Yes No Personal Care Services/Social Services O O One or both of the following core personal care services or social services on each day of attendance: P1 One or both of the following personal care services: P1a Supervision of, or assistance with, ADLs or IADLs. P1b Protective group supervision and interventions to assure participant safety and to minimize the risk of injury, accident, inappropriate behavior, or wandering. P2 One or more of the following social services provided by the CBAS center social worker or social worker assistant: P2a Observation, assessment, and monitoring of the participant’s psychosocial status. P2b Group work to address psychosocial issues. P2c Care coordination. Yes No Therapeutic Activities O O One or both of the following therapeutic activities provided by the CBAS center activity coordinator or other trained CBAS center personnel on each day of attendance: A1 Group or individual activities to enhance the social, physical, or cognitive functioning of the participant. A2 Facilitated participation in group or individual activities for those participants whose frailty or cognitive functioning level precludes them from active participation in scheduled activities. Yes No D. Meal Service O O M At least one meal offered per day. (20) TAR FOR REAUTHORIZATION OF CBAS SERVICES Yes No NA If this is a reauthorization TAR, the participant’s condition would likely deteriorate if the CBAS O O O services were denied. (21) Participant’s Individual Plan of Care (Core Services) (must be consistent with information provided in this IPC) Treatments/ Frequency Participant Problem Interventions of Discipline Specific CBAS CORE (must include a (Include whether Treatment/ Objective/Goal of Treatment/ SERVICES measurable starting individual and/or Intervention Intervention (Box 21) point) group intervention, (e.g., 2x per (must include measurable and any out-of-center week) activities) Professional Nursing Services
Yes No O O Personal Care Services/Social Services One or both of the following core personal care services or social services on each day of attendance: P1 One or both of the following personal care services: P1a Supervision of, or assistance with, ADLs or IADLs. P1b Protective group supervision and interventions to assure participant safety and to minimize the risk of injury, accident, inappropriate behavior, or wandering. P2 One or more of the following social services provided by the CBAS center social worker or social worker assistant: P2a Observation, assessment, and monitoring of the participant’s psychosocial status. P2b Group work to address psychosocial issues. P2c Care coordination. Yes No O O Therapeutic Activities One or both of the following therapeutic activities provided by the CBAS center activity coordinator or other trained CBAS center personnel on each day of attendance: A1 Group or individual activities to enhance the social, physical, or cognitive functioning of the participant. A2 Facilitated participation in group or individual activities for those participants whose frailty or cognitive functioning level precludes them from active participation in scheduled activities. Yes No O O D. Meal Service M At least one meal offered per day. (20) TAR FOR REAUTHORIZATION OF CBAS SERVICES Yes O No O NA O If this is a reauthorization TAR, the participant’s condition would likely deteriorate if the CBAS services were denied. (21) Participant’s Individual Plan of Care (Core Services) (must be consistent with information provided in this IPC) CBAS CORE SERVICES (Box 21) Participant Problem (must include a measurable starting point) Treatments/ Interventions (Include whether individual and/or group intervention, and any out-of-center activities) Frequency of Treatment/ Intervention (e.g., 2x per week) Discipline Specific Objective/Goal of Treatment/ Intervention (must include measurable Professional Nursing Services