Shared Living Quality Assurance Checklist Provider Name: ______________________________________________ Date: __________ Date of Contract: ____________ Individual’s Date of Birth: ____________ Date listed Check Name of Individual on off if Completing this Form Document Document found in (if applies) Record Shared Living Contract Shared Living Questionnaire Copy of DSP Certificate Copy Driver's License (every 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 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
Shared Living Quality Assurance Checklist Provider Name: ______________________________________________ Date: __________ Date of Contract: ____________ Individual’s Date of Birth: ____________ Name of Individual Completing this Form Document Date listed on Document (if applies) Check off if found in Record Shared Living Contract Shared Living Questionnaire Copy of DSP Certificate Copy Driver's License (every 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 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
Shared-Living-QA-Checklist%20(Word).docx