Do not use this document form no – longer in use Check all that apply: _X_ AH __EHP __ALP __Initial __RUG Category Change __12 Month DSS-4449-C1 (rev. 4/97) Name: This form may be used to verify that an Facility Name: individual's health/safety needs can appropriately be met in an adult home, enriched housing Pineview Commons LLC program or residence for adults. It may also be Address: used to verify that an applicant/resident of an 201 South Melcher Street Assisted Living Program (ALP) is medically Johnstown, NY 12095 eligible to reside in a nursing facility but does not require continual nursing or skilled care and the Weight B/P Sex Date of Birth individual's needs can be met in an ALP. M( ) F( ) / / Primary Diagnosis: Secondary Diagnosis: Significant medical history and current conditions: Continence: Bladder: __Yes __No Bowel: __Yes __No do not use this form old – Diet: document Regular, CAT NAS, CAT Consistent Carbohydrate, CAT Needs assistance with self-administration of meds? _X_Yes __ No Allergies: List ail current medications (prescription and OTC), including dosage, type, frequency, and method of administration, and note any special instructions:(attach additional sheet if necessary). MEDICATION DOSAGE TYPE FREQUENCY METHOD DO NOT USE THIS FORM – OLD DOCUMENT
Do not use this document – form no longer in use Check all that apply: _X_ AH __EHP __ALP __Initial __RUG Category Change __12 Month DSS-4449-C1 (rev. 4/97) Name: This form may be used to verify that an individual's health/safety needs can appropriately be met in an adult home, enriched housing program or residence for adults. It may also be used to verify that an applicant/resident of an Assisted Living Program (ALP) is medically eligible to reside in a nursing facility but does not require continual nursing or skilled care and the individual's needs can be met in an ALP. Facility Name: Pineview Commons LLC Address: 201 South Melcher Street Johnstown, NY 12095 Sex Date of Birth M( ) F( ) / / Weight B/P Primary Diagnosis: Secondary Diagnosis: Significant medical history and current conditions: do not use this form – old document Continence: Bladder: __Yes Bowel: __Yes __No __No Diet: Regular, CAT NAS, CAT Consistent Carbohydrate, CAT Needs assistance with self-administration of meds? _X_Yes __ No Allergies: List ail current medications (prescription and OTC), including dosage, type, frequency, and method of administration, and note any special instructions:(attach additional sheet if necessary). MEDICATION DOSAGE TYPE FREQUENCY METHOD DO NOT USE THIS FORM – OLD DOCUMENT
pineview%20admission.docx