eldersuite welcome packet welcome packet.pdf · welcome! this informational packet and the enclosed...

www.eldersuite.com

Welcome! This informational packet and the enclosed disc will give you a peak at the new TDH Connect replacement software, ElderSuite. ElderSuite is used everyday by more than 100 facilities across Texas. We are proud to announce that ElderSuite is the only complete business management system that is designed specifically for Texas DAHS facilities, includes TDHS approved forms, and eliminates the need for TDH Connect. Some of ElderSuite’s features include:

• Integrated HIPAA Compliant E-Billing • Star+Plus Managed Care Billing

• Integrated Access to Weekly R&S Reports • Claim for Reimbursement–TDHS Form 1532 (Food Billing)

• Private Pay Billing Reports • Claim for Reimbursement Worksheet–TDHS Form 4502

• Title XIX/XX Certification–TDHS Form 4535 • Case Information–TDHS Form 2067

• Application for Meals–TDHS Form 1652/1662 • Daily Transportation Record–TDHS Form 3682

• Daily Attendance Record–TDHS Form 3683 • Daily Meal Count & Attendance–TDHS Form 1535

• Health Assessment–TDHS Form 3050 • Physician Orders–TDHS Form 3055

• Client Roster Reports • Monthly Attendance Calendars

• Client Birthday Reports • Daily, Weekly, Monthly & Yearly Financial Reports

• Physician’s Standing Orders • Medication Administration Sheets

• Medical Treatment Sheets • Social History Assessments

• Nurses Notes • Client Admission Agreements

• Monthly Nursing Assessments • Monthly Fire Drill Assessments

• Integration of Online Criminal History Checks • Monthly Activity Assessments

• Integration of Online Payment Status • Plus, much more!

ElderSuite eliminates unnecessary duplication and helps increase your productivity and revenue. ElderSuite is completely network ready, completely multi-center ready with centralized billing features, completely secure with integrated user level security features, and most of all completely user-friendly. If the need does arise, you have unlimited access to toll-free technical support. You just give us a call and a support engineer will assist you with any ElderSuite questions or problems. ElderSuite will increase your productivity and revenue; I guarantee it. So, call me toll free at 1-888-999-8055 ext. 63 to schedule your free onsite training and get your free trial started today. If you prefer, I can be reached on my mobile phone at 830-377-4169. Remember, there are absolutely no obligations and no contracts to sign. Sincerely, Vince Cotton President

P.S. Included in the back of this packet, is a fully functional copy of ElderSuite. After installing ElderSuite, you will need to login with the user name “ADMIN” and the password “PASSWORD”. Once you log in you can change the administrator’s password and add new users.

MicroSolutions 820 Main St.

Kerrville, Texas 78028

www.eldersuite.com

So, How Much Does it Cost?

It’s very cost effective because we don’t actually sell you a software package that becomes obsolete in six months. You pay for the rights to use ElderSuite on a monthly basis. The cost is based on the number of clients you need to enter into the ElderSuite database. Just look at the table below:

Number of Clients Cost Per Month Up to 40 Clients $100 Up to 50 Clients $125 Up to 60 Clients $150 Up to 70 Clients $175

Up to 80 Clients $200 Up to 90 Clients $225 Unlimited Clients $250

These rates are all-inclusive with no hidden fees whatsoever. There are no technical support fees, no upgrade fees, no transactions fees, and no additional workstation fees. Here at MicroSolutions, what you see is what you get.

So, What Do I Get?

Free Setup & Training

You get free setup and on-site training. We will visit your facility free of charge to setup and train your staff. We will install the software on as many computers as you need to operate your facility. You can even install it at your home office. Free Technical Support

When you need additional help using ElderSuite, we offer free technical support. We don’t think you should have to pay long distance fees either. So, you can call us via our toll-free line at 1-888-999-8055. Free Upgrades

Anytime we update ElderSuite you will receive the upgrade absolutely free. You will generally receive at least one update per month. Free Remote Backup Service A remote backup service for your ElderSuite database is provided free of charge. The backup service allows you to backup your ElderSuite database to a secured, remote location. No Contracts We are so confident in ElderSuite that we never require you to sign a contract and you’re never obligated in any way to continue using our service. You can stop at any time!

Contact Information Assessment

TDHS Case Worker MHMR Case Worker

Emergency Contact No. 2

Physician

Jill

Address: 123 Her Street


(830)555-1212Home Phone:

Work Phone: (830)555-1212

Cell Phone: (830)555-1212

Name:

DaughterRelation:

Emergency Contact No. 1

Name:

Address:

Home Phone:

Work Phone:

Cell Phone: (830)555-1212

(830)555-1212

(830)555-1212


123 His Street

Bob

SonRelation:

(830)555-1212Phone:

My TDHS Case WorkerName:

123 My Street

Kerrville, TX 78028

(830)555-1212Fax:

Address:

My MHMR Case Worker

(830)555-1212

Name:

Address: 123 My Street

Kerrville, TX 78028

(830)555-1212

Phone:

Fax:

Name: My Primary Physician

Address 123 My Street

Kerrville, TX 78028

Phone: (830)555-1212

Fax: (830)555-1212

Psychiatrist

Name: My Psychiatrist


Kerrville, TX 78028

Phone: (830)555-1212

Fax: (830)555-1212

Client

Name: Lucy K Adams


Kerrville, TX 78028

Phone: (830)555-1212

Date of Birth: 10/3/1960

Age: 43

Gender: F

Race: Other

Start Date: 6/5/2002

Inactive Date:

DHS Date: 5/24/2002

USDA Date: 6/5/2002

DHS Title: XIX

Payment Type: TDHS

Other Pay Rate: $0.00 Resources: $0.00

Social Security No.

Medicaid No.

Medicare No.

255-51-6364

555555555

255-51-6364-

Mon. Tue. Wed. Thur. Fri.

Scheduled Days of Attendance

Client Photo

DateSignature - Center Representative

Medical Notes

Allergies

Advanced Directives

Hospital

Name: Sid Peterson Memoria Hospital


Kerrville, TX 78028

Phone: (830)555-1212

Fax: (830)555-1212

Pharmacy

Name: Walgreens


Kerrville, TX 78028

Phone: (830)555-1212

Fax: (830)555-1212

NCS, Low Fat, NAS Diet. Client is diabetic.

Penicillin, Demerol

Living Will Do Not Resuscitate Order (DNR) Durable Power of Attorney for Healthcare

Special Notes

Client has had a skin graft on her left foot due to problems with healing. She is diabetic and requires awheelchair now for mobility. She has also been diagnosed with Parkinson's

X

1

Lucy K Adams (830)555-1212 (830)555-1212

123 My Street Kerrville, TX 78028

555555555

Lucy K Adams 43 $565.00

$565.00

X

X

255-51-6364

Kerrville Adult Day Care Center Vincent Cotton 8308968051

820 Main St. Suite 214 Kerrville, TX 78028

Lucy Adams

123 My Street

Kerrville, TX 78028

Texas Departmentof Human Services

Form 3050July 1996

DAY ACTIVITY AND HEALTH SERVICES

HEALTH ASSESSMENT/PLAN OF CARE

SECTION I - IDENTIFICATION AND BACKGROUND INFORMATION

1. Client Name - Last First M.I. 2. Current Date of Admission

3. Client No. 4. Date of Birth (month/day/year) 5. Sex 6. Lives Alone 7. Reason for Assessment

SECTION II - HEALTH ASSESSMENT (if completed by Licensed Nurse) / CLIENT SELF-REPORT (if completed by facility staff based on client input)

Disease Diagnosis/Health Problems: Check only those diseases present that have a relationship to current ADL status, cognitivestatus, behavior status. medical treatments, or risk of death. (Do not list inactive diagnosis.)

A.

1. Diseases (check all that apply)

Allergies

Alzheimer's Disease

Anemia

Aphasia

Arteriosclerotic HeartDisease (ASHD)

Arthritis

Asthma

Cancer-Type:

Cardiac Dysrhythmia

Cataracts

Cerebral Palsy

CerebrovascularAccident (stroke)

Congestive Heart Failure

Dementia Other Than Alzheimer's

Diabetes Mellitus

Emphysema, COPD

Glaucoma

HIV Infection

Hypotension

Hypertension

Multiple Sclerosis

Osteoporosis

Parkinson'sDisease

PeripheralVascular Disease

Pneumonia

Renal Disease(end stage)

Seizure Disorder

Tuberculosis

Urinary TractInfection (recurrent)

Type:

Frequency:

2. Other Current Diagnoses

CVA S/P 1990; S/P MI 1990

3. Problems/Conditions and Signs/Symptoms (Check al l problems that are present or that client has experienced in the last seven days.)

4. Edema (check all that apply)

Chest Pain

Constipation

Cough

Diarrhea

Dizziness, Vertigo

Fecal Impaction

Fever

Generalized Weakness

Headache

Joint Pain

Malnourished

Obese

Pain-Complains or showsevidence of pain daily oralmost daily.

Shortness of Breath

Syncope (fainting)

Tremors

Upset Stomach/Indigestion

Vomitting

Wheezing

Other (specify):

Other (specify):PittingLocalized (not pitting)GeneralizedNone

Adams Lucy K

555555555 10/3/1960

6/5/2002

Functional/Physical StatusB.COMMUNICATION/HEARING PATTERNS

1. Hearing (with hearing aid, if used)

Hears Adequately-Normal Talk, TV, PhoneMinimal Difficulty WhenNot in Quiet Setting

Hears in Special Situation Only-MustAdjust Tonal Qual./Speak Distinctly

Highly Impaired/No Useful Hearing

2. Communication Devices/Techniques (check all that apply)

Hearing Aid Present, and Used Hearing Aid, Present but not UsedOther Receptive CommunicationTechnique Used (e.g., lip read)

Other

3. Making Self Understood

UnderstoodUsually Understood-DifficultyFinding Words/Finishing Thoughts

Sometimes Understood-Ability isLimited to Making Concrete Requests

Rarely/NeverUnderstood

4. Ability to Understand Others

UnderstandsUsually Understands-May MissSome Part of Intent or Message

Sometimes Understands-Responds Adequatelyto Simple, Direct Communication

Rarely/NeverUnderstands

VISION PATTERNS

Vision (check all that apply)

Adequate-Sees Fine DetailIncluding Newsprint

Severely Impaired-No Vision or Appearsto See Only Light, Color, or Shapes

Impaired-Sees Large Print but NotRegular Print (newsprint)

Uses Glasses Uses Contacts Uses Magnifying Glass

Highly Impaired-Limited Vision; Not able to See News paperHeadlines (appears to follow objects with eyes)

PROBLEM BEHAVIOR

Problem Behavior (check all that apply)

NONE

Motor Agitation (pacing,handwringing, picking)

Wandering (moves with no rational purpose)

Physically Abusive (othersare hit, shoved, scratched)

Socially inappropriate or Disruptive Behavior (disruptive sounds, screams,self-abusive acts, sexual behavior or disrobing in public, throws food)

Failure to Eat orTake Medications

Verbally Abusive (others arethreatened, screamed at, cursed)

Initial Ongoing TransferMale Female NoYes

CONTINENCE

Form 3050Page 2

1. Bowel Continence-Control of bowel movement, with appliance or bowel continence programs, if employed

Continent Occasionally Incontinent Incontinent

Continent Occasionally Incontinent Incontinent

2. Bladder Continence-Control of urination (if dribbles, volume sufficient to soak through underpants), with appliances (e.g. foley) or continence programs, if used.

SKIN CONDITION

1. Stasis Ulcer (open lesion caused by poor circulation to lower extremities)

Yes No If "Yes," describe:

2. Pressure Ulcers (Record the number of sites for presence of each stage of pressure ulcers. If none are present at a stage, enter "0")

NONE

Stage 1:

Stage 2:

Stage 3:

Stage 4:

A persistent area of skin redness (without a break in the skin) that does not disappear when pressure is relieved.

A partial thickness loss of skin layers that presents clinically as an abrasion, blister, or shallow crater.

A full thickness of skin lost, exposing subcutaneous tissues-presents deep crater with/without undermining adjacent tissue.

A full thickness of skin and subcutaneous tissue is lost, exposing muscle and/or bone.

No. Sites Location

3. Other Skin Problems or Lesions Present (check all that apply)

Skin Desensitized to Pain, Pressure, DiscomfortNONE

Open Lesions Other than Stasis/Pressure Ulcers, Or Cuts

Abrasions,Bruises

Dry, Fragile Skin

SurgicalWounds

Cuts (otherthan surgery)

Psoriasis Rashes

ORAL/DENTAL STATUS

Oral Problems

NONEChewingProblem

SwallowingProblem

MouthPain

Broken, Loose orCarlous Teeth

Debris (soft, easily movablesubstances) Present in Mouth

Some or All Natural Teeth Lost-Does Not Haveor Does Not Use Dentures (or partial plates)

Inflamed Gums (gingiva), Swollen or BleedingGums, Oral Abscesses, Ulcers, or Rashes

BODY CONTROL PROBLEMS

(check all that apply)

NONE

Arm-Part or Total Lossof Voluntary Movement

Balance-Part or Total Loss of Ability toBalance While Standing (prone to falling)

Leg-Part or Total Loss ofVoluntary Movement

Hempiegla orHemiparesis

Leg-Unsteady Galt Amputation

Hand-Lack of Dexterity (e.g., problem usingeating utensils or adjusting hearing aid)

Trunk-Part or Total Loss of Ability toPosition, Balance, or Turn Body

Contractures

NONE Face or Neck Shoulder or Elbow Hand or Wrist Hip or Knee Foot or Ankle Other

VITAL SIGNS/HEIGHT/WEIGHT

BP

142/84

Pulse

68

Respiration

16

Temp. (optional) Height

60"

Weight

189

SECTION III - PLAN OF CAREPersonal Care Assistance Required at FacilityA.

1. TRANSFER-How client moves between surfaces-To and From: bed, chair, wheelchair, standing position (exclude to and from bath and toilet)

No Setup or Physical Help Required Setup Help Only One-Person Physical Assistance Two-Person Physical Assistance

2. LOCOMOTION-How client moves between locations


Mobility Appliances/Devices used at Facility (check all that apply)

NONE

Lifted Manually

Cane, Walker, Crutch

Lifted Mechanically

Brace or Prosthesis

Transfer Aid (e.g., slide board)

Wheelchair-Wheels Self Wheelchair-Other Person Wheels

3. EATING-How client eats and drinks


Nutrition Approaches at Facility

Parental/IV Fluid

Plate Guard, StabilizedBuilt-Up Utensil, etc.

FeedingTube

Other(specify):

MechanicallyAltered Diet

Dietary SupplementBetween Meals

Syringe (oralfeeding)

TherapeuticDiet

Modified General NCS/LF/LC

4. TOILET USE-How client uses the toilet room, transfers on and off toilet, cleanses, changes pad, manages ostomy or catheter, adjusts clotes


Appliances and Programs (check all that apply)

Any Scheduled Toileting PlanExternal (condom)Catheter

IndwellingCatheter

Enemas,Irrigation

IntermittentCatheter

Pads,Briefs

Ostomy

5. MEDICATIONS (RN must complete for CBA/DAHS)

No Medication Self-Medications: Independent Assist/Supervise/RemindAdministration of Medications(nursing task)

Form 3050Page 3

5. PERSONAL HYGIENE-How client maintains personal hygiene, including hair care, brushing teeth, shaving, applying makeup, washing/drying face, hands, and perineum


Daily Cleaning of Teeth or Dentures or Daily Mouth Care at DAHS

6. TYPE OF BATH AT DAHS (check all that apply)

Client does not bathe at DAHSClient BathesPRN at DAHS

Tub orWhirlpool Bath

ShowerBedBath

SpongeBath

7. BATHING-Assistance provided at DAHS

Independent- No Help Provided

Supervision-Oversight Help Only

Physical Help Limited to Transfer Only

Physical Help in Partof Bathing Activity

TotalDependence

Special Treatments, Procedures, Training at DAHSB.

1. Special Care-Check treatments client currently receives or will receive at DAHS

Dressing Changes

Intake/Output

Monitoring Vital Signs

Diabetic Tests (urine, blood)Oxygen Therapy

Respiratory Care(Nebulizer, IPPB)

Syringe or Tub Feeding

Catheter Care

Weight Monitoring

Fluid Intake Monitoring

Other (Specify):

2. Active Skin Care Program at DAHS (check all that apply)

Turning or Repositioning ProgramSurgicalWound Care

Pressure Relieving Device(i.e. egg crate pads)

Ostomy Care (e.g. trach)(routine and stable)

Special Topical Applications ofLotion, Ointment, Medications

PressureUlcer Care

Other (Specify):

Special Nutrition orHydration Program

3. Foot Care Program at DAHS (check all that apply)

Foot Soaks Preventative or Protective Foot Care (e.g. special shoes, inserts, pads, toe separators, nail/callus trimming, etc.)

Scheduled Monitoringof Condition of Feet

Dressing With and WithoutTopical Medications, Etc. Other (Specify):

4. Rehabilitation/Restorative Care (check all that client receives at DAHS)

Range of Motion-Passive-Specify Joint(s):

Reality OrientationSplint or Brace Assistance

Range of Motion-Active-Specify Joint(s):

Reminiscence Therapy/Remotivation

All extremeties

5. Training & Skill Practice in:

Walking or Mobility TransferDressing orGrooming

Eating orSwallowing

AmputationCare

OtherCommunication

6. Health Teaching to be Provided at DAHS (check al l that apply)

Methods to minimize or prevent health problems (e.g., use of adaptive equipment,adequate nutrition/hydration, proper positioning, use of elastic stockings, etc.)

Medication Effects

Special Diet Requirements Symptoms to Report to Physician/Nurse Skin Care

Other:Diabetic Foot Care

SECTION IV - THERAPIESCheck therapies client CURRENTLY receives from ANY source.

Physical Therapy

Occupational Therapy

Speech-Language Pathology, Audiology Services

Respiratory Therapy

Psychological Therapy (licensed prof.)

Other (Specify):Chemotherapy

Radiation

Dialysis

SECTION V - PARTICIPATION IN ASSESSMENTClient

NoYesYes No FamilyNo

Family Significant Other

NoYes None

Signature-Client or Responsible Person Date

Comments:

Date Assessment Completed (m/d/y) Telephone No.

I certify that to the best of my knowledge, the information contained in this form is true and correct.

Signature-RN or LVN Completing Assessment

(Include RN or LVN Credential as appropriate)

X

Weekly Weekly Weekly Monthly

Carbidopa/Levodopa

Pentoxifylline ER

All other meds taken @ home

25/100

400 Mg

PO

PO

TID

TID


Form 3055June 1995PHYSICIAN'S ORDERS (DAY Activity and Health Services)

Day Activity and Health Services (DAHS) is a licensed day care program for the aged and/or disabled administered by the Texas Department of Human Services. The programprovider must have services available for eligible clients at least 10 hours per day, Monday through Friday, except holidays. Services include licensed nursing care; planned activities;hot lunch and mid-morning/afternoon snacks; personal care assistance; social services; and transportation to and from the facility, therapies, and treatments.

Client Name (Last, First, Middle)

Adams, Lucy K

Client No.

555555555Provider Agency Name Provider Agency Nurse

Provider Agency Address

Kerrville Adult Day Care Center

820 Main St. Suite 214 Kerrville, TX 78028

Super Nurse, LVN

Telephone No. (inc. A/C)

(830)896-8051

PHYSICIAN ORDERS: A physician's order is required for this service. A physician's order is also needed for medications/treatments/special diet.

MEDICAL DIAGNOSIS DATE OF ONSET*

ASHD

Arthritis

Asthma

*If date unknown, you may state "chronic" or "long-standing."

Present Condition

Stable Improving Deteriorating

Prognosis

Good Fair Poor

Restricted Activities

Special Diet

None DiabeticLowCholesterol

Low SaltCalorieRestricted

BlandOther(specify):

Ordered Treatment(s)

Specify Frequency (if ordered)

BP: Pulse: Resp.: Wgt.:

ORDERED MEDICATIONS DOSAGE ROUTE FREQUENCY MEDICATION ADMINISTRATION AT DAHS

Client MaySelf-Admin.

WithSupervision

LicensedNurse


WithSupervision

LicensedNurse


WithSupervision

LicensedNurse


WithSupervision

LicensedNurse


WithSupervision

LicensedNurse


WithSupervision

LicensedNurse


WithSupervision

LicensedNurse


WithSupervision

LicensedNurse

I HEREBY PRESCRIBE DAHS FOR THIS CLIENT

Please have client make an appointmentfor an evaluation of need for services.

I also certify that I am not a significant owner, partner or member of the provider agency requesting this order for DAHS.

Comments:

X

Today's Date (mo./day/yr.) Date of Verbal Order (if app.)

Signature-Physician

Physician's Name (please type or print)

Physician's Address (Street, City, State, ZIP)

License No. State

Telephone No. (inc. A/C)

MD DO

MEDICAL DIAGNOSIS DATE OF ONSET*

S/P CVA

Diabetes Type I

Glaucoma

Modified General NCS/LF/LC/NAS

Eastin, Levon

808 Bandera Hwy., Kerrville, Texas 78028

H6182

(830)555-1212

TX

Social History Assessment

Adams, Lucy K

4. Client's current living arrangements

9. Involvement with Organizations

14. Client's behavioral problems

15. Languages spoken by client

Client:

1. Client's current religion:........................................................................................................ Other

2. Client's current marital status:.............................................................................................. Divorced

Lives alone in her house. She has a sister who is developmentally disabled and unable to assist her in any way. Her only supportis an ex-husband.

Licensed Dietician in Nursing Home

3. Client's current occupation

5. Client's relationship with family and friends:...................................................................... Good

6. Client's emotional status:...................................................................................................... Fair

7. Client's mental status:........................................................................................................... Good

8. Hobbies and Leisure Time

Sewing and painting pictures.

Volunteer for Hospice and Food Bank

10. Client's ambulation:............................................................................................................. With Wheelchair

11. Client's communication skills:............................................................................................ Good

12. Client's vision:...................................................................................................................... Needs Glasses

13. Client's hearing:.................................................................................................................... Good

None known

English


16. Client's current limitations

17. Prosthetic devices & adjustments required by client

18. Other Notes

Client has been dx w/Parkinsons and is now in wheelchiar. She is also diabetic.

None known

Client says she has been lonely at home and wants to come back to daycare for the activities and socialization. She has severalhealth problems and feels she could use some help.

Case Name

Lucy K Adams

Address

123 My Street, Kerrville, TX 78028

Category

555555555

Case No. Category Case No.

Change in Circumstances

Change in Address/Telephone

Income

Resources

Deductions

Household Composition

Medical/Disability

AFDC

Absent Parent

Protective Services

Nursing Care/Level of Care

Medicaid

Community PlacementResources

Self-Support Services

EPSDT

ChildCare

Family HealthServices Nurse

EmploymentServices

RefugeeServices

FamilyPlanning

Other:

Other:

Comment/Response:

Signature Date

Telephone

TO: FROM:

Mail Code: Mail Code:

RESPONSE:

Comment/Response:

Signature Date

Telephone

Will not meet 14 day approval. Will not have signed Dr.s order within the 14 days.


Form 2067October 1992

CASE INFORMATION

TO: FROM:

Mail Code: Mail Code:

TDHS Case Woker

Austin, Texas 78512

P.O. Box 123


Kerrville, TX 78028

820 Main St.

1. To provide personal care, and such services as may be required for the health, safety, good grooming, and well-beingof the patient.2. To arrange for transfer of the patient to the hospital of choice in case of emergency, and immediately to notify thepatient's family of such transfer.

1. To provide such personal clothing and effects as needed or desired by the patient, such as spending money.

Signature of Client/Responsible Party Date Signature of Center Representative Date

3. To provide medical care as indicated by the patient's private physician except when such care is inappropriate for thelicensing guidlines of the center.

DAY CARE CENTER AGREEMENT

AGREEMENT OF PATIENT OR RESPONSIBLE PARTY

2. To be responsible for ambulance and hospital charges.

3. To be responsible for providing medical information, medications, and other treatment aids as necessary, and to follow

4. To pay basic rate agreed upon with the Kerrville Adult Day Care Center at specified time.

WAIVER

Kerrville Adult Day Care Center will not be liable or responsible for any and all claims and damages or for damages to orloss of property, arising out of or attributed, directly or indirectly, to the operations or performance of Kerrville Adult DayCare Center, under this agreement, except such claims as directly arise out of negligent acts of Kerrville Adult Day CareCenter, or its agents or employees.

FINANCIAL AGREEMENT

The patient or responsible party agrees to pay a daily rate of __________________ for services, as determined by theKerrville Adult Day Care Center income sliding scale, and Kerrville Adult Day Care Center will accept this arrangement infull consideration for care and services rendered. Charges will be billed on a monthly basis and payment will be made bythe 10th of each month. Charges are billed after services are rendered; therefore, a refund policy is not in effect.

I understand that complaints may be registered against this facility by calling the Texas Department of Human Services'Hot Line, toll-free at 1-800-458-9858.

1. I have received a copy of "Rights for the Elderly."

3. I have received a copy of "Client Code of Conduct."

4. I have received a copy of Medication Requirements.

5. I have received a copy of Complaint Procedures.

6. I have received a copy of the Fire Evacuation Pr ocedures.

7. I have received a copy of the USDA Food Program Information

8. I have received a copy of the Information regarding Advanced Directives.

I do have Advanced Directives

I do not have Advanced Directives

I have read this agreement and authorize Kerrville Adult Day Care Center to provide adult day care for either myself ormy family member as set forth by the terms of this agreement.

2. I have received a copy of "Rights for the Handicapped."

Social Security No, of Client/Responsible Party

Name of Patient

Lucy Adams

Responsible Party

Admission Agreement for Day Care ServicesKerrville Adult Day Care Center

and

Monthly Activity Assessment

Client:

Signature - Representative Date

Good1. Interacts with his or her peers:.........................................................................................................

Observations on Attitude and Social Interests

2. Has a good attitude, gets along with others, and respects others:..............................................

3. Is open to positive or negative criticism:........................................................................................

4. Assists his or her peers with crafts, activities, etc.:......................................................................

5. Uses appropriate language or tone of voice:..................................................................................

6. Is alert and attentive to his or her surroundings:...........................................................................

Good

Good

Good

Good

Needs Improvement

Date:Adams, Lucy K October 2003

1. Enjoys watching TV or videos:......................................................................................................... Fair

General Observations

2. Has the ability to follow instructions correctly:..............................................................................

3. Participates in arts and crafts, crocheting, sewing, etc.:...............................................................

4. Enjoys live music, dances, or singing:............................................................................................

5. Participates in shopping trips or other outings:.............................................................................

6. Has good personal hygiene:.............................................................................................................

7. Enjoys playing bingo or other games:.............................................................................................

8. Enjoys reading books, magazines, newspapers, etc.:...................................................................

9. Participates in exercise sessions, etc.:...........................................................................................

10. Volunteers to help others with projects, tasks, etc.:....................................................................

11. Participates in seasonal and other festivities:..............................................................................

12. Overall participation in activities:..................................................................................................

Good

Good

Fair

Good

Needs Improvement

Needs Improvement

Good

Good

Good

Good

Good

The client's routine and patterns have remained the same with no apparent changes. No furthercomments or recommendations are necessary:......................................................................................... Yes

If No, indicate changes:

Recommendations:None at this time.

Monthly Nursing Assessment

Client:

Yes1. The client is capable and does self-administer all meds...............................................................

Medication Administration

2. The client self-administers meds with supervision........................................................................

3. A licensed nurse is required to administer the client's meds.......................................................

4. The client's family manages meds, provides pillbox center and the nurse supervises.............

5. The client was provided with the following medication counseling/teaching relevant to current prescriptionsand med regimen:

6. Client's response to counseling/teaching:

No

No

Not Applicable

Not Applicable

Not Applicable

Date:Adams, Lucy K October 2003

1. Blood Pressure.................................................................................................................................. 120/70

Vital Sign Ranges for Month

2.Pulse.......................................................................................................................................................

3. Respiration.........................................................................................................................................

4. Finger Stick Blood Sugar test (FSBS):............................................................................................5.Weight.....................................................................................................................................................

68

Not Applicable

Not Applicable

165 lbs.

1. Client has no new orders this month, continuing to follow care plan.......................................... Yes

2. Client has the following new orders this month:

None.

New Orders and Treatments

Physical Rehabilitation

1. Client participates actively in group exercises...............................................................................

2. Client receives physician ordered physcial therapy.......(Frequency):.........................................

3. Client receives individualized restorative nursing therapy...........................................................

Daily

Not Applicable

No

No4. Client refuses or chooses not to participate in physical activities...............................................

Diet

1. Client has a special diet ordered......................................................................................................

2. Client's physician ordered diet is:

3. Client adheres to ordered diet..........................................................................................................

No

Not Applicable

Always

Yes4. Client was provided relevant diet teaching this month..................................................................


Special Treatments

1. Client was provided the following this month:

2. Other Treatments:

None.

Tube or Special Feeding

Respiratory Therapy

Transportation to Medical Appointments or Therapy

Edema Monitoring......Location:

Assistance with ADL's

Diabetic Foot Care/Foot Monitoring

Intake/Output

Hospitalizations

1. Client was hospitalized this month..................................................................................................

2. Client was hospitalized at:

3. Hospitalization Dates:

No

Not Applicable

Not Applicable

None.

Other Comments

Blood Sugar PRN

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

Monthly Weight

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

Weekly Blood Pressure

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 34 26 28 302 4HR

TREATMENTS 51 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 34 25 26 27 28 29 302 4 7 31HR 3

TREATMENT SHEET

Facility Name


Physician Name

Dr. Levon Eastin H.E.B.

Pharmacy Name

Patient Name

Adams, Lucy K

Sex Age

F 43

Date RN Signature LVN Signature

51 9 11 13 15 17 19 21 23 25 27 297 313Carbidopa/Levodopa 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR

Tab 1

25/100 Mg

PO

51 9 11 13 15 17 19 21 23 25 27 297 313Furosemide 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR

Tab 3

20 Mg

PO

51 9 11 13 15 17 19 21 23 25 27 297 313Humulin 70/30 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR

15 U

100 U

SQ

51 9 11 13 15 17 19 21 23 25 27 297 313Hydrocodone/Apap 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR

Tab 1

5/500 mg

PO

51 9 11 13 15 17 19 21 23 25 27 297 313Isosorbide 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR

Tab 1

30 Mg

PO

51 9 11 13 15 17 19 21 23 25 27 297 313Levaquin 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR

Tab 1

500 Mg

PO

51 9 11 13 15 17 19 21 23 25 27 297 313Paxil 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR

Tab 1

20 Mg

PO

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR

51 9 11 13 15 17 19 21 23 25 27 297 313 6 8 10 12 14 16 18 20 22 24 26 28 302 4HR

MEDICATIONS 51 6 8 9 10 11 12 13 14 15 16 17 18 19 20 21 22 23 24 25 26 27 28 29 302 4 7 31HR 3

MEDICATION ADMINISTRATION SHEET

Facility Name


Physician Name

Dr. Levon Eastin H.E.B.

Pharmacy Name

Patient Name

Adams, Lucy K

Sex Age

F 43

Date RN Signature LVN Signature

Medication

Carbidopa/Levodopa

Pharmacy Name

Wal-Greens

Start Date

2/20/2002

Stop Date RX Amount Issued Strength

25/100 Mg

Dosage

Tab 1

Route Admin.

PO

Self-Administered Supervised Administered

Directions for use:

TID

Scheduled Time for AdministrationPharmacy Name

Wal-Greens

Medication

Furosemide

Pharmacy Name

Wal-Greens

Start Date

2/20/2002


20 Mg

Dosage

Tab 3

Route Admin.

PO


Directions for use:

QD/Home Med


Wal-Greens

Medication

Humulin 70/30

Pharmacy Name

Wal-Greens

Start Date

2/20/2002


100 U

Dosage

15 U

Route Admin.

SQ


Directions for use:

Q AM; 10 U Q PM/ Home Med


Wal-Greens

Medication

Hydrocodone/Apap

Pharmacy Name

Wal-Greens

Start Date

5/30/2002


5/500 mg

Dosage

Tab 1

Route Admin.

PO


Directions for use:

Q 8H PRN/Pain


Wal-Greens

Medication Profiles

Lucy K Adams

Date

6/26/2002

Blood Pressure Pulse Respiratory Temperature Finger Stick

Notes:

Client has been assessed and continues to be capable of self-administering medications and treatments


Nurse's Notes

Lucy K Adams

Monthly Fire Drill Assessment


Fire1. Simulated Situation:..........................................................................................................

Pre-Drill Setup

2. Location:.............................................................................................................................

3. Type of Drill:.......................................................................................................................

Common Area

Full Evacuation

Date: October 2003

1. Did staff use proper judgement?..................................................................................... Yes

Post-Drill Assessment

2. Was the fire alarm system activated?..............................................................................

3. Was the fire department or 911 called?...........................................................................

4. How long did it take to call after sounding the alarm?..................................................

5. Were all clients moved to a safe area?............................................................................

6. Were all exits clear and easily accessible?....................................................................

7. Were all interior rooms inspected and doors closed?...................................................

8. Were slow moving or wheelchair bound clients assisted by staff in a timelymanner?..................................................................................................................................

9. How long did it take to completely evacuate the building and account for allclients?...................................................................................................................................

10. Who sounded the "All Clear"?.......................................................................................

11. Were all staff aware of responsibilities?.......................................................................

12. Was the emergency plan executed correctly?..............................................................

Yes

Yes

1

Yes

Yes

Yes

Yes

4

Director

Yes

Yes

Comments or Problems IdentifiedEverything went smooth.

Minutes

Minutes

13. Did clients hear the alarm?............................................................................................. Yes

14. Did clients respond promptly?....................................................................................... Yes

Yes15. Did clients follow procedures calmly, smoothly and efficiently?...............................

16. Did clients seem to know what to do and where to go?..............................................

17. Did clients respond quickly to "Roll Call"?...................................................................

18. Did clients stand by until "All Clear" was given?.........................................................

19. Did all clients participate in the drill?............................................................................

20. How many fire extinguishers were inspected/checked?.............................................

Yes

Yes

Yes

Yes

3

Signatures of Participating Staff

Adams, Leota G1. 255-25-2454 (830)555-1212 10/10/1916 87

Adams, Lucy K2. 255-51-6364 (830)555-1212 10/3/1960 43

Ammons, Robert L.3. 215-66-5113 (830)555-1212 10/11/1916 87

Blair, Lucille 4. 205-55-6265 (830)555-1212 10/25/1916 87

Boswell, Margaret E5. 123-45-6789 (830)555-1212 10/4/1964 39

Brown, Harold J6. 216-51-6256 (830)555-1212 10/26/1913 90

Burns, Robert N7. 243-55-6055 (830)555-1212 10/21/1923 80

Clayton, Austin B8. 216-65-1506 (830)555-1212 10/14/1915 88

Easton, Rose 9. 151-66-6635 (830)555-1212 10/13/1920 83

Esparza, Perfecto 10. 166-12-6605 (830)555-1212 10/18/1923 80

Gerken, Howard J11. 252-55-6131 (830)555-1212 10/5/1921 82

Heath, Edmund C12. 212-63-5510 (830)555-1212 10/21/1934 69

Herald, Nora F13. 255-15-1155 (830)555-1212 10/25/1929 74

Hoots, Danny L.14. 202-65-4526 (830)555-1212 10/28/1963 40

Lyons, Helen B15. 213-65-0530 (830)555-1212 10/22/1923 80

Manning, Kenneth C16. 200-65-6614 (830)555-1212 10/6/1924 79

Martinez, Lisa 17. 214-55-6065 (830)555-1212 10/31/1961 42

Mason, Esther M18. 214-36-4245 (830)555-1212 10/25/1932 71

McGrath, Brenda S.19. 216-23-0523 (830)555-1212 10/16/1965 38

Parker, Bob 20. 215-53-0265 (830)555-1212 10/19/1919 84

Radinz, Margaret 21. 125-26-1502 (830)555-1212 10/19/1937 66

Reeves, Dewey 22. 215-32-4666 (830)555-1212 10/24/1931 72

Rehmeyer, Betty M23. 205-62-4023 (830)555-1212 10/30/1924 79

Rice, Richard M24. 101-22-0550 (830)555-1212 10/25/1915 88

Shelton, Nellie H25. 216-54-0250 (830)555-1212 10/15/1916 87

Stoval, Annie B26. 251-56-4156 (830)555-1212 10/23/1920 83

Swanson, Betty L27. 245-65-6661 (830)555-1212 10/22/1925 78

Ward, Helen E28. 123-51-5541 (830)555-1212 10/13/1910 93

Watson, Frank M29. 256-55-5660 (830)555-1212 10/23/1920 83

Winstead, Minnie L30. 255-55-6410 (830)555-1212 10/14/1919 84

Client Roster

Name SSN Phone Birth Date Age

Adams, Lucy K1. 255-51-6364 (830)555-1212 10/3/1960 43

Boswell, Margaret E2. 123-45-6789 (830)555-1212 10/4/1964 39

Gerken, Howard J3. 252-55-6131 (830)555-1212 10/5/1921 82

Manning, Kenneth C4. 200-65-6614 (830)555-1212 10/6/1924 79

Adams, Leota G5. 255-25-2454 (830)555-1212 10/10/1916 87

Ammons, Robert L.6. 215-66-5113 (830)555-1212 10/11/1916 87

Ward, Helen E7. 123-51-5541 (830)555-1212 10/13/1910 93

Easton, Rose 8. 151-66-6635 (830)555-1212 10/13/1920 83

Clayton, Austin B9. 216-65-1506 (830)555-1212 10/14/1915 88

Winstead, Minnie L10. 255-55-6410 (830)555-1212 10/14/1919 84

Shelton, Nellie H11. 216-54-0250 (830)555-1212 10/15/1916 87

McGrath, Brenda S.12. 216-23-0523 (830)555-1212 10/16/1965 38

Esparza, Perfecto 13. 166-12-6605 (830)555-1212 10/18/1923 80

Parker, Bob 14. 215-53-0265 (830)555-1212 10/19/1919 84

Radinz, Margaret 15. 125-26-1502 (830)555-1212 10/19/1937 66

Burns, Robert N16. 243-55-6055 (830)555-1212 10/21/1923 80

Heath, Edmund C17. 212-63-5510 (830)555-1212 10/21/1934 69

Swanson, Betty L18. 245-65-6661 (830)555-1212 10/22/1925 78

Lyons, Helen B19. 213-65-0530 (830)555-1212 10/22/1923 80

Stoval, Annie B20. 251-56-4156 (830)555-1212 10/23/1920 83

Watson, Frank M21. 256-55-5660 (830)555-1212 10/23/1920 83

Reeves, Dewey 22. 215-32-4666 (830)555-1212 10/24/1931 72

Blair, Lucille 23. 205-55-6265 (830)555-1212 10/25/1916 87

Mason, Esther M24. 214-36-4245 (830)555-1212 10/25/1932 71

Rice, Richard M25. 101-22-0550 (830)555-1212 10/25/1915 88

Herald, Nora F26. 255-15-1155 (830)555-1212 10/25/1929 74

Brown, Harold J27. 216-51-6256 (830)555-1212 10/26/1913 90

Hoots, Danny L.28. 202-65-4526 (830)555-1212 10/28/1963 40

Rehmeyer, Betty M29. 205-62-4023 (830)555-1212 10/30/1924 79

Martinez, Lisa 30. 214-55-6065 (830)555-1212 10/31/1961 42

Birthday List for October

Name SSN Phone Birth Date Age

Attendance Calendar for Adams, Lucy K

25 26 27

7:00 am to 3:00

pm

Units: 2

28

7:00 am to 3:00

pm

Units: 2

29 30

7:00 am to 3:00

pm

Units: 2

31

18 19

7:00 am to 3:00

pm

Units: 2

20

7:00 am to 9:00

am

Units: 0

21

7:00 am to

11:00 am

Units: 1

22 23

7:00 am to 3:00

pm

Units: 2

24

11 12 13

7:00 am to 3:00

pm

Units: 2

14 15

7:00 am to 3:00

pm

Units: 2

16 17

1 2 3

8

7:00 am to 3:00

pm

Units: 2

9

7:00 am to 3:00

pm

Units: 2

104 5

7:00 am to 3:00

pm

Units: 2

6

7:00 am to 3:00

pm

Units: 2

7

Whole Days: 11 Half Days: 1 Losses: 1 Total Units: 23

Sunday Monday Tuesday Wednesday Thursday Friday Saturday

May 2003

1. 9:30 am 010:30 amAdams, Leota G TDHS

2. 9:25 am 24:25 pmBrown, Harold J TDHS

3. 9:00 am 112:30 pmEaston, Rose TDHS

4. 9:00 am 24:15 pmEsparza, Perfecto TDHS

5. 9:00 am 24:00 pmLyons, Helen B TDHS

6. 9:15 am 24:00 pmMartinez, Lisa TDHS

7. 9:10 am 24:05 pmReeves, Dewey TDHS

8. 9:00 am 24:00 pmRice, Richard M TDHS

9. 9:30 am 24:30 pmShelton, Nellie H TDHS

10. 9:15 am 24:15 pmWatson, Frank M TDHS

Daily Attendance Summary Report for 10/1/2003

Name Pickup Time 1 Drop Off Time 1 Pickup Time 2 UnitsDrop Off Time 2Payment Type

1. 555555555 10/25/1983 10/23/1983 42 $596.40Adams, Leota G

2. 555555555 1/15/2000 3/8/2001 16 $227.20Blair, Lucille

3. 555555555 5/15/2000 10/18/2000 41 $582.20Brown, Harold J

4. 555555555 3/26/2001 8/14/2001 39 $553.80Easton, Rose

5. 555555555 1/16/2001 2/14/2001 40 $568.00Esparza, Perfecto

6. 555555555 5/18/1994 5/18/1994 37 $525.40Lyons, Helen B

7. 555555555 8/14/2001 16 $227.20Manning, Kenneth C

8. 555555555 8/2/1982 8/2/1982 39 $553.80Martinez, Lisa

9. 555555555 8/17/2001 8/30/2001 32 $454.40Reeves, Dewey

10. 555555555 7/24/2000 13 $184.60Rehmeyer, Betty M

11. 555555555 5/7/1993 7/1/1996 34 $482.80Rice, Richard M

12. 555555555 5/5/1983 3/1/1994 33 $468.60Shelton, Nellie H

13. 555555555 11/14/2000 12/13/2000 26 $369.20Swanson, Betty L

14. 555555555 3/3/2000 8/17/2001 20 $284.00Watson, Frank M

Total Units:

Total Amount:

428

$6,077.60

Pre-Billing Summary Report - 9/1/2003 to 9/30/2003

Name Medicaid No. Start Date DHS Date Units Amount

Adams, Leota G 202 S. Georgia (830)555-12121.M-T-W-Th-F

Blair, Lucille 1912 S, Woodland (830)555-12122.M-T-W-Th-F

Boswell, Margaret E 10801 West I-40 (830)555-12123.

W-F

Burns, Robert N 3425 Julian BLVD. (830)555-12124.T-Th-

Easton, Rose 704 A S.Cleveland (830)555-12125.M-T-W-Th-F

Esparza, Perfecto 2608 7TH AVE #13 (830)555-12126.M-T-W-Th-F

Gerken, Howard J 1953 S. Roosevelt (830)555-12127.T-Th-

Herald, Nora F 1549 Smiley (830)555-12128.M-T-W-Th-F

Manning, Kenneth C 2200 W. 7th (830)555-12129.W-F

Radinz, Margaret 607 S. Mississippi (830)555-121210.T-Th-F

Rice, Richard M 4216 Hetrick (830)555-121211.M-T-W-Th-F

Swanson, Betty L 4700 S. Virginia #352 (830)555-121212.T-W-Th-

13.

14.

15.

16.

17.

18.

19.

20.

21.

22.

23.

24.

25.

Signature - DriverI certify that this information is true and correct:Route: My Route

Kerrville Adult Day Care Center 001003137 10/1/2003

Name of Facility Vendor No.



DAILY TRANSPORTATION RECORD

Page of

Date

CLIENT NAMETIME

Pick Up Drop Off

TIME

Pick Up Drop Off

1 1

8:00 AM

2:00 PM

8:25 AM

3:00 PM

9:30 AM

4:30 PM

9:30 AM

4:30 PM

9:15 AM

4:15 PMAdams, Leota G

1.

10In

Out

7:30 AM

3:30 PM

7:30 AM

1:00 PM

9:00 AM

4:00 PM

9:00 AM

4:00 PM

9:15 AM

4:15 PMBrown, Harold J

2.

9In

Out

9:45 AM

12:45 PM

9:30 AM

3:30 PM

9:45 AM

3:45 PM

9:30 AM

3:30 PMEaston, Rose

3.

7In

Out

8:15 AM

2:45 PM

9:00 AM

4:00 PM

9:00 AM

4:00 PM

9:15 AM

4:00 PMEsparza, Perfecto

4.

8In

Out

8:45 AM

2:30 PM

9:00 AM

4:00 PM

9:00 AM

4:00 PM

9:00 AM

4:00 PMLyons, Helen B

5.

7In

Out

7:30 AM

3:00 PM

9:30 AM

4:30 PMManning, Kenneth C

6.

4In

Out

9:00 AM

1:00 PM

7:30 AM

2:00 PM

9:00 AM

4:00 PM

9:00 AM

4:00 PM

9:00 AM

4:00 PMMartinez, Lisa

7.

9In

Out

8:25 AM

3:05 PM

8:45 AM

3:45 PM

9:15 AM

4:15 PMReeves, Dewey

8.

6In

Out

10:25 AM

2:45 PM

9:15 AM

3:15 PMRehmeyer, Betty M

9.

3In

Out

8:15 AM

2:15 PM

8:45 AM

4:00 PM

8:45 AM

4:00 PM

8:45 AM

4:00 PMRice, Richard M

10.

8In

Out

9:00 AM

3:30 PM

9:30 AM

4:30 PMShelton, Nellie H

11.

4In

Out

I hereby certify that this is a correct daily attendance record for DHS clients.

Signature-Facility Representative Date

Texas Departmentof Human Services DAILY ATTENDANCE RECORD



Kerrville Adult Day Care Center 001003137Page of

1 2

CLIENT NAME

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAYTOTALUNITSOF

SERVICE

Date Date Date Date Date

Time Time Time Time Time Time Time Time Time Time

9/8/2003 9/9/2003 9/10/2003 9/11/2003 9/12/2003

8:45 AM

3:45 PMSwanson, Betty L

1.

2In

Out

9:30 AM

4:00 PM

9:00 AM

3:30 PMWatson, Frank M

2.

4In

Out

3. In

Out

4. In

Out

5. In

Out

6. In

Out

7. In

Out

8. In

Out

9. In

Out

10. In

Out

11. In

Out

I hereby certify that this is a correct daily attendance record for DHS clients.

Signature-Facility Representative Date

Texas Departmentof Human Services DAILY ATTENDANCE RECORD



Kerrville Adult Day Care Center 001003137Page of

2 2

CLIENT NAME

MONDAY TUESDAY WEDNESDAY THURSDAY FRIDAYTOTALUNITSOF

SERVICE

Date Date Date Date Date

Time Time Time Time Time Time Time Time Time Time

9/8/2003 9/9/2003 9/10/2003 9/11/2003 9/12/2003

Adams, Leota1 87 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Adams, Lucy2 43 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Ammons, Robert3 87 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Blair, Lucille4 87 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Boswell, Margaret5 39 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Brown, Harold6 90 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Burns, Robert7 80 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Clayton, Austin8 88 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Easton, Rose9 83 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Esparza, Perfecto10 80 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Gerken, Howard11 82 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Heath, Edmund12 69 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Herald, Nora13 74 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Lyons, Helen14 80 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Manning, Kenneth15 79 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

DAY

MondayAGEPARTICIPANT'S NAME

Month and Year

09/2003

Agreement No. (TX No.)

TXName of Contractor


DATE

9/8/2003

Texas Departmentof Human Services DAILY MEAL COUNT AND ATTENDANCE RECORD (Centers and Emergency Shelters)

Form

Name of Facility

CENTERS: You may claim up to two meals and one snack or one meal and two snacks. EMERGENCY SHELTERS: You may claim up to three meals or two meals and one snack.

Kerrville Adult Day Care Center 1

TuesdayDAY DATE DAY DATE DAY DATE DAY DATE

Wednesday Thursday Friday9/9/2003 9/10/2003 9/11/2003 9/12/2003

2 3 4 5 6 7

July 1999

1535

Signature-Center/Shelter Representative Date

Total Number of Program Staff Meals

Total Number of Non-Program Meals

I CERTIFY that the information on this form is true and correct to the best of my knowledge and that I will claim reimbursement only for eligible meals served to eligible participants. I under-stand that misrepresentation may result in prosecution under applicable state or federal statutes. Page of1 2

Total

Number

of

Program

Participants

At

B

L

P

S

A

E

5 3 5 6

4 0 0 0

1 0 0 0 0

5 3 5 5 6

3 2 0 0 0

3

5

0 0 0 0

0 0 0

0

0 0

Martinez, Lisa1 42 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Mason, Esther2 71 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

McGrath, Brenda3 38 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Parker, Bob4 84 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Radinz, Margaret5 66 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Reeves, Dewey6 72 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Rehmeyer, Betty7 79 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Rice, Richard8 88 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Shelton, Nellie9 87 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Swanson, Betty10 78 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Watson, Frank11 83 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

Winstead, Minnie12 84 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E

13 At At At At AtS S S S SB B B B BA A A A AL L L L LP P P P PE E E E E



DAY

MondayAGEPARTICIPANT'S NAME

Month and Year

09/2003

Agreement No. (TX No.)

TXName of Contractor


DATE

9/8/2003

Texas Departmentof Human Services DAILY MEAL COUNT AND ATTENDANCE RECORD (Centers and Emergency Shelters)

Form

Name of Facility

CENTERS: You may claim up to two meals and one snack or one meal and two snacks. EMERGENCY SHELTERS: You may claim up to three meals or two meals and one snack.

Kerrville Adult Day Care Center 1

TuesdayDAY DATE DAY DATE DAY DATE DAY DATE

Wednesday Thursday Friday9/9/2003 9/10/2003 9/11/2003 9/12/2003

2 3 4 5 6 7

July 1999

1535

Signature-Center/Shelter Representative Date

Total Number of Program Staff Meals

Total Number of Non-Program Meals

I CERTIFY that the information on this form is true and correct to the best of my knowledge and that I will claim reimbursement only for eligible meals served to eligible participants. I under-stand that misrepresentation may result in prosecution under applicable state or federal statutes. Page of2 2

Total

Number

of

Program

Participants

At

B

L

P

S

A

E

3 3 4 5

2 0 0 0

1 0 0 0 0

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820 Main St., Kerrville, TX 78028

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Vincent Cotton

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(830)896-8051 31 2 54

Kerrville Adult Day Care Center 1 9/2003

Kerrville Adult Day Care Center 12 27

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Kerrville Adult Day Care Center 9/2003

eldersuite welcome packet welcome packet.pdf · welcome! this informational packet and the enclosed...

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