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Get LA OAAS-PF-11-015 2021-2024

ADDITIONAL PAGES MAY BE USED. Page of Reissued November 6 2015 Replaces June 25 2015 Issuance OAAS-PF-11-015 Page 1 of 7 WEEK OF THROUGH DAILY SERVICES/SUPPORTS DESCRIPTIONS COMMENTS AND PROGRESS NOTES DAY OF WEEK AND DATE DESCRIPTIONS COMMENTS AND PROGRESS NOTES Instructions for Completion of Community Choices Waiver CCW Service Log The Community Choices Waiver CCW Service Log hereinafter referred to as the Service Log is used by CCW participants receiving Personal Assistance Services PAS. COMMUNITY CHOICES WAIVER CCW SERVICE LOG PROVIDER AGENCY NAME DIRECT SERVICE WORKER S NAME PARTICIPANT NAME PARTICIPANT DOB Week Of Day Of Week Date 1st Arrival Time w/ Initials 1st Departure Time w/ Initials 2nd Arrival Time w/ Initials 2nd Departure Time w/ Initials Through Sunday Monday Tuesday Wednesday Thursday Friday Saturday Indicate Task Completed Each Day W/Initials in Column for the Type PAS provided Tasks F O R A M P Eating Bathing Dressing Grooming Transferring Ambulation Toileting Light Housekeeping Food Preparation Storage Shopping Laundry Medication Reminders Assist To Sched Med Appts Assist To Arrange Med Trans Accompany To Med Appts Protective Supervision Supv/Assist w/Health Tasks Escort for Assist w/Comm Tasks Extension of Therapy Services Daily Total Of Hours WEEKLY TOTAL of Hours WEEKLY PAS for 1 HOURS WEEKLY PAS AM DSW SUPERVISOR S REVIEW SIGNATURE DATE Use of this line is optional NOTE DAILY SERVICES/SUPPORTS DESCRIPTIONS COMMENTS AND PROGRESS NOTES ARE TO BE RECORDED ON PAGE 2 OF THIS FORM. The Service Log is used to document weekly services under PAS including daily progress notes. NOTE Services provided by only ONE WORKER to ONE PARTICIPANT may be documented on a SINGLE SERVICE LOG* When an error is made only the individual who made the entry is allowed to correct the error. Corrections must be made by drawing a single line through the incorrect entry writing error above the entry initialing the correction and placing the correct information on the form* The use of carbon is permissible. It is also permissible for this form to be two-sided* The following instructions should be used to complete the Service Log PAGE 1 OF THE SERVICE LOG Items 1-7 are to be completed by the provider agency. It is permissible for this information to be typed onto the form* Enter the provider agency s name. NOTE For Self-Direction participants enter Self-Direction. Enter the name of the direct service worker. Enter the participant s name. WEEK OF THROUGH DAY OF WEEK SUNDAY MONDAY DATE TUESDAY WEDNESDAY THURSDAY FRIDAY SATURDAY 1ST ARRIVAL TIME W/ SIGNED INITIALS 1ST DEPARTURE TIME W/ 2ND DEPARTURE TIME W/ Enter the beginning date of the prior authorization week example 9/06/15. Enter the ending date of the prior authorization week example 9/12/15. NOTE The prior authorization week begins on Sunday at 12 00 a*m* midnight and ends on the following Sunday at 12 00 a*m* midnight. For participants NOT in Self-Direction unused portions of the prior authorized weekly allocation MAY NOT be saved or borrowed from one week for use in another week.

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