Instructions for "Adult Day Intake Screening" - Pennsylvania

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This document was released by Pennsylvania Department of Aging and contains the most recent official instructions for Adult Day Intake Screening.

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Adult Day Intake Screening Instructions

The Pennsylvania Department of Aging, Division of Licensing provides this sample Intake Screening tool

for use by licensed Older Adult Daily Living Centers. Centers may customize this form to meet their

operational needs. It is important to remember when making any modifications, ensure that all

required elements of §11.101 are addressed on the center’s intake screening form.

The intake form is the key tool to determine the appropriateness of a potential client for your center. It

must be completed within 60 days prior to the date of admission per §11.101. Center personnel

complete the form, under the direction of the center director, with the applicant or responsible party, or

both. If a section of the form does not apply to the applicant’s situation be sure to mark the question

with an “n/a” to show that the question was addressed during the intake screening.

Part I: Personal Information Examples of identifying marks may include scars, moles, and birthmarks.

Responsible party may be designated by the client voluntarily or court appointed (e.g., power of

attorney, guardian). Required components of this section include date, applicant’s name, address, birth

date, social security number (last 4 is sufficient), and phone number. Identifying the responsible party,

financial responsible party, and at least two (recommended) emergency contacts is useful information if

the client becomes enrolled. Emergency contact information is required by §11.191.

Part II: Legal Status If the client has a written documentation of a power of attorney or guardianship

the center must obtain a copy per §11.8(d). As a best practice, centers are encouraged to obtain copies

of advance directives or living wills.

Part III: Referral Some referral examples include the Area Agency on Aging, the Alzheimer’s

Association, and friends/family.

Part IV: Living Arrangements and Transportation It is helpful to know if there will be someone at home

when a client is dropped off. Will family member, county transportation, the center, or the client

themself be the transportation to and from the center? Be specific as possible, especially if your center

provides transportation to and from the client’s home. It is helpful to know if there will be someone at

home when a client is dropped off.

Part V: Family and Social History The questions typed in blue allows for the opportunity to get to know

the client and preserve dignity and self-esteem.

Part VI: Medical Information and Health History Have the applicant rate their health; listening to their

answer can give you valuable insight. A medication list may be attached instead of written on the form.

Remember to compare this information with the initial client medical report.

Part VII: Medical Contacts Self-Explanatory

Part VIII: Caregiving It is important to have an awareness of other social service agencies involved in

the client’s care, especially care manager names and contact information, along with information on

informal supports. Capturing information on caregiver stress and limitations is beneficial for the

09/24/2014