Pa Home Trip

SC placed call to Pa’s CG and friend Teresa Lim and for monitoring phone call because none of the numbers on file for Pa was in working order. She reported that the Pa is doing well and is taking a break from radiation and chemo. She Provided the SC with Pa’s new phone numbers. SC asked about Pa’s service and Teresa reported that the Pa is receiving her PAS service specified in her care plan. Teresa reported that the Pa is happy with her current service and do wish to make any changes right now. The Pa is satisfied with her services and feels they are meeting her needs. No falls, hospitalizations, changes in health status or medications were reported. The SC end call with Teresa and place call to Pa via language line interpreter Michelle. The

Pt is a 84 year old Cascasion female living with her husband in their home. Husband reported the Pts Alzhemers has be pergresing for the last 8-9 years. Pt had open heart surgery in 2012, which contributed to the memory loss decline and increasing level of Alzhemer symtoms, husband verbalized. Husband reports they have been married for 19 years. Pt has a sister living Florda, two daughters living in Texas and Wyoming and one son in New York. The children stay in contact with them every other day. Pt reports she worked as a RN at the VA Hospital in New Mexico. Pt is not independent in the home without the husbands assistance. Pt does ambulate well in the home, but does have a walker in needed. Husband assists the Pt all her ADL's in the home and drives her to the store and for MD appointments. Husband currently suffers from Hemochromatosis (too much iron in one's body). Husband reports he manages well with his illness while taking care of Pt at the sametime. Husband reports the Pt's Alzehmers level appears to be stable at this time, but is quite forgetful at times and needs his assistance. Husband said they are managing

He reports the patient’s roommate was subsequently evicted from his home after the landlord inquired about the ambulance visiting. He reports he contacted her father concerning the patient residing within the family home, but the father has said no. In addition, he reports he has attempted to contact her uncle but has been unable to make contact with him. He reports he has attempted to make contact with her said friend who is considering allowing her the opportunity to reside with her but she has not answered her phone and he has been unable to leave a voice message. He reports no one wants her in their home, and the patient has “burned her bridges” with family members. He reports her family would benefit from counseling. In addition, he reports her family has high expectations of CPS. He reports her current case was not going to close within 12 days of 06/30/2017. In addition, the case will not

The patient is very independent in his home and is able to perform all ADLS within the home without any addtional assistance. MSW asked patient if he was interested in any addtional care giving support in the home, but patient declined addtional support at this time. Patinet stated he gets transportation from his neiabors to the store when needed. MSW offered the patient additional transportation services, but the patient declined needing any addtional transportation services at this time.Patient reported falling back in 2004 off the steps and was air lifted to the hospital. Patient reports having diffculty paying doctors and helicoter bills. Patinet's only income is through SS for $847. Patient reported that was the only time he was fallen in his life. Patinet has only been in the hospital two times during his lifetime. MSW offered life alert services, but the patient was not interested. Patient stated his only concern was being able to afford his doctor and helicotor transportion bills. MSW connected AHCCCS and spoke to represtative regarding getting patient signed up for the medicare savings program. Representative stated the patient has already applied for AHCCCS back in

On 8/7/2015, CM met with the client and completed Bi-Weekly ILP Review. Client arrived early for the meeting; she was alert, satisfactorily groomed, and casually dressed. In the meeting she was cooperative and friendly. CM inquires how client is doing since the last Bi-Weekly ILP Review. Client reported she is exhausted from running around obtaining relevant documents to be submitted to Lemle & Wolfe, Inc. by 8/3/2015. She continues to reports she has Straight Medicaid and she is searching for a Managed Cared that cover oxygen tanks.

SC completed monitoring telephone call with Pa on 1/20/2016. SC called Pa. Pa reported that ding “good”. Pa reported no new health problems, no medications, no falls, and no hospitalizations. Pa reported no outstanding doctor’s visits. Pa reported that’s he saw her PCP on 1/19/2016. SC reviewed Pa's ISP. Pa confirms that she is receiving services in the following type, scope, amount, frequency and duration of services specified in the ISP agency model aide via Total Home Health Care from 10-2PM, Monday through Sunday. Pa's aide provides assists her with the completion of ADLs, IALDs and supervision as needed. Pa has PERS system which gives her access to emergency medical service. Pa also, receives HMD from PCA weekly. She reported being satisfied

CM was out for the period of 5/22/2015 to 6/9/2015. On 6/11/2015, CM met with the client and completed Bi-Weekly ILP Review. Client arrived early for the meeting. She was dressed appropriately for the weather. She appears to be friendly and cooperative. In the meeting the client was very talkative. She mentioned to CM her niece gave birth to a baby girl and she can wait to see the baby. She also mentioned to spoke with her sons last night and everything is well with her family. CM inquires if client participate in the onsite Recreation Activities. Client reported she doesn’t participate in the some of the activities. She prefers to go to Bread of Life for food and socialization.

Smith in her home. Ms. Smith was in good spirits and her children were still asleep. She was informed that she needed to bring in a copy of her updated I.D. or Driver’s License. Ms. Smith agreed to have a copy of her I.D. prepared for the next HV. She was asked by the Housing Specialist if she had any goals that she was ready to work on. Ms. Smith stated that she was ready to take her GED test, but wasn’t able to pay for the test due to having limited funds. The client was told that the Case Manger would find out if the agency had funds to pay for her GED test. After the discussion the client was informed about the Home Visit form that needs to be signed by her at the end of the visit for PSH (Permanent Supportive Housing). The Housing Specialist completed a tour of her home and her home was immaculate. All utilities were on and functioning. There were no needed home repairs and no record of destruction of the property. The visited went

:01 PM-3:00 PM SC received a telephone call from Pa states that she was discharged to home on 1/22/2016 from PowerBack Rehab, and she wants her services to start again. SC asked Pa when she was discharged from the hospital. The Pa reported that she was discharged to rehab on 12/22/2015. The Pa stated that she needs someone to help her with her personal care and home management. SC asked Pa where Quintella is (Pa’s DCW/dtr). The Pa reported that she don’t know but she is gone and not coming back. SC informed Pa that the SC spoke with the DCW/dtr Quintilla Bentley on 1/14/2016 and she reported that she (Pa) was scheduled for surgery on the same day 1/14/2016. The Pa exclaimed that whatever she reported was not true. The Pa reported that she had surgery on the 12/14/2015. The SC

CM was out on vacation for the period of 5/2/2016 to 5/9/2016. On 5/19/2016, CM met with the client to update Assessment and to complete Other ILP Review. In the meeting client appears to be friendly and cooperative. She appears to have some cognitive impairment. Client reported WECARE/Wellness referred the client to see Dr. Larissa Lempert/Neurology. Next upcoming appointment is scheduled for 5/26/2016. During the meeting session, client was dressed appropriately for the weather and had good hygiene. She ambulates with a cane due to leg problem. Client affect was flat. Client denied suicidal or homicidal ideation.

SC placed phone call to Pa’s caregiver and informed her that Pa’s services were approved and the ERS providers will be contacting her to schedule appointment for equipment installation. SC asked CG if Pa has select and agency to oversee his care and she said they chose Sear care. SC asked if she is already signed up with the provider and she said no she going call them in the near future. SC urged CG to do so inform SC when she is completely hired by agency so SC will remove hold. CG agreed. 11/18/2015 7:15-729

SC asked William is his health being moniitor William said yes. He noted the nurse checkes his medication and make sure he goes to the doctor. Willaim noted he has not be sick PROGRESS MADE ON OUTCOME because willaim has his health montoir. Supervised Living

CM inquired how the client and her son was doing , Client stated she and son Christopher are doing well, she’s also looking for a job even though her medical condition limits her from doing much. Client stated she applied to a few fast food restaurants and is waiting for a responses. Client also informed CM she went to her WeCare program today. Client reports her next appointment with WeCare is October 12, 2017 at 1pm, at that time she will know if she able to work or not because of her medical

In May, 2016 The 7th grade went on a field trip to Philadelphia, Pennsylvania. This was one of the best days of school. That morning all the 7th grade got to school early. We were all excited and ready to go on this educational trip. The bus ride was one of the best parts of the trip. I got to sit with my friends in the very back of the bus. It was a lot of fun. When we got there we met are tour guides. The 7th grade was so excited to to Philadelphia.

He is in his early 90’s, has multiple medical comorbidities, attends group exercise classes 3 times a week, very strong personality, fiercely independent, retired lawyer, now dependent on a 4-wheel walker due to multiple loss of balance(lately), and had to give up his dog (3 weeks ago) to the care of his caregiver since he was at risk of falling. According to the resident service director of ILF, patient was asked to use the walker inside the apartment which he refused to adhere to, he was told by his neurologist and his daughter to quit driving due to his neuropathy and other medical conditions, which he flat out refused to do so. He reacted very strongly by refusing to go back to the neurologist and is not on speaking terms with his daughter. He claims that he fired his neurologist since they didn’t seem to agree on anything. During the screening process, patient scored really poorly with the TUG test and the 30 sec chair rise test indicating a high fall risk category and poor bilateral lower extremity muscle performance skills sets. Physical therapist asked him about his medication management and he mentioned that his anti- depression pills were not effective at all.PT found patient crying out every time he mentioned his wife and stated that he missed his wife very much. Pt was having