. Bowel Continence-Control of bowel movement, with appliance or bowel continence programs, if employed
Continent Occasionally Incontinent Incontinent
Continent Occasionally Incontinent Incontinent
2. Bladder Continence-Control of urination (if dribbles, volume sufficient to soak through underpants), with appliances (e.g. foley) or continence programs, if used.
SKIN CONDITION
1. Stasis Ulcer (open lesion caused by poor circulation to lower extremities)
Yes No If "Yes," describe:
2. Pressure Ulcers (Record the number of sites for presence of each stage of pressure ulcers. If none are present at a stage, enter "0")
NONE
Stage 1:
Stage 2:
Stage 3:
Stage 4:
A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved.
A partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater.
A full thickness of skin lost, exposing subcutaneous tissues-presents deep crater with/without undermining adjacent tissue.
A full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone.
No. Sites Location
3. Other Skin Problems or Lesions Present (check all that apply)
Skin Desensitized to Pain, Pressure, DiscomfortNONE
Open Lesions Other than Stasis/Pressure Ulcers, Or Cuts
Abrasions,Bruises
Dry, Fragile Skin
SurgicalWounds
Cuts (otherthan surgery)
Psoriasis Rashes
ORAL/DENTAL STATUS
Oral Problems
NONEChewingProblem
SwallowingProblem
MouthPain
Broken, Loose orCarlous Teeth
Debris (soft, easily movablesubstances) Present in Mouth
Some or All Natural Teeth Lost-Does Not Haveor Does Not Use Dentures (or partial plates)
Inflamed Gums (gingiva), Swollen or BleedingGums, Oral Abscesses, Ulcers, or Rashes
BODY CONTROL PROBLEMS
(check all that apply)
NONE
Arm-Part or Total Lossof Voluntary Movement
Balance-Part or Total Loss of Ability toBalance While Standing (prone to falling)
Leg-Part or Total Loss ofVoluntary Movement
Hempiegla orHemiparesis
Leg-Unsteady Galt Amputation
Hand-Lack of Dexterity (e.g., problem usingeating utensils or adjusting hearing aid)
Trunk-Part or Total Loss of Ability toPosition, Balance, or Turn Body
Contractures
NONE Face or Neck Shoulder or Elbow Hand or Wrist Hip or Knee Foot or Ankle Other
VITAL SIGNS/HEIGHT/WEIGHT
BP
142/84
Pulse
68
Respiration
16
Temp. (optional) Height
60"
Weight
189
SECTION III - PLAN OF CAREPersonal Care Assistance Required at FacilityA.
1. TRANSFER-How client moves between surfaces-To and From: bed, chair, wheelchair, standing position (exclude to and from bath and toilet)
No Setup or Physical Help Required Setup Help Only One-Person Physical Assistance Two-Person Physical Assistance
2. LOCOMOTION-How client moves between locations
No Setup or Physical Help Required Setup Help Only One-Person Physical Assistance Two-Person Physical Assistance
Mobility Appliances/Devices used at Facility (check all that apply)
NONE
Lifted Manually
Cane, Walker, Crutch
Lifted Mechanically
Brace or Prosthesis
Transfer Aid (e.g., slide board)
Wheelchair-Wheels Self Wheelchair-Other Person Wheels
3. EATING-How client eats and drinks
No Setup or Physical Help Required Setup Help Only One-Person Physical Assistance Two-Person Physical Assistance
Nutrition Approaches at Facility
Parental/IV Fluid
Plate Guard, StabilizedBuilt-Up Utensil, etc.
FeedingTube
Other(specify):
MechanicallyAltered Diet
Dietary SupplementBetween Meals
Syringe (oralfeeding)
TherapeuticDiet
Modified General NCS/LF/LC
4. TOILET USE-How client uses the toilet room, transfers on and off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clotes
No Setup or Physical Help Required Setup Help Only One-Person Physical Assistance Two-Person Physical Assistance
Appliances and Programs (check all that apply)
Any Scheduled Toileting PlanExternal (condom)Catheter
IndwellingCatheter
Enemas,Irrigation
IntermittentCatheter
Pads,Briefs
Ostomy
5. MEDICATIONS (RN must complete for CBA/DAHS)
No Medication Self-Medications: Independent Assist/Supervise/RemindAdministration of Medications(nursing task)
Form 3050Page 3
5. PERSONAL HYGIENE-How client maintains personal hygiene, including hair care, brushing teeth, shaving, applying makeup, washing/drying face, hands, and perineum
No Setup or Physical Help Required Setup Help Only One-Person Physical Assistance Two-Person Physical Assistance
Daily Cleaning of Teeth or Dentures or Daily Mouth Care at DAHS
6. TYPE OF BATH AT DAHS (check all that apply)
Client does not bathe at DAHSClient BathesPRN at DAHS
Tub orWhirlpool Bath
ShowerBedBath
SpongeBath
7. BATHING-Assistance provided at DAHS
Independent- No Help Provided
Supervision-Oversight Help Only
Physical Help Limited to Transfer Only
Physical Help in Partof Bathing Activity
TotalDependence
Special Treatments, Procedures, Training at DAHSB.
1. Special Care-Check treatments client currently receives or will receive at DAHS
Dressing Changes
Intake/Output
Monitoring Vital Signs
Diabetic Tests (urine, blood)Oxygen Therapy
Respiratory Care(Nebulizer, IPPB)
Syringe or Tub Feeding
Catheter Care
Weight Monitoring
Fluid Intake Monitoring
Other (Specify):
2. Active Skin Care Program at DAHS (check all that apply)
Turning or Repositioning ProgramSurgicalWound Care
Pressure Relieving Device(i.e. egg crate pads)
Ostomy Care (e.g. trach)(routine and stable)
Special Topical Applications ofLotion, Ointment, Medications
PressureUlcer Care
Other (Specify):
Special Nutrition orHydration Program
3. Foot Care Program at DAHS (check all that apply)
Foot Soaks Preventative or Protective Foot Care (e.g. special shoes, inserts, pads, toe separators, nail/callus trimming, etc.)
Scheduled Monitoringof Condition of Feet
Dressing With and WithoutTopical Medications, Etc. Other (Specify):
4. Rehabilitation/Restorative Care (check all that client receives at DAHS)
Range of Motion-Passive-Specify Joint(s):
Reality OrientationSplint or Brace Assistance
Range of Motion-Active-Specify Joint(s):
Reminiscence Therapy/Remotivation
All extremeties
5. Training & Skill Practice in:
Walking or Mobility TransferDressing orGrooming
Eating orSwallowing
AmputationCare
OtherCommunication
6. Health Teaching to be Provided at DAHS (check al l that apply)
Methods to minimize or prevent health problems (e.g., use of adaptive equipment,adequate nutrition/hydration, proper positioning, use of elastic stockings, etc.)
Medication Effects
Special Diet Requirements Symptoms to Report to Physician/Nurse Skin Care
Other:Diabetic Foot Care
SECTION IV - THERAPIESCheck therapies client CURRENTLY receives from ANY source.
Physical Therapy
Occupational Therapy
Speech-Language Pathology, Audiology Services
Respiratory Therapy
Psychological Therapy (licensed prof.)
Other (Specify):Chemotherapy
Radiation
Dialysis
SECTION V - PARTICIPATION IN ASSESSMENTClient
NoYesYes No FamilyNo
Family Significant Other
NoYes None
Signature-Client or Responsible Person Date
Comments:
Date Assessment Completed (m/d/y) Telephone No.
I certify that to the best of my knowledge, the information contained in this form is true and correct.
Signature-RN or LVN Completing Assessment
(Include RN or LVN Credential as appropriate)
X
Weekly Weekly Weekly Monthly
Carbidopa/Levodopa
Pentoxifylline ER
All other meds taken @ home
25/100
400 Mg
PO
PO
TID
TID
Texas Departmentof Human Services
Form 3055June 1995PHYSICIAN'S ORDERS (DAY Activity and Health Services)
Day Activity and Health Services (DAHS) is a licensed day care program for the aged and/or disabled administered by the Texas Department of Human Services. The programprovider must have services available for eligible clients at least 10 hours per day, Monday through Friday, except holidays. Services include licensed nursing care; planned activities;hot lunch and mid-morning/afternoon snacks; personal care assistance; social services; and transportation to and from the facility, therapies, and treatments.
Client Name (Last, First, Middle)
Adams, Lucy K
Client No.
555555555Provider Agency Name Provider Agency Nurse
Provider Agency Address
Kerrville Adult Day Care Center
820 Main St. Suite 214 Kerrville, TX 78028
Super Nurse, LVN
Telephone No. (inc. A/C)
(830)896-8051
PHYSICIAN ORDERS: A physician's order is required for this service. A physician's order is also needed for medications/treatments/special diet.
MEDICAL DIAGNOSIS DATE OF ONSET*
ASHD
Arthritis
Asthma
*If date unknown, you may state "chronic" or "long-standing."
Present Condition
Stable Improving Deteriorating
Prognosis
Good Fair Poor
Restricted Activities
Special Diet
None DiabeticLowCholesterol
Low SaltCalorieRestricted
BlandOther(specify):
Ordered Treatment(s)
Specify Frequency (if ordered)
BP: Pulse: Resp.: Wgt.:
ORDERED MEDICATIONS DOSAGE ROUTE FREQUENCY MEDICATION ADMINISTRATION AT DAHS
Client MaySelf-Admin.
WithSupervision
LicensedNurse
Client MaySelf-Admin.
WithSupervision
LicensedNurse
Client MaySelf-Admin.
WithSupervision
LicensedNurse
Client MaySelf-Admin.
WithSupervision
LicensedNurse
Client MaySelf-Admin.
WithSupervision
LicensedNurse
Client MaySelf-Admin.
WithSupervision
LicensedNurse
Client MaySelf-Admin.
WithSupervision
LicensedNurse
Client MaySelf-Admin.
WithSupervision
LicensedNurse
I HEREBY PRESCRIBE DAHS FOR THIS CLIENT
Please have client make an appointmentfor an evaluation of need for services.
I also certify that I am not a significant owner, partner or member of the provider agency requesting this order for DAHS.
Comments:
X
Today's Date (mo./day/yr.) Date of Verbal Order (if app.)
Signature-Physician
Physician's Name (please type or print)
Physician's Address (Street, City, State, ZIP)
License No. State
Telephone No. (inc. A/C)
MD DO
MEDICAL DIAGNOSIS DATE OF ONSET*
S/P CVA
Diabetes Type I
Glaucoma
Modified General NCS/LF/LC/NAS
Eastin, Levon
808 Bandera Hwy., Kerrville, Texas 78028
H6182
(830)555-1212
TX
Social History Assessment
Adams, Lucy K
4. Client's current living arrangements
9. Involvement with Organizations
14. Client's behavioral problems
15. Languages spoken by client
Client:
1. Client's current religion:........................................................................................................ Other
2. Client's current marital status:.............................................................................................. Divorced
Lives alone in her house. She has a sister who is developmentally disabled and unable to assist her in any way. Her only supportis an ex-husband.
Licensed Dietician in Nursing Home
3. Client's current occupation
5. Client's relationship with family and friends:...................................................................... Good
6. Client's emotional status:...................................................................................................... Fair
7. Client's mental status:........................................................................................................... Good
8. Hobbies and Leisure Time
Sewing and painting pictures.
Volunteer for Hospice and Food Bank
10. Client's ambulation:............................................................................................................. With Wheelchair
11. Client's communication skills:............................................................................................ Good
12. Client's vision:...................................................................................................................... Needs Glasses
13. Client's hearing:.................................................................................................................... Good
None known
English
DateSignature - Center Representative
16. Client's current limitations
17. Prosthetic devices & adjustments required by client
18. Other Notes
Client has been dx w/Parkinsons and is now in wheelchiar. She is also diabetic.
None known
Client says she has been lonely at home and wants to come back to daycare for the activities and socialization. She has severalhealth problems and feels she could use some help.
Case Name
Lucy K Adams
Address
123 My Street, Kerrville, TX 78028
Category
555555555
Case No. Category Case No.
Change in Circumstances
Change in Address/Telephone
Income
Resources
Deductions
Household Composition
Medical/Disability
AFDC
Absent Parent
Protective Services
Nursing Care/Level of Care
Medicaid
Community PlacementResources
Self-Support Services
EPSDT
ChildCare
Family HealthServices Nurse
EmploymentServices
RefugeeServices
FamilyPlanning
Other:
Other:
Comment/Response:
Signature Date
Telephone
TO: FROM:
Mail Code: Mail Code:
RESPONSE:
Comment/Response:
Signature Date
Telephone
Will not meet 14 day approval. Will not have signed Dr.s order within the 14 days.
Texas Departmentof Human Services
Form 2067October 1992
CASE INFORMATION
TO: FROM:
Mail Code: Mail Code:
TDHS Case Woker
Austin, Texas 78512
P.O. Box 123
Kerrville Adult Day Care Center
Kerrville, TX 78028
820 Main St.
1. To provide personal care, and such services as may be required for the health, safety, good grooming, and well-beingof the patient.2. To arrange for transfer of the patient to the hospital of choice in case of emergency, and immediately to notify thepatient's family of such transfer.
1. To provide such personal clothing and effects as needed or desired by the patient, such as spending money.
Signature of Client/Responsible Party Date Signature of Center Representative Date
3. To provide medical care as indicated by the patient's private physician except when such care is inappropriate for thelicensing guidlines of the center.
DAY CARE CENTER AGREEMENT
AGREEMENT OF PATIENT OR RESPONSIBLE PARTY
2. To be responsible for ambulance and hospital charges.
3. To be responsible for providing medical information, medications, and other treatment aids as necessary, and to follow
4. To pay basic rate agreed upon with the Kerrville Adult Day Care Center at specified time.
WAIVER
Kerrville Adult Day Care Center will not be liable or responsible for any and all claims and damages or for damages to orloss of property, arising out of or attributed, directly or indirectly, to the operations or performance of Kerrville Adult DayCare Center, under this agreement, except such claims as directly arise out of negligent acts of Kerrville Adult Day CareCenter, or its agents or employees.
FINANCIAL AGREEMENT
The patient or responsible party agrees to pay a daily rate of __________________ for services, as determined by theKerrville Adult Day Care Center income sliding scale, and Kerrville Adult Day Care Center will accept this arrangement infull consideration for care and services rendered. Charges will be billed on a monthly basis and payment will be made bythe 10th of each month. Charges are billed after services are rendered; therefore, a refund policy is not in effect.
I understand that complaints may be registered against this facility by calling the Texas Department of Human Services'Hot Line, toll-free at 1-800-458-9858.
1. I have received a copy of "Rights for the Elderly."
3. I have received a copy of "Client Code of Conduct."
4. I have received a copy of Medication Requirements.
5. I have received a copy of Complaint Procedures.
6. I have received a copy of the Fire Evacuation Pr ocedures.
7. I have received a copy of the USDA Food Program Information
8. I have received a copy of the Information regarding Advanced Directives.
I do have Advanced Directives
I do not have Advanced Directives
I have read this agreement and authorize Kerrville Adult Day Care Center to provide adult day care for either myself ormy family member as set forth by the terms of this agreement.
2. I have received a copy of "Rights for the Handicapped."
Social Security No, of Client/Responsible Party
Name of Patient
Lucy Adams
Responsible Party
Admission Agreement for Day Care ServicesKerrville Adult Day Care Center
and
Monthly Activity Assessment
Client:
Signature - Representative Date
Good1. Interacts with his or her peers:.........................................................................................................
Observations on Attitude and Social Interests
2. Has a good attitude, gets along with others, and respects others:..............................................
3. Is open to positive or negative criticism:........................................................................................
4. Assists his or her peers with crafts, activities, etc.:......................................................................
5. Uses appropriate language or tone of voice:..................................................................................
6. Is alert and attentive to his or her surroundings:...........................................................................
Good
Good
Good
Good
Needs Improvement
Date:Adams, Lucy K October 2003
1. Enjoys watching TV or videos:......................................................................................................... Fair
General Observations
2. Has the ability to follow instructions correctly:..............................................................................
3. Participates in arts and crafts, crocheting, sewing, etc.:...............................................................
4. Enjoys live music, dances, or singing:............................................................................................
5. Participates in shopping trips or other outings:.............................................................................
6. Has good personal hygiene:.............................................................................................................
7. Enjoys playing bingo or other games:.............................................................................................
8. Enjoys reading books, magazines, newspapers, etc.:...................................................................
9. Participates in exercise sessions, etc.:...........................................................................................
10. Volunteers to help others with projects, tasks, etc.:....................................................................
11. Participates in seasonal and other festivities:..............................................................................
12. Overall participation in activities:..................................................................................................
Good
Good
Fair
Good
Needs Improvement
Needs Improvement
Good
Good
Good
Good
Good
The client's routine and patterns have remained the same with no apparent changes. No furthercomments or recommendations are necessary:......................................................................................... Yes
If No, indicate changes:
Recommendations:None at this time.
Monthly Nursing Assessment
Client:
Yes1. The client is capable and does self-administer all meds...............................................................
Medication Administration
2. The client self-administers meds with supervision........................................................................
3. A licensed nurse is required to administer the client's meds.......................................................
4. The client's family manages meds, provides pillbox center and the nurse supervises.............
5. The client was provided with the following medication counseling/teaching relevant to current prescriptionsand med regimen:
6. Client's response to counseling/teaching:
No
No
Not Applicable
Not Applicable
Not Applicable
Date:Adams, Lucy K October 2003
1. Blood Pressure.................................................................................................................................. 120/70
Vital Sign Ranges for Month
2.Pulse.......................................................................................................................................................
3. Respiration.........................................................................................................................................
4. Finger Stick Blood Sugar test (FSBS):............................................................................................5.Weight.....................................................................................................................................................
68
Not Applicable
Not Applicable
165 lbs.
1. Client has no new orders this month, continuing to follow care plan.......................................... Yes
2. Client has the following new orders this month:
None.
New Orders and Treatments
Physical Rehabilitation
1. Client participates actively in group exercises...............................................................................
2. Client receives physician ordered physcial therapy.......(Frequency):.........................................
3. Client receives individualized restorative nursing therapy...........................................................
Daily
Not Applicable
No
No4. Client refuses or chooses not to participate in physical activities...............................................
Diet
1. Client has a special diet ordered......................................................................................................
2. Client's physician ordered diet is:
3. Client adheres to ordered diet..........................................................................................................
No
Not Applicable
Always
Yes4. Client was provided relevant diet teaching this month..................................................................
Signature - Representative Date
Special Treatments
1. Client was provided the following this month:
2. Other Treatments:
None.
Tube or Special Feeding
Respiratory Therapy
Transportation to Medical Appointments or Therapy
Edema Monitoring......Location:
Assistance with ADL's
Diabetic Foot Care/Foot Monitoring
Intake/Output
Hospitalizations
1. Client was hospitalized this month..................................................................................................
2. Client was hospitalized at:
3. Hospitalization Dates:
No
Not Applicable
Not Applicable
None.
Other Comments
Blood Sugar PRN
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
Monthly Weight
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
Weekly Blood Pressure
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR
TREATMENTS 51 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 34 25 26 27 28 29 302 4 7 31HR 3
TREATMENT SHEET
Facility Name
Kerrville Adult Day Care Center
Physician Name
Dr. Levon Eastin H.E.B.
Pharmacy Name
Patient Name
Adams, Lucy K
Sex Age
F 43
Date RN Signature LVN Signature
51 9 11 13 15 17 19 21 23 25 27 297 313Carbidopa/Levodopa 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR
Tab 1
25/100 Mg
PO
51 9 11 13 15 17 19 21 23 25 27 297 313Furosemide 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR
Tab 3
20 Mg
PO
51 9 11 13 15 17 19 21 23 25 27 297 313Humulin 70/30 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR
15 U
100 U
SQ
51 9 11 13 15 17 19 21 23 25 27 297 313Hydrocodone/Apap 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR
Tab 1
5/500 mg
PO
51 9 11 13 15 17 19 21 23 25 27 297 313Isosorbide 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR
Tab 1
30 Mg
PO
51 9 11 13 15 17 19 21 23 25 27 297 313Levaquin 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR
Tab 1
500 Mg
PO
51 9 11 13 15 17 19 21 23 25 27 297 313Paxil 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR
Tab 1
20 Mg
PO
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR
51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR
MEDICATIONS 51 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 302 4 7 31HR 3
MEDICATION ADMINISTRATION SHEET
Facility Name
Kerrville Adult Day Care Center
Physician Name
Dr. Levon Eastin H.E.B.
Pharmacy Name
Patient Name
Adams, Lucy K
Sex Age
F 43
Date RN Signature LVN Signature
Medication
Carbidopa/Levodopa
Pharmacy Name
Wal-Greens
Start Date
2/20/2002
Stop Date RX Amount Issued Strength
25/100 Mg
Dosage
Tab 1
Route Admin.
PO
Self-Administered Supervised Administered
Directions for use:
TID
Scheduled Time for AdministrationPharmacy Name
Wal-Greens
Medication
Furosemide
Pharmacy Name
Wal-Greens
Start Date
2/20/2002
Stop Date RX Amount Issued Strength
20 Mg
Dosage
Tab 3
Route Admin.
PO
Self-Administered Supervised Administered
Directions for use:
QD/Home Med
Scheduled Time for AdministrationPharmacy Name
Wal-Greens
Medication
Humulin 70/30
Pharmacy Name
Wal-Greens
Start Date
2/20/2002
Stop Date RX Amount Issued Strength
100 U
Dosage
15 U
Route Admin.
SQ
Self-Administered Supervised Administered
Directions for use:
Q AM; 10 U Q PM/ Home Med
Scheduled Time for AdministrationPharmacy Name
Wal-Greens
Medication
Hydrocodone/Apap
Pharmacy Name
Wal-Greens
Start Date
5/30/2002
Stop Date RX Amount Issued Strength
5/500 mg
Dosage
Tab 1
Route Admin.
PO
Self-Administered Supervised Administered
Directions for use:
Q 8H PRN/Pain
Scheduled Time for AdministrationPharmacy Name
Wal-Greens
Medication Profiles
Lucy K Adams
Date
6/26/2002
Blood Pressure Pulse Respiratory Temperature Finger Stick
Notes:
Client has been assessed and continues to be capable of self-administering medications and treatments
DateSignature - Center Representative
Nurse's Notes
Lucy K Adams
Monthly Fire Drill Assessment
Signature - Representative Date
Fire1. Simulated Situation:..........................................................................................................
Pre-Drill Setup
2. Location:.............................................................................................................................
3. Type of Drill:.......................................................................................................................
Common Area
Full Evacuation
Date: October 2003
1. Did staff use proper judgement?..................................................................................... Yes
Post-Drill Assessment
2. Was the fire alarm system activated?..............................................................................
3. Was the fire department or 911 called?...........................................................................
4. How long did it take to call after sounding the alarm?..................................................
5. Were all clients moved to a safe area?............................................................................
6. Were all exits clear and easily accessible?....................................................................
7. Were all interior rooms inspected and doors closed?...................................................
8. Were slow moving or wheelchair bound clients assisted by staff in a timelymanner?..................................................................................................................................
9. How long did it take to completely evacuate the building and account for allclients?...................................................................................................................................
10. Who sounded the "All Clear"?.......................................................................................
11. Were all staff aware of responsibilities?.......................................................................
12. Was the emergency plan executed correctly?..............................................................
Yes
Yes
1
Yes
Yes
Yes
Yes
4
Director
Yes
Yes
Comments or Problems IdentifiedEverything went smooth.
Minutes
Minutes
13. Did clients hear the alarm?............................................................................................. Yes
14. Did clients respond promptly?....................................................................................... Yes
Yes15. Did clients follow procedures calmly, smoothly and efficiently?...............................
16. Did clients seem to know what to do and where to go?..............................................
17. Did clients respond quickly to "Roll Call"?...................................................................
18. Did clients stand by until "All Clear" was given?.........................................................
19. Did all clients participate in the drill?............................................................................
20. How many fire extinguishers were inspected/checked?.............................................
Yes
Yes
Yes
Yes
3
Signatures of Participating Staff
Adams, Leota G1. 255-25-2454 (830)555-1212 10/10/1916 87
Adams, Lucy K2. 255-51-6364 (830)555-1212 10/3/1960 43
Ammons, Robert L.3. 215-66-5113 (830)555-1212 10/11/1916 87
Blair, Lucille 4. 205-55-6265 (830)555-1212 10/25/1916 87
Boswell, Margaret E5. 123-45-6789 (830)555-1212 10/4/1964 39
Brown, Harold J6. 216-51-6256 (830)555-1212 10/26/1913 90
Burns, Robert N7. 243-55-6055 (830)555-1212 10/21/1923 80
Clayton, Austin B8. 216-65-1506 (830)555-1212 10/14/1915 88
Easton, Rose 9. 151-66-6635 (830)555-1212 10/13/1920 83
Esparza, Perfecto 10. 166-12-6605 (830)555-1212 10/18/1923 80
Gerken, Howard J11. 252-55-6131 (830)555-1212 10/5/1921 82
Heath, Edmund C12. 212-63-5510 (830)555-1212 10/21/1934 69
Herald, Nora F13. 255-15-1155 (830)555-1212 10/25/1929 74
Hoots, Danny L.14. 202-65-4526 (830)555-1212 10/28/1963 40
Lyons, Helen B15. 213-65-0530 (830)555-1212 10/22/1923 80
Manning, Kenneth C16. 200-65-6614 (830)555-1212 10/6/1924 79
Martinez, Lisa 17. 214-55-6065 (830)555-1212 10/31/1961 42
Mason, Esther M18. 214-36-4245 (830)555-1212 10/25/1932 71
McGrath, Brenda S.19. 216-23-0523 (830)555-1212 10/16/1965 38
Parker, Bob 20. 215-53-0265 (830)555-1212 10/19/1919 84
Radinz, Margaret 21. 125-26-1502 (830)555-1212 10/19/1937 66
Reeves, Dewey 22. 215-32-4666 (830)555-1212 10/24/1931 72
Rehmeyer, Betty M23. 205-62-4023 (830)555-1212 10/30/1924 79
Rice, Richard M24. 101-22-0550 (830)555-1212 10/25/1915 88
Shelton, Nellie H25. 216-54-0250 (830)555-1212 10/15/1916 87
Stoval, Annie B26. 251-56-4156 (830)555-1212 10/23/1920 83
Swanson, Betty L27. 245-65-6661 (830)555-1212 10/22/1925 78
Ward, Helen E28. 123-51-5541 (830)555-1212 10/13/1910 93
Watson, Frank M29. 256-55-5660 (830)555-1212 10/23/1920 83
Winstead, Minnie L30. 255-55-6410 (830)555-1212 10/14/1919 84
Client Roster
Name SSN Phone Birth Date Age
Adams, Lucy K1. 255-51-6364 (830)555-1212 10/3/1960 43
Boswell, Margaret E2. 123-45-6789 (830)555-1212 10/4/1964 39
Gerken, Howard J3. 252-55-6131 (830)555-1212 10/5/1921 82
Manning, Kenneth C4. 200-65-6614 (830)555-1212 10/6/1924 79
Adams, Leota G5. 255-25-2454 (830)555-1212 10/10/1916 87
Ammons, Robert L.6. 215-66-5113 (830)555-1212 10/11/1916 87
Ward, Helen E7. 123-51-5541 (830)555-1212 10/13/1910 93
Easton, Rose 8. 151-66-6635 (830)555-1212 10/13/1920 83
Clayton, Austin B9. 216-65-1506 (830)555-1212 10/14/1915 88
Winstead, Minnie L10. 255-55-6410 (830)555-1212 10/14/1919 84
Shelton, Nellie H11. 216-54-0250 (830)555-1212 10/15/1916 87
McGrath, Brenda S.12. 216-23-0523 (830)555-1212 10/16/1965 38
Esparza, Perfecto 13. 166-12-6605 (830)555-1212 10/18/1923 80
Parker, Bob 14. 215-53-0265 (830)555-1212 10/19/1919 84
Radinz, Margaret 15. 125-26-1502 (830)555-1212 10/19/1937 66
Burns, Robert N16. 243-55-6055 (830)555-1212 10/21/1923 80
Heath, Edmund C17. 212-63-5510 (830)555-1212 10/21/1934 69
Swanson, Betty L18. 245-65-6661 (830)555-1212 10/22/1925 78
Lyons, Helen B19. 213-65-0530 (830)555-1212 10/22/1923 80
Stoval, Annie B20. 251-56-4156 (830)555-1212 10/23/1920 83
Watson, Frank M21. 256-55-5660 (830)555-1212 10/23/1920 83
Reeves, Dewey 22. 215-32-4666 (830)555-1212 10/24/1931 72
Blair, Lucille 23. 205-55-6265 (830)555-1212 10/25/1916 87
Mason, Esther M24. 214-36-4245 (830)555-1212 10/25/1932 71
Rice, Richard M25. 101-22-0550 (830)555-1212 10/25/1915 88
Herald, Nora F26. 255-15-1155 (830)555-1212 10/25/1929 74
Brown, Harold J27. 216-51-6256 (830)555-1212 10/26/1913 90
Hoots, Danny L.28. 202-65-4526 (830)555-1212 10/28/1963 40
Rehmeyer, Betty M29. 205-62-4023 (830)555-1212 10/30/1924 79
Martinez, Lisa 30. 214-55-6065 (830)555-1212 10/31/1961 42
Birthday List for October
Name SSN Phone Birth Date Age
Attendance Calendar for Adams, Lucy K
25 26 27
7:00 am to 3:00
pm
Units: 2
28
7:00 am to 3:00
pm
Units: 2
29 30
7:00 am to 3:00
pm
Units: 2
31
18 19
7:00 am to 3:00
pm
Units: 2
20
7:00 am to 9:00
am
Units: 0
21
7:00 am to
11:00 am
Units: 1
22 23
7:00 am to 3:00
pm
Units: 2
24
11 12 13
7:00 am to 3:00
pm
Units: 2
14 15
7:00 am to 3:00
pm
Units: 2
16 17
1 2 3
8
7:00 am to 3:00
pm
Units: 2
9
7:00 am to 3:00
pm
Units: 2
104 5
7:00 am to 3:00
pm
Units: 2
6
7:00 am to 3:00
pm
Units: 2
7
Whole Days: 11 Half Days: 1 Losses: 1 Total Units: 23
Sunday Monday Tuesday Wednesday Thursday Friday Saturday
May 2003
1. 9:30 am 010:30 amAdams, Leota G TDHS
2. 9:25 am 24:25 pmBrown, Harold J TDHS
3. 9:00 am 112:30 pmEaston, Rose TDHS
4. 9:00 am 24:15 pmEsparza, Perfecto TDHS
5. 9:00 am 24:00 pmLyons, Helen B TDHS
6. 9:15 am 24:00 pmMartinez, Lisa TDHS
7. 9:10 am 24:05 pmReeves, Dewey TDHS
8. 9:00 am 24:00 pmRice, Richard M TDHS
9. 9:30 am 24:30 pmShelton, Nellie H TDHS
10. 9:15 am 24:15 pmWatson, Frank M TDHS
Daily Attendance Summary Report for 10/1/2003
Name Pickup Time 1 Drop Off Time 1 Pickup Time 2 UnitsDrop Off Time 2Payment Type
1. 555555555 10/25/1983 10/23/1983 42 $596.40Adams, Leota G
2. 555555555 1/15/2000 3/8/2001 16 $227.20Blair, Lucille
3. 555555555 5/15/2000 10/18/2000 41 $582.20Brown, Harold J
4. 555555555 3/26/2001 8/14/2001 39 $553.80Easton, Rose
5. 555555555 1/16/2001 2/14/2001 40 $568.00Esparza, Perfecto
6. 555555555 5/18/1994 5/18/1994 37 $525.40Lyons, Helen B
7. 555555555 8/14/2001 16 $227.20Manning, Kenneth C
8. 555555555 8/2/1982 8/2/1982 39 $553.80Martinez, Lisa
9. 555555555 8/17/2001 8/30/2001 32 $454.40Reeves, Dewey
10. 555555555 7/24/2000 13 $184.60Rehmeyer, Betty M
11. 555555555 5/7/1993 7/1/1996 34 $482.80Rice, Richard M
12. 555555555 5/5/1983 3/1/1994 33 $468.60Shelton, Nellie H
13. 555555555 11/14/2000 12/13/2000 26 $369.20Swanson, Betty L
14. 555555555 3/3/2000 8/17/2001 20 $284.00Watson, Frank M
Total Units:
Total Amount:
428
$6,077.60
Pre-Billing Summary Report - 9/1/2003 to 9/30/2003
Name Medicaid No. Start Date DHS Date Units Amount
Adams, Leota G 202 S. Georgia (830)555-12121.M-T-W-Th-F
Blair, Lucille 1912 S, Woodland (830)555-12122.M-T-W-Th-F
Boswell, Margaret E 10801 West I-40 (830)555-12123.
W-F
Burns, Robert N 3425 Julian BLVD. (830)555-12124.T-Th-
Easton, Rose 704 A S.Cleveland (830)555-12125.M-T-W-Th-F
Esparza, Perfecto 2608 7TH AVE #13 (830)555-12126.M-T-W-Th-F
Gerken, Howard J 1953 S. Roosevelt (830)555-12127.T-Th-
Herald, Nora F 1549 Smiley (830)555-12128.M-T-W-Th-F
Manning, Kenneth C 2200 W. 7th (830)555-12129.W-F
Radinz, Margaret 607 S. Mississippi (830)555-121210.T-Th-F
Rice, Richard M 4216 Hetrick (830)555-121211.M-T-W-Th-F
Swanson, Betty L 4700 S. Virginia #352 (830)555-121212.T-W-Th-
13.
14.
15.
16.
17.
18.
19.
20.
21.
22.
23.
24.
25.
Signature - DriverI certify that this information is true and correct:Route: My Route
Kerrville Adult Day Care Center 001003137 10/1/2003
Name of Facility Vendor No.
Texas Departmentof Human Services
Form 3682October 1996
DAILY TRANSPORTATION RECORD
Page of
Date
CLIENT NAMETIME
Pick Up Drop Off
TIME
Pick Up Drop Off
1 1
8:00 AM
2:00 PM
8:25 AM
3:00 PM
9:30 AM
4:30 PM
9:30 AM
4:30 PM
9:15 AM
4:15 PMAdams, Leota G
1.
10In
Out
7:30 AM
3:30 PM
7:30 AM
1:00 PM
9:00 AM
4:00 PM
9:00 AM
4:00 PM
9:15 AM
4:15 PMBrown, Harold J
2.
9In
Out
9:45 AM
12:45 PM
9:30 AM
3:30 PM
9:45 AM
3:45 PM
9:30 AM
3:30 PMEaston, Rose
3.
7In
Out
8:15 AM
2:45 PM
9:00 AM
4:00 PM
9:00 AM
4:00 PM
9:15 AM
4:00 PMEsparza, Perfecto
4.
8In
Out
8:45 AM
2:30 PM
9:00 AM
4:00 PM
9:00 AM
4:00 PM
9:00 AM
4:00 PMLyons, Helen B
5.
7In
Out
7:30 AM
3:00 PM
9:30 AM
4:30 PMManning, Kenneth C
6.
4In
Out
9:00 AM
1:00 PM
7:30 AM
2:00 PM
9:00 AM
4:00 PM
9:00 AM
4:00 PM
9:00 AM
4:00 PMMartinez, Lisa
7.
9In
Out
8:25 AM
3:05 PM
8:45 AM
3:45 PM
9:15 AM
4:15 PMReeves, Dewey
8.
6In
Out
10:25 AM
2:45 PM
9:15 AM
3:15 PMRehmeyer, Betty M
9.
3In
Out
8:15 AM
2:15 PM
8:45 AM
4:00 PM
8:45 AM
4:00 PM
8:45 AM
4:00 PMRice, Richard M
10.
8In
Out
9:00 AM
3:30 PM
9:30 AM
4:30 PMShelton, Nellie H
11.
4In
Out
I hereby certify that this is a correct daily attendance record for DHS clients.
Signature-Facility Representative Date
Texas Departmentof Human Services DAILY ATTENDANCE RECORD
Form 3683October 1996
Name of Facility Vendor No.
Kerrville Adult Day Care Center 001003137Page of
1 2
CLIENT NAME
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAYTOTALUNITSOF
SERVICE
Date Date Date Date Date
Time Time Time Time Time Time Time Time Time Time
9/8/2003 9/9/2003 9/10/2003 9/11/2003 9/12/2003
8:45 AM
3:45 PMSwanson, Betty L
1.
2In
Out
9:30 AM
4:00 PM
9:00 AM
3:30 PMWatson, Frank M
2.
4In
Out
3. In
Out
4. In
Out
5. In
Out
6. In
Out
7. In
Out
8. In
Out
9. In
Out
10. In
Out
11. In
Out
I hereby certify that this is a correct daily attendance record for DHS clients.
Signature-Facility Representative Date
Texas Departmentof Human Services DAILY ATTENDANCE RECORD
Form 3683October 1996
Name of Facility Vendor No.
Kerrville Adult Day Care Center 001003137Page of
2 2
CLIENT NAME
MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAYTOTALUNITSOF
SERVICE
Date Date Date Date Date
Time Time Time Time Time Time Time Time Time Time
9/8/2003 9/9/2003 9/10/2003 9/11/2003 9/12/2003
Adams, Leota1 87 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Adams, Lucy2 43 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Ammons, Robert3 87 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Blair, Lucille4 87 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Boswell, Margaret5 39 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Brown, Harold6 90 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Burns, Robert7 80 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Clayton, Austin8 88 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Easton, Rose9 83 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Esparza, Perfecto10 80 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Gerken, Howard11 82 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Heath, Edmund12 69 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Herald, Nora13 74 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Lyons, Helen14 80 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Manning, Kenneth15 79 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
DAY
MondayAGEPARTICIPANT'S NAME
Month and Year
09/2003
Agreement No. (TX No.)
TXName of Contractor
Kerrville Adult Day Care Center
DATE
9/8/2003
Texas Departmentof Human Services DAILY MEAL COUNT AND ATTENDANCE RECORD (Centers and Emergency Shelters)
Form
Name of Facility
CENTERS: You may claim up to two meals and one snack or one meal and two snacks. EMERGENCY SHELTERS: You may claim up to three meals or two meals and one snack.
Kerrville Adult Day Care Center 1
TuesdayDAY DATE DAY DATE DAY DATE DAY DATE
Wednesday Thursday Friday9/9/2003 9/10/2003 9/11/2003 9/12/2003
2 3 4 5 6 7
July 1999
1535
Signature-Center/Shelter Representative Date
Total Number of Program Staff Meals
Total Number of Non-Program Meals
I CERTIFY that the information on this form is true and correct to the best of my knowledge and that I will claim reimbursement only for eligible meals served to eligible participants. I under-stand that misrepresentation may result in prosecution under applicable state or federal statutes. Page of1 2
Total
Number
of
Program
Participants
At
B
L
P
S
A
E
5 3 5 6
4 0 0 0
1 0 0 0 0
5 3 5 5 6
3 2 0 0 0
3
5
0 0 0 0
0 0 0
0
0 0
Martinez, Lisa1 42 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Mason, Esther2 71 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
McGrath, Brenda3 38 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Parker, Bob4 84 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Radinz, Margaret5 66 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Reeves, Dewey6 72 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Rehmeyer, Betty7 79 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Rice, Richard8 88 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Shelton, Nellie9 87 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Swanson, Betty10 78 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Watson, Frank11 83 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
Winstead, Minnie12 84 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
13 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
14 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
15 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E
DAY
MondayAGEPARTICIPANT'S NAME
Month and Year
09/2003
Agreement No. (TX No.)
TXName of Contractor
Kerrville Adult Day Care Center
DATE
9/8/2003
Texas Departmentof Human Services DAILY MEAL COUNT AND ATTENDANCE RECORD (Centers and Emergency Shelters)
Form
Name of Facility
CENTERS: You may claim up to two meals and one snack or one meal and two snacks. EMERGENCY SHELTERS: You may claim up to three meals or two meals and one snack.
Kerrville Adult Day Care Center 1
TuesdayDAY DATE DAY DATE DAY DATE DAY DATE
Wednesday Thursday Friday9/9/2003 9/10/2003 9/11/2003 9/12/2003
2 3 4 5 6 7
July 1999
1535
Signature-Center/Shelter Representative Date
Total Number of Program Staff Meals
Total Number of Non-Program Meals
I CERTIFY that the information on this form is true and correct to the best of my knowledge and that I will claim reimbursement only for eligible meals served to eligible participants. I under-stand that misrepresentation may result in prosecution under applicable state or federal statutes. Page of2 2
Total
Number
of
Program
Participants
At
B
L
P
S
A
E
3 3 4 5
2 0 0 0
1 0 0 0 0
3 3 4 4 5
2 1 0 0 0
3
4
0 0 0 0
0 0 0
0
0 0
1 3 5 6 72
0
0
0
0
0
0
0
0
12
2
206
8
Kerrville Adult Day Care Center
820 Main St., Kerrville, TX 78028
9/2003
21 218
17 4 3
Vincent Cotton
1
(830)896-8051 31 2 54
Kerrville Adult Day Care Center 1 9/2003
Kerrville Adult Day Care Center 12 27
1 2 3 4 5
2 3 5 6 7
1 2 3 4 65 7
0
0
0
0
0
0
0
0
0
0
8
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
5
3
0
0
0
11
11
11
11
13
0
0
206
9
9
11
10
13
0
0
10
10
12
12
0
0
0
10
8
10
11
8
6
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
2
0
0
0
0
0
0
0
0
6
6
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
0
12
Kerrville Adult Day Care Center 9/2003
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