ALP Certification and Re-Certification Monitoring Entrance Form

Revised 8-27-14 ALP MONITORING ENTRANCE FORM Please complete the following form and have the information requested available when the monitor arrives at the program Initial  Recertification  Complaint  Incident  Other: ______Intake #: Program Name: ______Date: ______

Program Administrator: ______Hire Date: ______ALP Training date: ______

Program Address: ______City: ______

State: ______Zip Code: ______Administrator’s E-Mail Address: ______

Program Telephone Number: ______Program FAX Number: ______

Cell Phone Number: ______Date of last visit: ______Type of visit: ______CENSUS PROGRAM CHARACTERISTICS ALP Is this program: Tenants receiving no services ______ALP with general population only (no dementia unit ) Tenants without cognitive impairment:  ______ALP with a general population unit and a dementia Tenants in non-dementia program or unit with unit  GDS of 4 or above: ______Dementia Specific Program  Total number of Tenants in ALP: ______Part of a Continuing Care Retirement Community (CCRC)  ALP-D Note:Respite Check provider if program was dementia specific for two Tenants in dementia program or unit without sequential  re-certification onsites. If so, program cognitive impairment: ______If so, to how many elders? ______Tenants in a dementia program or unit with Please have the following information available when the monitorGDS of arrives: 4 or above: ______(any lists should be typed on 8 ½ by 11 paper) Total number of Tenants in an ALPD: ______ A current list of tenants, their admit date and GDS score if above four  A current staff list, dates of hire and designation of work responsibility  Incident and medication error reports for last three months  Child and Dependent Adult Abuse investigations

Does the program contract with Hospice, Home Health, Staff Agency Yes  No  If so who: Provider: ______

______Provider: ______

Training documentation of outside providers, i.e. Hospice, Home Health, Staff Agency provided: ______

Dependent Adult Abuse training provider course number: ______

Name of delegating RN: ______Hire Date: ______ALP training completed: ______

Does the program employ:  LPNs  CNAs  CMAs  Universal Workers

Staffing patterns per shift: 1 Revised 8-27-14 a.m. shift: General Population ______Dementia Unit ______p.m. shift: General Population ______Dementia Unit ______night shift: General Population ______Dementia Unit ______

Have direct care staff been trained by a RN and demonstrated their competency to an RN? Yes  No  Program Name: ______Date: ______

MEDICATION ADMINISTRATION

Does the program have a list of medications taken by tenants who self-administer  Yes  No

Are medications stored in tenant’s rooms  Centralized medication room  Medication cart 

______# of tenants who self-administer ______# of tenants who receive medication administration

Medications locked when administered by the program? Yes ___ No ___ Narcotics count completed Yes ___ No __ Shift count ___ Weekly___

Medication administration times: ______

List the following information by full name (be specific with full name of tenant listed):

______# of tenants who are known sex offenders ______

______# of tenants with a waiver from the department as they exceed level of care, i.e. hospice, recent hospitalization, etc.

______

______# of tenants with managed risk statements. Do these tenants have a GDS of 4>

______

______# of tenants hospitalized in last three months

______

______# of tenants/spouses who receive veteran’s benefits

______

______# of tenants who have eloped from the program

______

______# of tenants who wander throughout the program.

______

______# of tenants for whom funds are managed

______

______# of tenants who require or wish to use bedrails 2 Revised 8-27-14

______

______# of tenants with a history of suicidal ideation ______

______# of tenants who experienced theft of personal belongings, medications ______

______# of tenants who are consistently refusing personal and/or health related cares ______

______

Program Name: ______Date: ______

______# of tenants receiving Hospice care ______

Tenant: ______Hospice Agency Name: ______Phone Number: ______Address: ______City: ______State: ______Zip: ______Hospice RN: ______Hospice Contact: ______

Tenant: ______Hospice Agency Name: ______Phone Number: ______Address: ______City: ______State: ______Zip: ______

3 Revised 8-27-14 Hospice RN: ______Hospice Contact: ______