DSHS Form DSHS 10-616 Attachment F - Ccrss Certification Evaluation Staff Interview - Certified Community Residential Services and Supports - Washington

Form DSHS10-616 or the "Attachment F - Ccrss Certification Evaluation Staff Interview - Certified Community Residential Services And Supports" is a form issued by the Washington State Department of Social and Health Services.

Download a PDF version of the Form DSHS10-616 down below or find it on the Washington State Department of Social and Health Services Forms website.

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ATTACHMENT F
CCRSS PROVIDER NAME
CERTIFICATION NUMBER
RCS CONTRACTED EVALUATOR / STAFF NAME
CERTIFICATION EVALUATION DATE(S)
AGING AND LONG-TERM SUPPORT ADMINISTRATION (ALTSA)
RESIDENTIAL CARE SERVICES
CERTIFIED COMMUNITY RESIDENTIAL SERVICES AND SUPPORTS (CCRSS)
CCRSS Certification Evaluation Staff Interview
CLIENT NAME
CLIENT SAMPLE ID NUMBER
DATE OF INTERVIEW
STAFF NAME
STAFF SAMPLE ID NUMBER
A. Client Needs
What kind of support and assistance does client need?
Tell me about the instruction and supports that you
provide to client.
How did you learn about client’s needs and how to
provide instruction and supports to her/him?
B. Client Health Care and Medication
Tell me about client health care needs.
What kind of medication assistance does client need?
Is there nurse delegation for any task?
What kinds of medications does client take?
What are the medications used to treat?
Where can you find information on the side effects?
What is the process if a client refuses to take their
medication?
Page 1 of 3
CCRSS CERTIFICATION EVALUATION STAFF INTERVIEW
DSHS 10-616 (11/2018)
ATTACHMENT F
CCRSS PROVIDER NAME
CERTIFICATION NUMBER
RCS CONTRACTED EVALUATOR / STAFF NAME
CERTIFICATION EVALUATION DATE(S)
AGING AND LONG-TERM SUPPORT ADMINISTRATION (ALTSA)
RESIDENTIAL CARE SERVICES
CERTIFIED COMMUNITY RESIDENTIAL SERVICES AND SUPPORTS (CCRSS)
CCRSS Certification Evaluation Staff Interview
CLIENT NAME
CLIENT SAMPLE ID NUMBER
DATE OF INTERVIEW
STAFF NAME
STAFF SAMPLE ID NUMBER
A. Client Needs
What kind of support and assistance does client need?
Tell me about the instruction and supports that you
provide to client.
How did you learn about client’s needs and how to
provide instruction and supports to her/him?
B. Client Health Care and Medication
Tell me about client health care needs.
What kind of medication assistance does client need?
Is there nurse delegation for any task?
What kinds of medications does client take?
What are the medications used to treat?
Where can you find information on the side effects?
What is the process if a client refuses to take their
medication?
Page 1 of 3
CCRSS CERTIFICATION EVALUATION STAFF INTERVIEW
DSHS 10-616 (11/2018)
ATTACHMENT F
CCRSS PROVIDER NAME
CERTIFICATION NUMBER
RCS CONTRACTED EVALUATOR / STAFF NAME
CERTIFICATION EVALUATION DATE(S)
C. Finance / Food / Meals
What assistance does the client need to pay bills and buy
food?
Where is the EBT card kept?
Who can use it?
Who does the food shopping and how often?
How is the food purchased, stored and prepared?
Do the client’s share food or eat meals family style?
Who does the cooking?
Do you know what a healthy diet is? How do you assist
the client with a healthy diet?
D. Mandatory Reporting
What is Mandatory Reporting?
How would you know if a client was being abused,
neglected, or financially exploited?
E. Positive Behavior Support Plan
Does the client have a Positive Behavior Support Plan?
Show me where it’s kept and how you access it.
Page 2 of 3
CCRSS CERTIFICATION EVALUATION STAFF INTERVIEW
DSHS 10-616 (11/2018)
ATTACHMENT F
CCRSS PROVIDER NAME
CERTIFICATION NUMBER
RCS CONTRACTED EVALUATOR / STAFF NAME
CERTIFICATION EVALUATION DATE(S)
AGING AND LONG-TERM SUPPORT ADMINISTRATION (ALTSA)
RESIDENTIAL CARE SERVICES
Community Residential Services and Supports
Certification Evaluation Staff Interview Notes
NOTE: This form should be used to document any additional information or data that does not fit in the designated space.
Page 3 of 3
CCRSS CERTIFICATION EVALUATION STAFF INTERVIEW
DSHS 10-616 (11/2018)

Download DSHS Form DSHS 10-616 Attachment F - Ccrss Certification Evaluation Staff Interview - Certified Community Residential Services and Supports - Washington

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