Form DHS-4691-ENG "Pca Time and Activity Documentation" - Minnesota

What Is Form DHS-4691-ENG?

This is a legal form that was released by the Minnesota Department of Human Services - a government authority operating within Minnesota. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on August 1, 2016;
  • The latest edition provided by the Minnesota Department of Human Services;
  • 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 fillable version of Form DHS-4691-ENG by clicking the link below or browse more documents and templates provided by the Minnesota Department of Human Services.

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Download Form DHS-4691-ENG "Pca Time and Activity Documentation" - Minnesota

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Clear Form
*DHS-4691-ENG*
DHS-4691-ENG
8-16
PCA Time and Activity Documentation
PCA AGENCY NAME
DATES/LOCATION OF RECIPIENT STAY IN HOSPITAL/CARE FACILITY/INCARCERATION
PHONE NUMBER
Dates of Service
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
(in consecutive order)
Activities
Dressing
Grooming
Bathing
Eating
Transfers
Mobility
Positioning
Toileting
Health Related
Behavior
IADLs
Visit One
Ratio staff to recipient
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
Shared services location
Time in
AM
AM
AM
AM
AM
AM
AM
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
Time out
AM
AM
AM
AM
AM
AM
AM
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
Visit Two
Ratio staff to recipient
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
Shared services location
Time in
AM
AM
AM
AM
AM
AM
AM
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
Time out
AM
AM
AM
AM
AM
AM
AM
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
Daily Total
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
(minutes)
Total Minutes
Total 1:1
Total 1:2
Total 1:3
This Time Sheet
MINUTES
MINUTES
MINUTES
Acknowledgement and Required Signatures
After the PCA has documented his/her time and activity, the recipient must draw a line through any dates/times he/she did not receive
services from the PCA. Review the completed time sheet for accuracy before signing. It is a crime to provide false information on PCA
billings for Medical Assistance payment. By signing below you swear and verify the time and services entered above are accurate and that
the services were performed by the PCA listed below as specified in the PCA Care Plan.
RECIPIENT NAME (FIRST, MI, LAST)
MA MEMBER # or DATE OF BIRTH RECIPIENT/RESPONSIBLE PARTY SIGNATURE
DATE
I certify and swear under penalty of law that I have accurately reported on this time sheet the hours I actually worked, the services I
provided, and the dates and times worked. I understand that misreporting my hours is fraud for which I could face criminal prosecution
and civil proceedings.
PCA NAME (FIRST, MI, LAST)
PCA NPI/UMPI
PCA SIGNATURE
DATE
Review
PCA Provider Time and Activity Documentation
for additional policy information about timesheet requirements.
Page 1 of 3
Clear Form
*DHS-4691-ENG*
DHS-4691-ENG
8-16
PCA Time and Activity Documentation
PCA AGENCY NAME
DATES/LOCATION OF RECIPIENT STAY IN HOSPITAL/CARE FACILITY/INCARCERATION
PHONE NUMBER
Dates of Service
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
MM/DD/YY
(in consecutive order)
Activities
Dressing
Grooming
Bathing
Eating
Transfers
Mobility
Positioning
Toileting
Health Related
Behavior
IADLs
Visit One
Ratio staff to recipient
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
Shared services location
Time in
AM
AM
AM
AM
AM
AM
AM
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
Time out
AM
AM
AM
AM
AM
AM
AM
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
Visit Two
Ratio staff to recipient
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
1:1
1:2
1:3
Shared services location
Time in
AM
AM
AM
AM
AM
AM
AM
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
Time out
AM
AM
AM
AM
AM
AM
AM
(circle AM/PM)
PM
PM
PM
PM
PM
PM
PM
Daily Total
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
MINUTES
(minutes)
Total Minutes
Total 1:1
Total 1:2
Total 1:3
This Time Sheet
MINUTES
MINUTES
MINUTES
Acknowledgement and Required Signatures
After the PCA has documented his/her time and activity, the recipient must draw a line through any dates/times he/she did not receive
services from the PCA. Review the completed time sheet for accuracy before signing. It is a crime to provide false information on PCA
billings for Medical Assistance payment. By signing below you swear and verify the time and services entered above are accurate and that
the services were performed by the PCA listed below as specified in the PCA Care Plan.
RECIPIENT NAME (FIRST, MI, LAST)
MA MEMBER # or DATE OF BIRTH RECIPIENT/RESPONSIBLE PARTY SIGNATURE
DATE
I certify and swear under penalty of law that I have accurately reported on this time sheet the hours I actually worked, the services I
provided, and the dates and times worked. I understand that misreporting my hours is fraud for which I could face criminal prosecution
and civil proceedings.
PCA NAME (FIRST, MI, LAST)
PCA NPI/UMPI
PCA SIGNATURE
DATE
Review
PCA Provider Time and Activity Documentation
for additional policy information about timesheet requirements.
Page 1 of 3
Instructions for PCA Time and Activity Documentation
This form documents time and activity between one PCA and one recipient. Document up to two visits per day on this form.
Employers may have additional instructions or documentation requirements. For shared care, you must use a separate form
for each person for whom you are providing care.
Name of PCA Provider Agency
Mobility
Moving including assistance with ambulation, including
Enter name of the PCA provider agency and its
use of a wheelchair. Mobility does not include providing
phone number.
transportation for a recipient.
Recipient Stays
Positioning
Enter dates and location of recipient stays in a hospital, care
Including assistance with positioning or turning a recipient
facility or incarceration.
for necessary care and comfort.
Dates of Service
Toileting
Dates of service must be in consecutive order. Enter the date
Bowel/bladder elimination and care, transfers, mobility,
in mm/dd/yy format for each date you provide service. The
positioning, feminine hygiene, use of toileting equipment or
recipient must draw a line through any dates and times PCA
supplies, cleansing the perineal area and inspecting skin and
services were not provided.
adjusting clothing.
Activities
Health-related Procedures and Tasks
For each date you provided care, write your initials next
Health related procedures and tasks according to PCA policy.
to all the activities you provided. Your initials indicate you
Examples include: range of motion and passive exercise,
provided the service as described in the PCA Care Plan. If
assistance with self-administered medication including
you provide a service more than once in a day, initial only
bringing medication to the recipient, and assistance with
once. The following are general descriptions of activities of
opening medication under the direction of the recipient or
daily living and instrumental activities of daily living.
responsible party, interventions, monitoring and observations
Dressing
for seizure disorders, and other activities listed on the care
plan and considered within the scope of the PCA service
Choosing appropriate clothing for the day, includes laying-
meeting the definition of health-related procedures and tasks.
out of clothing, actual applying and changing clothing,
special appliances or wraps, transfers, mobility and
Behavior
positioning to complete this task.
Redirecting, intervening, observing, monitoring and
Grooming
documenting behavior.
Personal hygiene, includes basic hair care, oral care, nail care
IADLs (Instrumental Activities of Daily Living)
(except recipients who are diabetic or have poor circulation),
Covered service for recipients over age 18 years only, such
shaving hair, applying cosmetics and deodorant, care of
as: meal planning and preparation, basic assistance with
eyeglasses, contact lenses, hearing aids.
paying the bills, shopping for food, clothing, and other
Bathing
essential items, performing household tasks integral to the
personal care assistance services; assisting with recipient’s
Starting and finishing a bath or shower, transfers, mobility,
communication by telephone, and other media, and
positioning, using soap, rinsing, drying, inspecting skin and
accompanying the recipient with traveling to medical
applying lotion.
appointments and participation in the community.
Eating
Visit One
Getting food into the body, transfers, mobility, positioning,
hand washing, applying of orthotics needed for eating,
Documentation of the first visit of the day.
feeding, preparing meals and grocery shopping.
Ratio of PCA to Recipient
1:1 = One PCA to one recipient
Transfers
1:2 = One PCA to two recipients (shared services)
Moving from one seating/reclining area or position
1:3 = One PCA to three recipients (shared services)
to another.
Circle the appropriate ratio of PCA to recipients for
this visit.
Page 2 of 3
DHS-4691-ENG 8-16
Visit Two
Time out
Enter time in the hours and minutes that you stopped
Documentation of the second visit of the day.
providing care and circle AM or PM.
Ratio of PCA to Recipient
Daily Total
1:1 = One PCA to one recipient
1:2 = One PCA to two recipients (shared services)
Add the total time in minutes that you spent with this
1:3 = One PCA to three recipients (shared services)
recipient for the care documented in one column.
Total Minutes This Time Sheet
Circle the appropriate ratio of PCA to recipients for
this visit.
Add the time in minutes for all visits on this entire time
sheet and enter the total in the appropriate ratio box.
Shared Services Location
(Required for shared services only) Write a brief description
Acknowledgement and Required
of the location where you provided the shared services,
Signatures
examples include school, work, store and home.
Recipient/responsible party prints the recipient’s first name,
middle initial, last name, and MA Member (MHCPID)
Time in
Number or birth date (for identifying purposes). Recipient/
Enter time in hours and minutes that you started providing
responsible party signs and dates form. PCA prints his/
care and circle AM or PM.
her first name, middle initial, last name, individual
PCA Unique Minnesota Provider Identifier (UMPI) (for
identifying purposes). PCA signs and dates form.
PCA AGENCY PHONE NUMBER
Attention. If you need free help interpreting this document, call the above number.
.‫مالحظة: إذا أردت مساعدة مجانية لترجمة هذه الوثيقة، اتصل على الرقم أعاله‬
kM N t’ s M K al’ . ebI G ~ k ¨tU v karCM n Y y k~ ¬ g karbkE¨bäksarenHeday²tKi t «f sU m ehATU r s& B Í t amelxxagelI .
Pažnja. Ako vam treba besplatna pomoć za tumačenje ovog dokumenta, nazovite gore naveden broj.
Thov ua twb zoo nyeem. Yog hais tias koj xav tau kev pab txhais lus rau tsab ntaub ntawv no pub dawb,
ces hu rau tus najnpawb xov tooj saum toj no.
ໂປຣດຊາບ. ຖ ້ າ ຫາກ ທ ່ າ ນຕ ້ ອ ງການການຊ ່ ວ ຍເຫຼ ື ອ ໃນການແປເອກະສານນ ີ ້ ຟ ຣ ີ , ຈ ົ ່ ງ ໂທຣໄປທ ີ ່ ໝາຍເລກຂ ້ າ ງເທ ີ ງ ນ ີ ້ .
Hubachiisa. Dokumentiin kun bilisa akka siif hiikamu gargaarsa hoo feete, lakkoobsa gubbatti kenname bibili.
Внимание: если вам нужна бесплатная помощь в устном переводе данного документа, позвоните по
указанному выше телефону.
Digniin. Haddii aad u baahantahay caawimaad lacag-la’aan ah ee tarjumaadda qoraalkan, lambarka kore wac.
Atención. Si desea recibir asistencia gratuita para interpretar este documento, llame al número indicado
arriba.
Chú ý. Nếu quý vị cần được giúp đỡ dịch tài liệu này miễn phí, xin gọi số bên trên.
ADA3 (9-15)
For accessible formats of this publication,
ask your PCA. For assistance with additional
equal access to human services, contact your
PCA agency’s ADA coordinator.
Page 3 of 3
DHS-4691-ENG 8-16
Page of 3