Patients in Care Provide the average number of individuals within the the following facility’s care who have disabilities and/or dependencies: Disability or Other Challenges or Confined to Alzheimer’s, dementia cognitive impairment: bed: Require Blind or low hour constant vision: care: Deaf or hearing Chronic condition impaired: (please specify): Speech Other (please impaired: specify): Limited mobility or difficulty walking: Primary language other than English: Dependency Dialysis: Insulin: Walker/cane/scooter/wheelchair: Other (please Ventilator: Oxygen: specify): Service Power animal: Dependent: Other machine dependent: Bariatric Bed: Table : Primary and Sister Facilities (See Attachment E) Primary Facility Address (Street, City, Facility Name County Contact Number State, Zip) Branch Offices Address (Street, City, Facility Name County Contact Number State, Zip)
Patients in Care Provide the average number of individuals within the facility’s care who have the following disabilities and/or dependencies: Disability or Other Challenges Alzheimer’s, dementia or cognitive impairment: Confined to bed: Blind or low vision: Require constant care: Deaf or hearing impaired: Chronic condition (please specify): Speech impaired: Other (please specify): Limited mobility or difficulty walking: Primary language other than English: Dependency Dialysis: Insulin: Walker/cane/scooter/wheelchair: Ventilator: Oxygen: Other (please specify): Service animal: Power Dependent: Other machine dependent: Bariatric Bed: Table : Primary and Sister Facilities (See Attachment E) Primary Facility Facility Name Address (Street, City, State, Zip) County Contact Number Branch Offices Facility Name Address (Street, City, State, Zip) County Contact Number hour
HospiceEOP.docx