Instructions for "Adult Day Intake Screening" - Pennsylvania

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

Instruction Details:

  • This 2-page document is available for download in PDF;
  • Actual and applicable for the current year;
  • Complete, printable, and free.

Download your copy of the instructions by clicking the link below or browse hundreds of other forms in our library legal documents released by the Pennsylvania Department of Aging.

ADVERTISEMENT
ADVERTISEMENT

Download Instructions for "Adult Day Intake Screening" - Pennsylvania

308 times
Rate (4.8 / 5) 22 votes
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
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
coordination of care as well as helping the caregiver with their burdens through other services and
supports.
Part IX: ADLs, IADLs, and Physical Aids Indicating things like normal toileting patterns is helpful. An
example would be to indicate the client has a bowel movement (BM) every day, every other day, etc.
Notes about devices used can include a narrative if explanation would be helpful. For example, you may
put, “Uses wheelchair for long distances but generally can use cane within center.”.
Part X: Nutrition In addition to capturing any dietary restrictions due to medical conditions, remember
to investigate any possible cultural dietary concerns.
Part XI: Cognitive/Behavioral Status This section is vital as the center may encounter applicants whose
clinical care needs can be met, but have underlying behavioral issues that raise concerns with the
center’s ability to provide services.
Part XII: Optional Add any additional information as appropriate to help in making a determination as
to whether or not the person is appropriate for adult day services and can be safety served by the
center.
09/24/2014
Page of 2