<p> 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: ______</p><p>Program Administrator: ______Hire Date: ______ALP Training date: ______</p><p>Program Address: ______City: ______</p><p>State: ______Zip Code: ______Administrator’s E-Mail Address: ______</p><p>Program Telephone Number: ______Program FAX Number: ______</p><p>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</p><p>Does the program contract with Hospice, Home Health, Staff Agency Yes  No  If so who: Provider: ______</p><p>______Provider: ______</p><p>Training documentation of outside providers, i.e. Hospice, Home Health, Staff Agency provided: ______</p><p>Dependent Adult Abuse training provider course number: ______</p><p>Name of delegating RN: ______Hire Date: ______ALP training completed: ______</p><p>Does the program employ:  LPNs  CNAs  CMAs  Universal Workers </p><p>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 ______</p><p>Have direct care staff been trained by a RN and demonstrated their competency to an RN? Yes  No  Program Name: ______Date: ______</p><p>MEDICATION ADMINISTRATION </p><p>Does the program have a list of medications taken by tenants who self-administer  Yes  No</p><p>Are medications stored in tenant’s rooms  Centralized medication room  Medication cart </p><p>______# of tenants who self-administer ______# of tenants who receive medication administration</p><p>Medications locked when administered by the program? Yes ___ No ___ Narcotics count completed Yes ___ No __ Shift count ___ Weekly___</p><p>Medication administration times: ______</p><p>List the following information by full name (be specific with full name of tenant listed): </p><p>______# of tenants who are known sex offenders ______</p><p>______# of tenants with a waiver from the department as they exceed level of care, i.e. hospice, recent hospitalization, etc. </p><p>______</p><p>______# of tenants with managed risk statements. Do these tenants have a GDS of 4> </p><p>______</p><p>______# of tenants hospitalized in last three months </p><p>______</p><p>______# of tenants/spouses who receive veteran’s benefits </p><p>______</p><p>______# of tenants who have eloped from the program</p><p>______</p><p>______# of tenants who wander throughout the program.</p><p>______</p><p>______# of tenants for whom funds are managed</p><p>______</p><p>______# of tenants who require or wish to use bedrails 2 Revised 8-27-14</p><p>______</p><p>______# of tenants with a history of suicidal ideation ______</p><p>______# of tenants who experienced theft of personal belongings, medications ______</p><p>______# of tenants who are consistently refusing personal and/or health related cares ______</p><p>______</p><p>Program Name: ______Date: ______</p><p>______# of tenants receiving Hospice care ______</p><p>Tenant: ______Hospice Agency Name: ______Phone Number: ______Address: ______City: ______State: ______Zip: ______Hospice RN: ______Hospice Contact: ______</p><p>Tenant: ______Hospice Agency Name: ______Phone Number: ______Address: ______City: ______State: ______Zip: ______Hospice RN: ______Hospice Contact: ______</p><p>Tenant: ______Hospice Agency Name: ______Phone Number: ______Address: ______City: ______State: ______Zip: ______</p><p>3 Revised 8-27-14 Hospice RN: ______Hospice Contact: ______</p><p>4</p>