AHCA Form 1823 "Resident Health Assessment for Assisted Living Facilities" - Florida

What Is AHCA Form 1823?

This is a legal form that was released by the Florida Agency For Health Care Administration - a government authority operating within Florida. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on March 1, 2017;
  • The latest edition provided by the Florida Agency For Health Care Administration;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of AHCA Form 1823 by clicking the link below or browse more documents and templates provided by the Florida Agency for Health Care Administration.

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Download AHCA Form 1823 "Resident Health Assessment for Assisted Living Facilities" - Florida

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Resident Health Assessment for
Assisted Living Facilities
To Be Completed By Facility:
Resident Information
Resident Name:
DOB:
Authorized Representative (
):
if applicable
Facility Information
Facility Name:
Telephone Number: (
)
Street Address:
Fax Number: (
)
City:
County:
Zip:
Contact Person:
INSTRUCTIONS TO LICENSED HEALTH CARE PROVIDERS:
After completion of all items in Sections 1 and 2 (pages 1 – 4), return this form to the facility at the address
indicated above.
SECTION 1. Health Assessment
NOTE: This section must be completed by a licensed health care provider and must include a face-to-face examination and
interview with the resident.
Known Allergies:
Height:
Weight:
Medical History and Diagnoses:
Physical or Sensory Limitations:
Cognitive or Behavioral Status:
Nursing/Treatment/Therapy Service Requirements:
Special Precautions:
Elopement Risk:
Yes:
No:
AHCA Form 1823, March 2017
58A-5.0181(2)(b), F.A.C.
Page 1 of 5
Forms available at: http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/alf.shtml
Resident Health Assessment for
Assisted Living Facilities
To Be Completed By Facility:
Resident Information
Resident Name:
DOB:
Authorized Representative (
):
if applicable
Facility Information
Facility Name:
Telephone Number: (
)
Street Address:
Fax Number: (
)
City:
County:
Zip:
Contact Person:
INSTRUCTIONS TO LICENSED HEALTH CARE PROVIDERS:
After completion of all items in Sections 1 and 2 (pages 1 – 4), return this form to the facility at the address
indicated above.
SECTION 1. Health Assessment
NOTE: This section must be completed by a licensed health care provider and must include a face-to-face examination and
interview with the resident.
Known Allergies:
Height:
Weight:
Medical History and Diagnoses:
Physical or Sensory Limitations:
Cognitive or Behavioral Status:
Nursing/Treatment/Therapy Service Requirements:
Special Precautions:
Elopement Risk:
Yes:
No:
AHCA Form 1823, March 2017
58A-5.0181(2)(b), F.A.C.
Page 1 of 5
Forms available at: http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/alf.shtml
To Be Completed By Facility:
Resident Name:
DOB:
Authorized Representative (
):
if applicable
SECTION 1. Health Assessment (continued)
NOTE: This section must be completed by a licensed health care provider and must include a face-to-face examination and
interview with the resident.
A. To what extent does the individual need supervision or assistance with the following?
Key
I = Independent
S = Needs Supervision
A = Needs Assistance
T = Total Care
Indicate by a checkmark (✓) in the appropriate column below, the extent to which the individual is able to perform
each of the activities of daily living. If “Needs Supervision” or “Needs Assistance” is indicated, explain the extent
and type of supervision or assistance needed in the comments column.
ACTIVITIES OF DAILY LIVING
I
S
A
T
COMMENTS
Ambulation
Bathing
Dressing
Eating
Self Care (grooming)
Toileting
Transferring
B. Special Diet Instructions:
Regular
Calorie Controlled
No Added Salt
Low Fat/Low Cholesterol
Other
(specify, including consistency changes such as puree):
C. Does the individual have any of the following conditions/requirements? If yes, please include an
explanation in the comments column.
STATUS
Yes/No
COMMENTS
A communicable disease, which could be transmitted to
other residents or staff?
Bedridden?
Any stage 2, 3 or 4 pressure sores?
Pose a danger to self or others? (Consider any significant
history of physically or sexually aggressive behavior.)
Require 24-hour nursing or psychiatric care?
D. In your professional opinion, can this individual’s needs be met in an assisted living facility, which is
not a medical, nursing or psychiatric facility? Yes
No
Comments (use additional paper if necessary):
AHCA Form 1823, March 2017
58A-5.0181(2)(b), F.A.C.
Page 2 of 5
Forms available at: http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/alf.shtml
To Be Completed By Facility:
Resident Name:
DOB:
Authorized Representative (
):
if applicable
SECTION 2-A. Self-Care and General Oversight Assessment
NOTE: This section must be completed by a licensed health care provider and must include a face-to-face examination and
interview with the resident.
A. Ability to Perform Self-Care Tasks:
Key
I = Independent
S = Needs Supervision
A = Needs Assistance
Indicate by a checkmark (✓) in the appropriate column below, the extent to which the individual is able to perform
each of the listed self-care tasks. If “Needs Supervision” or “Needs Assistance” is indicated, explain the extent and
type of supervision or assistance necessary in the comments column.
TASKS
I
S
A
COMMENTS
Preparing Meals
Shopping
Making Phone Calls
Handling Personal Affairs
Handling Financial Affairs
Other
B. General Oversight:
Key
I = Independent
W = Weekly
D = Daily
O = Other
Indicate by a checkmark (✓) in the appropriate column below, the extent to which the individual needs general
oversight. If other, explain in the comments column.
TASKS
I
W
D
O
COMMENTS
Observing Wellbeing
Observing Whereabouts
Reminders for Important Tasks
Other
Other
Other
Other
C. Additional Comments/Observations (use additional paper if necessary):
AHCA Form 1823, March 2017
58A-5.0181(2)(b), F.A.C.
Page 3 of 5
Forms available at: http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/alf.shtml
To Be Completed By Facility:
Resident Name:
DOB:
Authorized Representative (
):
if applicable
SECTION 2-B. Self-Care and General Oversight Assessment – Medications
NOTE: This section must be completed by a licensed health care provider and must include a face-to-face examination and
interview with the resident.
A. List all current medications prescribed below (attach additional pages if necessary):
MEDICATION
DOSAGE
DIRECTIONS FOR USE
ROUTE
1.
2.
3.
4.
5.
6.
7.
8.
9.
10.
11.
12.
B. Does the individual need help with taking his or her medications (meds)? Yes
No
If yes,
place a checkmark (✓) in front of the appropriate box below:
Needs Assistance With Self Administration
Needs Medication Administration
This allows unlicensed staff to assist with oral
Not all assisted living facilities have
and topical medication
licensed staff to perform this service
Able To Administer Without Assistance
C. Additional Comments/Observations (use additional pages if necessary):
NOTE: MEDICAL CERTIFICATION IS INCOMPLETE WITHOUT THE FOLLOWING INFORMATION
Name of Examiner (please print):
Medical License #:
Telephone Number:
Title of Examiner (check box)
MD
DO
ARNP
PA
Address of Examiner:
Signature of Examiner:
Date of Examination:
AHCA Form 1823, March 2017
58A-5.0181(2)(b), F.A.C.
Page 4 of 5
Forms available at: http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/alf.shtml
To Be Completed By Facility:
Resident Name:
DOB:
Authorized Representative (
):
if applicable
SECTION 3. Services Offered or Arranged By The Facility For The Resident
NOTE: This section must be completed by the ALF Administrator or designee.
THIS SECTION MUST BE COMPLETED FOR ALL RESIDENTS and must be based on needs identified in Sections 1
and 2 of this form, or electronic documentation, which at a minimum includes the elements below. The facility
may attach resident service plans, care plans, or community living support plans to this form to satisfy this
requirement, provided the documentation corresponds with the information listed below.
Needs Identified from
Services
Service Frequency
Service Provider
Initial Date of
#
Sections 1 and 2
Needed
& Duration
Name
Service
1
2
3
4
5
6
7
8
9
10
11
12
13
14
15
Name of Resident or Authorized Representative
(print):
**(By signing this form, I agree to the services identified above to be provided by the assisted living facility to meet identified needs.)**
Signature of Resident or Authorized Representative
:
Date
If Authorized Representative, provide contact #
Name of Administrator or Designee
(print):
Signature of Administrator or Designee:
Date
AHCA Form 1823, March 2017
58A-5.0181(2)(b), F.A.C.
Page 5 of 5
Forms available at: http://ahca.myflorida.com/MCHQ/Health_Facility_Regulation/Assisted_Living/alf.shtml
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