Skilled Service Components. List the amount Number of days Total To be completed by the member, of time required service will be minutes legal guardian, nurse/ Describe CDAC Provider Activity as allowable by each day for provided per for the member’s therapist, and CDAC provider. the Iowa Administrative Code. each activity. month. line. S8 Colostomy care. 0 S9 Care of medical conditions out of 0 control (includes brittle diabetes and comfort care of terminal conditions) when hospice is not utilized. S10 Post-surgical nurse delegated 0 activities under the supervision of the licensed nurse. S11 Monitoring medication requiring 0 close supervision because of a fluctuating physical or psychological condition. S12 Preparing and monitoring responses 0 to therapeutic diets. S13 Recording and reporting of changes 0 in vital signs to the nurse or therapist. Total Minutes 0 Enter the number in the the Total Units Per Month box below: “Total Units” box into 0 Member Name:
Skilled Service Components. To be completed by the member, member’s legal guardian, nurse/ therapist, and CDAC provider. Describe CDAC Provider Activity as allowable by the Iowa Administrative Code. List the amount of time required each day for each activity. Number of days service will be provided per month. Total minutes for the line. S8 Colostomy care. 0 S9 Care of medical conditions out of control (includes brittle diabetes and comfort care of terminal conditions) when hospice is not utilized. 0 S10 Post-surgical nurse delegated activities under the supervision of the licensed nurse. 0 S11 Monitoring medication requiring close supervision because of a fluctuating physical or psychological condition. 0 S12 Preparing and monitoring responses to therapeutic diets. 0 S13 Recording and reporting of changes in vital signs to the nurse or therapist. 0 Total Minutes 0 Enter the number in the “Total Units” box into the Total Units Per Month box below: 0 Member Name:
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