Form DHS-690 "Targeted Case Management Contact Monitoring Form - Medicaid" - Arkansas

What Is Form DHS-690?

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

Form Details:

  • Released on January 1, 2016;
  • The latest edition provided by the Arkansas 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-690 by clicking the link below or browse more documents and templates provided by the Arkansas Department of Human Services.

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Download Form DHS-690 "Targeted Case Management Contact Monitoring Form - Medicaid" - Arkansas

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Targeted Case Management Contact Monitoring Form
Initial
Scheduled Visit
Significant Change
Participant Name ______________________________
Program________________________
Waiver Eligibility Dates _____________________ Last Four Digits of SSN XXX-XX-_______
Agencies/Services Provided in Home (based on Person Centered Service Plan-PCSP):
Date of Contact ___________________
Type of Visit:
Home
Telephone
Start Time ________
Stop Time ________
Name of Person Contacted __________________________
Relationship to Client____________
1. Does a home health nurse come to see you?
Yes
No
If yes, what is the name of the agency? _______________________________________________________________
What are the type, amount, and frequency of services? __________________________________________________
_______________________________________________________________________________________________
2. When was your last hospital admission? Why and how long? _____________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3. When was your last nursing home admission? Why and how long? _________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
4. Does someone help you take your medication?
Yes
No If yes, who helps you and how do they help you?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
1
DMS-690 (1-1-16)
Targeted Case Management Contact Monitoring Form
Initial
Scheduled Visit
Significant Change
Participant Name ______________________________
Program________________________
Waiver Eligibility Dates _____________________ Last Four Digits of SSN XXX-XX-_______
Agencies/Services Provided in Home (based on Person Centered Service Plan-PCSP):
Date of Contact ___________________
Type of Visit:
Home
Telephone
Start Time ________
Stop Time ________
Name of Person Contacted __________________________
Relationship to Client____________
1. Does a home health nurse come to see you?
Yes
No
If yes, what is the name of the agency? _______________________________________________________________
What are the type, amount, and frequency of services? __________________________________________________
_______________________________________________________________________________________________
2. When was your last hospital admission? Why and how long? _____________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
3. When was your last nursing home admission? Why and how long? _________________________________________
_______________________________________________________________________________________________
_______________________________________________________________________________________________
4. Does someone help you take your medication?
Yes
No If yes, who helps you and how do they help you?
_______________________________________________________________________________________________
_______________________________________________________________________________________________
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DMS-690 (1-1-16)
5. Who do you call if you have a problem with an attendant(s)? ________________________________________________
6. Do you have a copy of your current person-centered service plan?
Yes
No
7. Who do you call if you want to make any changes to your person-centered service plan? __________________________
8. If you were dissatisfied with any of the services offered, have you reported this to your case manager or DAAS RN?
If yes, to whom did you report? ________________________________________________________________________
9. Do you have family who lives close to you?
Yes
No
If yes, who are they and what type of support do they provide to you?
________________________________________________________________________________________________
________________________________________________________________________________________________
If not, does anyone check on you?
Yes
No If yes, who and how often? __________________________________
10. Is there a pet(s) in the home?
Yes
No
If yes, what kind? ____________________________________________
Is the participant able to care for the pet?
Yes
No
Does it cause safety issues?
Yes
No
If yes, explain: ____________________________________________________________________________________
11. Overall are you pleased with the waiver services you receive?
Yes
No
If not, what changes/comments would you make to improve enrollment and service delivery?
________________________________________________________________________________________________
________________________________________________________________________________________________
12. Based on information from the participant and/or family, are services being delivered according to the waiver service plan
or provider service plan (as applicable/required)?
Services:
____________________________________________________________________________________
____________________________________________________________________________________
If no, document why: ______________________________________________________________________________
____________________________________________________________________________________
13. Do these services appear to remain appropriate to the waiver participant’s needs?
Yes
No
If no, document the date the copy of person-centered service plan was mailed to the participant.
Date ________________
14. Look at the residence. Is it neat, clean, foul odored, sanitary, or unsanitary? Document findings and observations.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
DMS-690 (1-1-16)
2
15. Look at cabinets/refrigerator. Document food supply.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
16. Look in bathrooms. Document observations.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
17. Document waiver participant’s mobility, transferring, etc. based on what you are told and what you observe.
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
18. Targeted Case Manager's observations since the last visit? (Document changes in functional abilities,
changes in residence and its condition, changes in attitude, behavior, appearance, progress or lack of progress, etc.)
___________________________________________________________________________________________________
___________________________________________________________________________________________________
___________________________________________________________________________________________________
Complete if Home Delivered Meals is on the PCSP:
N/A
19. Are you receiving HDM?
Yes
No
What types of meals do you receive?
Hot
Frozen
Both
20. How are the meals heated? __________________________________________________________________________
21. Who heats the meals? ___________________________________________________________________________
22. Are you pleased with the meals?
Yes
No
23. Do you see the person who brings your meal?
Yes
No
24. Do they leave without seeing you?
Yes
No
25. Does your meal provider ask you for a donation?
Yes
No
26. Do you usually eat most of the meal they bring?
Yes
No
27. How many frozen meals do you get at one time?_____________________________________________
28. Do you have room for that many meals?
Yes
No
29. Observe how many meals are in the freezer? __________________________________________
DMS-690 (1-1-16)
3
Complete if Personal Emergency Response System is on the PCSP:
N/A
30. Do you wear your PERS button?
Yes
No
31. Would you prefer the necklace or wristband?
Necklace
Wristband
32. Have you had to push the button?
Yes
No
If yes, why? What happened? When?
________________________________________________________________________________________________
________________________________________________________________________________________________
33. Did the response center answer quickly?
Yes
No
34. Does your PERS provider call you every month to test your unit?
Yes
No
PERS Unit tested while TCM was making a home visit.
Response Time: ______________________________
Operator Name:______________________________
Complete if Adult Day Services or Adult Day Health Services is on the PCSP:
N/A
35. Do you like participating in day services?
Yes
No
36. How many days each week do you go to the center? ______________________________________________________
37. How many hours each day do you stay at the center? _____________________________________________________
38. Do you want to continue going the same amount of time?
Yes
No
39. What types of activities do you do at the center?__________________________________________________________
________________________________________________________________________________________________
40. In what ways do the workers involve you in activities?______________________________________________________
________________________________________________________________________________________________
41. How do you travel to the center? ______________________________________________________________________
42. What is your favorite thing(s) about the center? __________________________________________________________
_________________________________________________________________________________________________
43. What do you dislike the most about the center? __________________________________________________________
________________________________________________________________________________________________
Complete if Respite Care is on the PCSP (
):
N/A
Please address questions to the primary caregiver
44. Do you receive respite care ?
Yes
No
If yes, from whom?___________________________________________
45. How often do you receive respite care?_________________________________________________________________
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DMS-690 (1-1-16)
46. Who is the primary caregiver being relieved?____________________________________________________________
47. Is the frequency of respite care adequate?______________________________________________________________
48. In what ways could respite care be improved? ___________________________________________________________
Complete if Attendant Care Services are on the PCSP:
N/A
49. How many attendants come to your home to help you?____________________________________________________
50. Did you hire the attendants that come to your home?
Yes
No
If no, what agency sent the aides or companions that come to your home? ___________________________________
________________________________________________________________________________________________
51. Are you related to your attendants?
Yes
No
If yes, how are you related to them?
__________________________________________________
________________________________________________________________________________________________
52. How long have your attendants worked with you? ________________________________________________________
53. Does your paid caregiver live in the home with you? If yes, provide his/her name?_______________________________
54. Have you had a change in the attendants working for you in the last 6 months?
Yes
No
If yes, how many times and why?
________________________________________________________________________________________________
________________________________________________________________________________________________
55. How long do your attendants usually stay each visit?______________________________________________________
56. Is the amount of time good for you?
Yes
No
If no, is it
Too long
Not enough time
57. How do your attendants help you? (List tasks and be specific) _______________________________________________
________________________________________________________________________________________________
________________________________________________________________________________________________
58. What are your attendants not doing that you would like them to do?
Please list and be specific.
_______________________________________________________________________________________________
_______________________________________________________________________________________________
59. Do your attendants come the same time every day?
Yes
No
60. Does someone help you take a bath?
Yes
No
If yes, who__________________________________________
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DMS-690 (1-1-16)