Waiver Documentation for HOMEMAKER/PERSONAL CARE SERVICES Waiver Recipient: Mickey Mouse Provider Name: Disney World Service Location: , Tallmadge Medicaid #: 100900500500 Provider #: 7712345 County: *Staffing ratio is 1:1 (staff to recipient) unless otherwise noted *All services provided in the home (service location) unless otherwise noted Month/Year: October 2012 *All services are routine HPC unless noted otherwise Initial boxes when services are provided or write: A-Absent, S-Sick, R-Refused Services Description 1 1 1 1 1 1 1 1 1 1 2 2 2 2 2 2 2 2 2 2 3 3 Identify Frequency and Duration 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 2 3 4 5 6 7 8 9 0 1 Provide auditory supervision in home and L L L L L W W W W W community Assist with doing Laundry 1x/week up to L W 2 hours Encourage eating slowly at each L L L W W W meal/snack Encourage exercise 1x/week L W Assist with dressing for the weather L L L W W W and/or activity appropriately as needed Assist w/tooth brushing by guiding him L L L L L W W W W W to brush top and bottom teeth
Waiver Documentation for HOMEMAKER/PERSONAL CARE SERVICES Waiver Recipient: Mickey Mouse Provider Name: Disney World Service Location: , Tallmadge Medicaid #: 100900500500 Provider #: 7712345 County: *Staffing ratio is 1:1 (staff to recipient) unless otherwise noted *All services provided in the home (service location) unless otherwise noted Month/Year: October 2012 *All services are routine HPC unless noted otherwise Initial boxes when services are provided or write: A-Absent, S-Sick, R-Refused Services Description Identify Frequency and Duration 1 2 3 4 5 6 7 8 9 1 0 1 1 1 2 1 3 1 4 1 5 1 6 1 7 1 8 1 9 2 0 2 1 2 2 2 3 2 4 2 5 2 6 2 7 2 8 2 9 3 0 3 1 Provide auditory supervision in home and community L W L W L W L W L W Assist with doing Laundry 1x/week up to 2 hours L W Encourage eating slowly at each meal/snack L W L W L W Encourage exercise 1x/week L W Assist with dressing for the weather and/or activity appropriately as needed L W L W L W Assist w/tooth brushing by guiding him to brush top and bottom teeth L W L W L W L W L W
3-Documentation-basic-HPC-Example.docx