Document found in (if applies) Record Shared Living Contract Shared Living Questionnaire Copy of DSP Certificate Copy Driver's License driver) Copy of HS Diploma or GED Copy of Automobile Registration Copy of Automobile Insurance Copy of Home Owner/Renter's Insurance Proof of Vaccinations for Pets Copy of Member’s Current PCP Copy of CNA-M/CRMA Certificate, SL Medication Certificate, or RN License Date listed Check Name of Individual on off if Completing this Form Document Document found in (if applies) Record Member Information (MaineCare Manual 21.09 Member Records) Progress Notes that identify progress toward goals outlined in the PCP (includes signature) Progress Notes that document the level of services per the PCP Collected requisite daily documentation Collected Medication Administration Reports (MAR’s) Confirmation that the licensee (if applicable) is in good standing with the licensing Agency conducted home visits other month (member present for at least 2 per yr.) Agency conducted phone contact every other (month the home is not visited) month
Document (if applies) found in Record Shared Living Contract Shared Living Questionnaire Copy of DSP Certificate Copy Driver's License driver) Copy of HS Diploma or GED Copy of Automobile Registration Copy of Automobile Insurance Copy of Home Owner/Renter's Insurance Proof of Vaccinations for Pets Copy of Member’s Current PCP Copy of CNA-M/CRMA Certificate, SL Medication Certificate, or RN License Name of Individual Completing this Form Document Date listed on Document (if applies) Check off if found in Record Member Information (MaineCare Manual 21.09 Member Records) Progress Notes that identify progress toward goals outlined in the PCP (includes signature) Progress Notes that document the level of services per the PCP Collected requisite daily documentation Collected Medication Administration Reports (MAR’s) Confirmation that the licensee (if applicable) is in good standing with the licensing Agency conducted home visits other month (member present for at least 2 per yr.) Agency conducted phone contact every other month (month the home is not visited)
Shared-Living-Manual.docx