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961 Grand Avenue St. Paul, MN 55105 BI-WEEKLY PCA TIME & Tele: 651-789-2299 Fax: 651-306-1359 ACTIVITY DOCUMENTATION [email protected]

EMPLOYEE NAME: ______FIRST AND LAST NAME CLIENT NAME: ______PERIOD COVERED: ___/___/20___ TO ___/___/20___ LAST NAME, FIRST NAME Please write your initials next to all the activities you provided on a daily basis. PROCEDURES / DAYS MON TUES WED TH FRI SAT SUN MON TUES WED TH FRI SAT SUN Review Care Plan Daily! ACTIVITIES PROVIDED Dressing Grooming Bathing Eating Transfers Mobility Positioning Toileting Light Housekeeping Laundry Health Related Behavior Other

CHECK HERE IF YOU HAVE ADDITIONAL CLIENT OBSERVATIONS / CONCERNS. PLEASE DOCUMENT THESE ON BACK OF THE WHITE CHARTING SHEET AND NOTIFY YOUR SUPERVISOR OF ANY UNSUAL BEHAVIORS / OBSERVATIONS / CONCERNS IMMEDIATELY.

VISIT ONE VISIT TWO VISIT THREE DAILY TOTAL TIME DAY DATE IN OUT IN OUT IN OUT IN HOURS & MINUTES (HH:MM) AM AM AM AM AM AM MONDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM TUESDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM WEDNESDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM THURSDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM FRIDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM SATURDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM SUNDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM MONDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM TUESDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM WEDNESDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM THURSDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM FRIDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM SATURDAY / /20___ PM PM PM PM PM PM AM AM AM AM AM AM SUNDAY / /20___ PM PM PM PM PM PM

TOTAL HOURS & MINUTES (HH:MM) THIS TIME SHEET *** PLEASE SUBMIT THE COMPLETED WEEKLY PCA JOURNAL(S) WITH YOUR TIMESHEET. THANK YOU! ***

Acknowledgement and Required Signatures: After the PCA has documented his/her time and activity, the recipient must draw a line through any times and dates he/she did not receive from the PCA. Review the completed time sheet for accuracy before signing. IT IS A FEDERAL CRIME TO PROVIDE FALSE INFORMATION ON PCA BILLINGS FOR MEDICAL ASSISTANCE PAYMENT. Your signature verifies the time and services entered above are accurate and that the services were performed as specified in the PCA Care Plan. RECIPIENT NAME (First, MI, Last) MA MEMBER # OR BIRTH DATE PCA NAME (First, MI, Last) PCA PROVIDER NUMBER

Employee Signature: ______Date: ______RECIPIENTI certify that the/ RESPONSIBLE hours recorded PARTY are true SIGNATURE and correct, were workedDATE by me during the week endingPCA SIGNATUREas shown and were properly certified by the client / authorizedDATE representative. HH 0806 Timesheet TAD ALT 070107 CPH.DOC

TERMS AND CONDITIONS

Caring Professionals Homecare, LLC hereinafter referred to as “Agency” FOR EMPLOYEE: FOR CLIENT:

I certify that the hours recorded on the reverse side Client certifies that the hours recorded on the Instructions for completing your time sheet: are true and correct, were worked by me during the reverse side are true and correct and that the week ending as shown and were properly certified work was completed in a satisfactory manner. In * Use one time sheet for each client and each 2 week by the client or the client’s authorized the event of any claim under the Agency fidelity pay period. representative. bond, client agrees to notify Agency within 20 * A pay period is defined as Monday – Sunday (2 week days of the Incident and understands that the I understand that this timeslip is a record of my failure to notify Agency in writing within such time cycle). Record Sunday’s date as the end of the pay visits and hours worked. If I do not sign it and will constitute a waiver of the claim. period. deliver or fax it to the central office, I cannot be * Record your time worked, less lunch, for each day paid. Agency does not allow its employees to borrow worked. items such as money or automobiles from its * Record your time in and time out for each visit that I agree to notify the Agency by phone or mail within clients. Please comply with our policy. started providing care and circle AM or PM. 48 hours of termination of each assignment. If I fail * Daily Total – Add the total time in hours and minutes to give such notice, Agency may assume that I am Client also referred to as the Recipient agrees to not available for employment. draw a line through any dates and times PCA that you spent working with this recipient for the care services were not provided. documented in the box called “Daily total in hours and In the event of an injury to myself or my assigned minutes.” client, I agree to notify the Agency within 24 hours * Total hours and minutes this time sheet – Add the of such incident. time in hours and minutes (HH:MM format) for all visits on this entire timesheet in the box provided. * You are paid based upon the hours and * For each date you provided care, write your initials minutes you work. Minutes are rounded up next to all the activities you provided. Your initials or down to the closest 15 minute unit. indicate you provided the service as described in the PCA Care plan for each client. * When adding up your hours, add your * You may mail or fax your completed time sheet to the hours first and write them down. Then add office or drop original off in person by 11:00pm – every up all of your minutes and divide by 60 to other Monday after the end of the pay period. get the total hours and the remaining Employees will be paid on Fridays in accordance with minutes must then be rounded up or down company pay schedule. Timesheets submitted late will to the following values: result in a delay in processing your check and/or will be subject to a late fee to accommodate paycheck :00 :15 :30 :45 processing as stated in the employee handbook. * Yellow copy of time sheet is to remain with client after both you and Client sign after services have been provided for the pay period.

Office: White Copy Client: Yellow Copy

The following are general descriptions of activities of daily living and instrumental activities of daily living as adapted from the Minnesota Department of Human Services (DHS).

Dressing – Appropriate clothing for the day, includes laying out of clothing, Light Housekeeping – Integral to personal care may include washing dishes, actual application and changing of clothing, orthotics, prosthetics, transfers, putting dishes in dishwasher or hand washing, clearing tables, taking out mobility and positioning to complete this task. garbage, making the bed and cleaning the bathroom. Grooming – Personal hygiene, includes hair care, oral care, nail care, shaving Laundry – Laundry integral to personal care includes sorting clothes, putting hair, applying cosmetics and deodorant, care of eyeglasses, contact lenses, clothes in washer and dryer, adding soap and/or dryer sheet, folding and putting hearing aids and applying orthotics. away clothes. Bathing – Starting and finishing a bath or shower, transfers, mobility, positioning, Positioning – Moving the person’s body for necessary care and comfort or to using soap, rinsing, drying, inspecting skin & applying lotion. relieve pressure areas. Eating – Getting food into the body, transfers, mobility, positioning, hand Mobility – Moving from one place to another including using a wheelchair. washing, feeding, preparing meals and grocery shopping. Toileting – Bowel/bladder elimination and care, transfers, mobility, positioning, Transfers – Moving from one seating/reclining area to another. feminine hygiene, use of toileting equipment or supplies, cleaning the perineal area and inspecting the skin and adjusting clothing. Health-related Functions – Hands-on assistance, supervision and cueing for Behavior – Redirecting, intervening, observing, monitoring and documenting health related tasks under the direction of a Qualified Professional or the person’s behavior. physician. Other – Other activities performed in the care plan not specified above.

PCA / STAFF: USE THIS AREA TO DOCUMENT CLIENT OBSERVATIONS / CONCERNS. YOU MUST NOTIFIY YOUR SUPERVISOR OF ANY UNUSUAL BEHAVIORS / OBSERVATIONS / CONCERNS IMMEDIATELY: