Form PPS10510 "Emergency Adult Protective Services (Aps) Admission to Nursing Facility" - Kansas

Form PPS10510 is a Kansas Department for Children and Families form also known as the "Emergency Adult Protective Services (aps) Admission To Nursing Facility". The latest edition of the form was released in July 1, 2016 and is available for digital filing.

Download an up-to-date Form PPS10510 in PDF-format down below or look it up on the Kansas Department for Children and Families Forms website.

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Download Form PPS10510 "Emergency Adult Protective Services (Aps) Admission to Nursing Facility" - Kansas

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State of Kansas
PPS 10510
Department for Children
REV 7/2016
and Families Protection and Prevention Services
EMERGENCY ADULT PROTECTIVE SERVICES (APS)
ADMISSION TO NURSING FACILITY
Purpose:
This form is to be presented to Kansas Department of Health and Environment
surveyors, Health Care Finance, and Kansas Department for Aging and
Disabilities Services program mangers by a Nursing Facility to document the
admission of a customer receiving Adult Protective Services at a time when there
was no Area Agency on Aging CARE Assessor available and no trained CARE
assessor on the Nursing Facility’s staff available to perform the required CARE
assessment prior to admission.
This is to certify that ________________________________________was admitted to
___________________________________at ________________________________
Name of Nursing Facility
Address & City
on _____________________ with the assistance of DCF Adult Protective Services and
Date and Time
________________________________________________________ (if applicable).
Specify Relationship: Neighbor, Relative, Caregiver
SIGNATURES:
___________________________
_____________________________________
Date and Time
Signature of DCF/APS Specialist
___________________________
_____________________________________
Date and Time
Signature of other person assisting
Client at time of admission.
(If applicable)
The Nursing Facility must notify the local Area Agency on Aging of the admission and
obtain a CARE assessment for the customer on the next working day following admission.
CC: Nursing Facility
DCF/APS
Local AAA
Client
State of Kansas
PPS 10510
Department for Children
REV 7/2016
and Families Protection and Prevention Services
EMERGENCY ADULT PROTECTIVE SERVICES (APS)
ADMISSION TO NURSING FACILITY
Purpose:
This form is to be presented to Kansas Department of Health and Environment
surveyors, Health Care Finance, and Kansas Department for Aging and
Disabilities Services program mangers by a Nursing Facility to document the
admission of a customer receiving Adult Protective Services at a time when there
was no Area Agency on Aging CARE Assessor available and no trained CARE
assessor on the Nursing Facility’s staff available to perform the required CARE
assessment prior to admission.
This is to certify that ________________________________________was admitted to
___________________________________at ________________________________
Name of Nursing Facility
Address & City
on _____________________ with the assistance of DCF Adult Protective Services and
Date and Time
________________________________________________________ (if applicable).
Specify Relationship: Neighbor, Relative, Caregiver
SIGNATURES:
___________________________
_____________________________________
Date and Time
Signature of DCF/APS Specialist
___________________________
_____________________________________
Date and Time
Signature of other person assisting
Client at time of admission.
(If applicable)
The Nursing Facility must notify the local Area Agency on Aging of the admission and
obtain a CARE assessment for the customer on the next working day following admission.
CC: Nursing Facility
DCF/APS
Local AAA
Client
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