WtJlMme To Add Tn .LiftJ AduU DD)'('JU''C
Helping fDmilic~ my together!
111ank you for yoUI' lime. we appreciate you checking out our dayeare and
choosing to pursue the application process. This packet has step-by-step
instlUction sheels to help mekc the application process as easy as possible.
ror additional help please conta(',t;
Add To Lite Adult Dayc-.arc tnc.
5877 Old TImuqLlanll Road
Jacksonville, Florida 31210
Phone(904)779-1777
Fax(904)779-t 7tJ
EmaiL [email protected]
Website: www..AddTolifeAdu!tDaycare.com
~
Instructions:
• The first
is your funding application.
• Fill out your funding application to the best of your knowledge and
return with tbe resf. ofyour packet to Add To Life.
" Add To Life will thx your funding application to help you gel funding as
fast as possible.
CARES INTAKE FORM
DEMOGRAPHIC
SSN,
..1
1
_
Fi,'st Name,
MI,
L,.,t Namc
Dat~ "f Birth:
..I
J
Datc of D~~fh,
.J ..I
M~dk~id NumLJcr:
Mcdicare A &. B:
.
Medicare HMO
~
M~dicllr~ Nllmbcr:
.
A-A'i""/P"'fi,M-.n~"
S-I"'"
,'''A_~J"""Am,""o o-o,,~ J)-I;"lo,"",
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Race:
Ethl'idty,
H-HiJp"nlc O-O,~" U-U,.l"","
Sex,
F-F,~,"~
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Addre.. 1:
.
..
Addre~1 2,
Zip Code:
Ciry:
Slate:
COlln'Y of S~rvic~,
PII'Jne Number: ( I
CoUnty 01 Residence
_
_
_
_
_
_
CASE ASSIGNMENT
'
Initi~l Dat~:
Refen,l
Sonr~e
Rderral SOuToe:
Ph"ne Number: l
)
A5.i""ed T,,:
,,
Name:
_
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(;_C,~~ES
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Payment Type,
Living Arrangement: __
MEDJ"M,di",ld
__
ArCH-M"I, Forn'l, a,,,, H,,,,,
AL,'N~ALF
Living Situation,
Sped~i Project Cue,
Provider Name:
Dpe-n Reo'on:
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NUfiO-N,,,,'., Hom,
=
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ADDITIONAL CLlENT INFORMATION
Client Home AddrclJ' ---------------------------------------------------------------------------_
Zip Cod.,
Phone Number: L(_~I_.
_
_
DiT~~tiom'
_______
~_~_~~~
Responsible Parry'
Phone Nnmber: (
Caregi\lCr Name'
Primary Physid~n:
Intake Si""atltTe:
~
•
u
_
Rela[ion~hip:
)
~
~
_
~_
:::::i')::.:::
Phone Number, [(
Phone Number:
r.
~
Dare
_
_
_
Very IInDortant section
The ne,;:t five pages of the application are medical releLJ.Se fOlms.
The purpose ofthe furms is 1:0 .qhow lh"l your loved one is free of
communicable disC3HefO, including TB. While also giving UfO an overview of
lheir medical conditions and other important health informatIon to hdp us
belter care for your loved one.
Your doctor can choose to fill out FOimA (state medical rele3Sc 300S form)
or FOlm B (Add To Life's medical rele:lse form).
Roth forms are acceptable!
CJ1Cst :t-ray will be acceptable up to 1 yr and TB test is acceptable for 45
dayI'. The lest will bave to be in Ihis time fi"ame to enter daycare or the test
will have 10 be done again.
Ho,plI.1 Ad",t.,iorII
DIsch.'ll. D.t..
'OCIAc
PATIENT TRANSFER JlND CONTINUITY OF CARE
F..,Rity
F."lity
To
~"""
OK
"'A'''' I.',
PATIENl'SDOe~~_
CLAIM
RACE
'"
OL~IJ.I
"__._
~o,
~IRSTNAME
PATIENT'S ,""",T NAME
0'"'01'''-'
0 00"'" 0"'''''"'0
AOV"""O MIO'O",
MTIENrSADDRESS
CJ YE' 0.0
,
NEARESTRELATlVE
PHYSJc:",L EltAlII (m., ott.el1]
PHYSICIAN INFORMATION
NAME'--C-;~;:C=CC=OCCC-~---o=CCCC=
Pl1DNE
P,l.olplo Dlog"o']"'
s..,Ol\lI.'Y DIoIl~OII.'
DIIObl'll" DI"gnolll:
SU'II"'Y Pilt10rmed & Dlt.
"-,
""
~",dlop"l",o..".
A,domon
~.
MEDlCAnON AND TREATMENT ORDERS
(o~pl.'
",oy h••" ••hed)
RotI:Il.
E'-,,",".'·
~I."rorog"'"
AII"'II:/IDN\I ~.n.!"~y
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_
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- - - - - _.. _ - - - - - ­
, __
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_
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•••••• ""
._
''''''1:1.''
TYP~
IJ
QF CARE
a
NO RESUL....
R~COMM~N
ED:
o
Sklll.d Nu,ol"O I~CF) our.t1••;.;:=;:;:~
n Int.,m.dlol. G.ore Duratlo"_
0
o
0
''"''''
~"
,."
TUHE FEr:t:lNGH
FREQUENCY "0--­
TYPE OFFEEOING
-
CMANCE FEEDING TUB~
'REQUENCY
CJlT>lETER
FREOUENCY
CO~~'lJo:JUS
_
DATE l,}o,T CHANGED
0
QSTOMY CAR.!;
FREQUENCY
o
~ ...
far th. oond."n lor whl'h
du~ng ho'p~.IIJ.lim
1>eI.~e
r.",lv.d oor.
Err""l;"e D"", __'_ ,
_
~'"""ii:===r~::::~~~::""-'ny,lol""', Signoruro
o DECUBITUS CARE
SIT~
~'l.E
o I o.~lfy I~,tlhl. p.Uentr.qulfeo ~,C.F. NUrfllng Hom.
I''';" ,.. 'oOk ' ....1
TRJlC~
CARE
FREQUEtoICV
Cl,ol. R.hQh P"'onllQI
Good F.lr Poor
Admlooln" OQfoto Nursing Hom. , - - ' _ '_ _ D DRESSING
FREQUE~CV
0 SUCTlQNlNG
Sill'
c~ru;,;,~,~===
RESlJl.TS
~~
NA9O,L CANNLIVo
"
o DRJlININGWOUND
n1'E
'''R'CAn CATMETEFl
,"EQUHICY
SOLUTION
SIZE
PllINT PHYSICIAN'S
NAM~
STAGE
MEDICA1l0NlS0LIJ1lON
',d".'~
m"","M,,,, ",,..~I~~ """"'" .' .~., ,~"..",..."'"'
Form a
MEDICAL RELEASE FORM
Date
~
_
has been found free from TB in
communicable state as demonstrated by
a
(PPD or
x-ray) and Is apparently free of signs and symptoms of other
communlcable diseases.
Physician's Signature
Add To Life Adult D~V ~re
5"877 Old T1muorlJllo~ Rood
Jacksonvill" FI, .~nlg
(SQ'l) 779-1777
Applicant lnltl~I
_
FDrm B
Initial ~_
Annual _ _
PHYSIOAN'S ORDERS
Client
_
Address
_
Insurance:
_
Social Security Number:
Medicare #:
_
_
Date of Birth:
_
Current Diagnosis: (Physical or Mental)
Current Medications
(Over the Counter medications Induded)
Tylenol 500 mg
Dosage
1-2 Tablets
Frequency
PRN
Add To LIfe Adult Day Care
5"877 Old Timuquana Road
Jacksonv!lle FI, 3~~111
(1104) 779"1777
/lppllcanllnltlal
_
Form B
~_
I certify that patient may self-administer medications.
__ I certify that medication may be given as listed above.
Mobility:
Ambulatory __ cane _ _
Wheelchair _ _
walker _ _
Physical limitations:
Diet: _ _ Regular
_ _ Ground
-==
_
-==
Low Salt
Pureed
_
Low Salt/Low Sugar
Low Fat
Diabetic
Allergies: (Medialtions and/or Food)
Vital Signs: Blood Pressure _ _
Respiration: _ _
Pulse: _ _
Communicable Disease: All tests must be done within 45 days prior to
admission to Add To Life Adult Day care center
Is this client free of communicable disease? _ _ Yes
TB Test:
Date of T"B~te::st:===::;:=Results: _
OR
Chest x·ray: Date of x-ray
_
Results:
Add To Life Adult Day CBIl!
SBn Old Trmuquana Road
Jack50nvllle FI, 32219
(i()4) 77N7n
_ _ No
_
_
Applicant Inltial'
_
Form B
Special Health and Safety Needs:
COMMENTS:
Date of last office visit:
_
This client may be at risk for institutionalization if not admitted to an adult
daycare program.
MedIcation changes require a new order that will be sent to you.
Physician's Signature
Date
Physician's Name (PLEASE PRINT)
Add To Life Adult Day Care
sa" Old Timuquana Road
Jad<sonville FI, 32219
(90Q) 779-1777
Applicant Inltlal,
_
Lad sedion
The last half ofthl:: paeket is 1'0 tell m: about your loved one; likes, dislikes,
and ba.sic illforrna;.ioll ahout tbem. While aIM int'ol'Jl1ing yon of the ~ervices
we provide .IIn([ it goes over rightq <lnd chokes of yonr loved one.
Fini~hed?
Ifyou have filled {lut the packet to I'he best of yOUI' knowledge nnd have
Yllur TB test (Form A or Form B), lhen yml can come on into the daycElr'~.
and we will take Cilre of Ihe rest.
If you have any questions please don't hesitate to call!!!
HOW DID YOU HEAR ABOUT US?
Daily Fee:'
Date of enrollment:
_
CLIENT INFORMATION
Personal Information
(MIl
(firn)
Name (last)
Date of birth
Age Sex
Religion
Address
Marital Status
City State
Zip Code
Medicare #
Social SeOJrity #
Telephone#
Medicaid #
Emergency Information
Emergency contact or quardian/respoDslble party
Name: ~~
Relationship:
_
_
Address:,---cc---c----------------­
Telephone (home):
(work):
_
Nearest Relativ~
Name:=c:;::
Relationship:
Address:
_
_
Telephone (home):
(work):
Add To Lire Adult Day Care
SBn Old nmuquana Rood
JacKs-onvllle FI, J~219
(90~) 779·1777
Applicant InTtl~"
_
Non-local Relative
Name:CSJ~::========-----­
Relatio~shiP:
Address:
Telephone (home):
(work):
_
Attending P-lJysician(s)
Name:
Telephone:
Address:
_
Hospital Emergency:
Ambulanc.e Service: _
Add To Life Mult Day ~re
!iBn Old Tlmuquana Road
Jadlsonvllle FI, 31119
(904)779"1777
Applicant Inltla"
_
ON
Former Occupation:
_
Educational Background:
_
Presently living with:
_
Spouse's Name:
_
Children's Name:
(if any)
_
Ottler family (names, relation, locatlon):
Most Frequent ConlDct:
_
Does client receive servIces from any local agencies? (Visiting nurses,
Meals-on-Wheels, counseling, therapy, church, etc.):
DOES CUENT INDICATE NEED TO GO TO THE BATHROOM?
IF YES, HOW?
_
_
IS CUENT INDEPENDENT IN ANY HOUSEHOLD ACTlVITlES? (LAUNDRY,
HOUSEWORK, MEAL PREPARATION, SHOPPING, USING PHONE)
DESCRIBE:
Add To Life Adult Day care
5877 Old Timuquana Road
JiI~ksonvllle FI, 32219
(904) 779-1777
Appllumt Initial
_
Bowel control?
Does clIent have bladder control? _ _
If no, check one: _ _ Occasional incontinence
_ _ Frequent incontinence
Interests/Activities
Does client:
Yes
No
Details if significant
Enjoy music? (types)
Watch lV? (favorite program)
Play musical instrument?
Uke gardening?
Enjoy pets?
Enjoy painting?
Enjoy cooking?
Enjoy woodcrafts?
Enjoy sports?
Enjoy exercise?
Enjoy arts and crafts?
Enjoy magazines or books?
Enjoy sewing?
Does dlent smoke?
Frequency:
--"_
Does client drink alcoholic beverages?
Frequency: _ _~_
_
Special Hobbies:
Add To Life Ad,lIt Day Care
5877 Old TImuql1aM Road
Jackoonvllle FI, 3<219
(91)4) n9-1777
Applicant InltlaL
_
_
Does clIent demonstrate:
No
Yes
Details if sIgnificant
Significant memory loss?
Frequent mood changes?
Frequent wandering?
Paranoia?
Hostility?
Denial?
Confusion?
Depression?
Describe current sleep patterns:
Describe current eating habits:
=-_
Type of diet:
_ _ Other
Regular
_ _ Low Sodium
Can client feed hImself? -,---,-­
Need assistance or direction?
Does client have natural teeth? _ _
_ _ Diabetic
_
Dentures: (uses) __
(not used) __
Food preferences:
Beverage preferences:
Specific food/drink dislikes:
Does client have any assistive devices?
_ _ Eyeglasses
Hearing Aid
COlostomy
_ _ Brace
,==.Other Prosthesis
Wheelchair, cane, walker
Add To Life Adult Day Cilre
SS77 O'id nmuquana Road
Jaooonvllle fl. 32219
(904) 779-1777
Applicant Inltlal
_
PHYSICAL I:I~QRY;
~_
DATE OF MOST RECE,rr MEDICAL EXAM:
HAS CLIENT BEEN HOSPITALIZED IN THE LAST YEAR?,
_
IF YES, DATES/REASON FOR HOSPITALIZATION:
CURRENT PRESCRIPTION MEDICATIONS AND DOSAGE:
aTe MEDICATIONS TAKEN REGULARLY:
OTHER MEDICAL HISTORY:
PHYSIOAN APPOINTMENT SCHEDULE:
LONG-TERM GOALS:
SHORT-TERM GOALS:
Jlgbaviorall Functional
Onset of Symptoms:
When was client diagnosed?
Add To L~re Adult Day CzIre
5Bn Old Tlmuquana Road
Jacl<5onvllle Fl, 32219
(904) 779-1777
AppllcantInltlal'
_
Subject: Release Farm
The undersigned cllel'lt, responsible relative, guardian (underline one) of
hereby autharize consents ttl said client's use of the
fac1l!tles and equipment provided by Add To life Adult Daycare center, Inc. I/We also
release Add To Life's officIals, agents, employees, and/or ather person, firm, or
corporations charged or chargeable with responsibility or liability from any and all
claims, demands, damages, costs, elo:penses, loss of SErvices, actions, and cause of
action, which could arise out of any act or occurrences and particularly on account of
personal InJury, sustained by the said client, while said dlent Is on the premises of a
facility operated by Add To Life Adult Daycare Center, Inc.
Authorization Is also grantf-d:
1. To any physician, hospital, clinic, or medical service for the release of medical
and/or psychiatric information on said client to Add To life Adult Daycare
Center, Inc.
2. To any social service agency for the release of Information ttl Add To li~
Adult Daycare Center, Inc. regarding Its contact with saId client.
3. For the release of any necessary Information on the said client by Add To Life
Adult Daycare center, Inc., to its agencies and or medical equipment
pe~nne' in order to obtain appropriate reqUisite services.
4. For the use In publicIty releases of photographs of activities Involving said
dlent.
5. To Add To ute Adult Daycare Center, Inc. to secure any emergency medical
service as needed In the event that I can not be contacted Immediately.
Preferred hospital is
and
Primary care Physician is
Client's Name
Client's Signature
RelativE Guardian's Name
Relative Guardian's Signature
Director's Signature
"',.
Add To Life Adult D~y Care
S877 Old limuqll~nil Ro~d
]~cksonvl!le FI, 32219
(91)4) 779-1777
Appllcanllnitl81
~
RATE AGREEMENT
Daily charges will be based on Medicaid rates per day. As of 04/01/2009 a
rate increase became effective for all CCEjADI/MW/3E funded clients. The
new rate is $8.56 per hour, or a flat $63.00 day rate. Clients funded by
outside sources, subject to contract agreement. Scholarships may be
available for non-funded clients.
Payment is required at the beginning of the week and/or month. Funded
clients must have current service authorizations on file.
If you know that the client will not be attending on a regularly scheduled
day, to avoid being chmged for that day, twenty-four (24) hours notice
must be given.
Refund policy: Since pClyment is made at the beginning of the week/month,
any excess payment will be credited toward the following week.
DATE:
_
DAILY RATE:
_
1 have received a copy of Add To Life Adult Daycare Center's policies. I
hereby agree to comply with the stated policies and procedures and to
resp~ct the personal rights and private property of the other participants.
Participant's/Guardian's Signature
Director's Signature
Add To Life Adult Day Oil'e
5677 Old iimuquana Road
Jacksonville Fl, ;)2219
Applicant lnlbal'
_
Adrni!'lslon Criteria
PARnOPANTS SHALL BE:
--JndIVidu"is with
11:
diagnosis of Alztielmer's Disease or ~ related disorder determined
by medical assessment In[:llXIlng:
cr Scan, neurological exam, and blood tests.
0,
--rndivldu~ls over age is with learning challenges experiencing decrellsed awareness,
confusion, disorientation, w)thdraw~l, p<1ranoia, memory impairment,
IDS'S'
of social
skills, and/or increased dependency who are In need of a protective environment free of
health and safety hazards.
·"Free of communicable diseases-evidenced by atterlillng physician's statement (with
negative lB test or acceptable chest x-ray completed within 45 days of acceptance to
program)
--Admitted subject to a 30 day probatlon period In Which the participant Is found to
adjust Elnd benefit from the environment.
--Those having completed <lll necesS<lry admission forms:
1. Medical Statement
2. Agreement Controld
3. Client Information Data
4. MedlcatlOll Administratlon/supervislon permission (where applicable)
If client has monles/valuables~-WE ARE NOT RESPONSIBLE FOR lHE LOSS, If ANY, OF
THESE--PLEASE DO NOT BRING VALUABLES WITH YOU!
The Add To Life Adult Daycare Center's eligibility gUidelines and Program Policies have
been discussed with me (client) and/or significant members or friends. I understand
this Informatlon and agree to abide by these policies.
D,te
Client Signature
Guardian/Family Member/caregiver
Da~re
Director
Add To Lifi! Adult OilY care
Se77 Old Tlrn~'<luana RDdd
J~cksonvl!,le
A, 32219
(900l) n9-1777
Date
Date
Applicant Inltla'LI
_
ADMISSION AGREEMENT
The Add To Ufe Adult Daycare center, Inc. agrees to offer needed Adult
Day Health Care servIces, including, but not limited to, nutritional services,
recreational actiVities, social service, and nursing services by a registered
nurse, and/or LPN when RN ;s not available.
In return, the client agrees to attend ( ) days a week for a minimum of
four hours.
The Add To Life Adult Daycare Center, Inc. Is closed On the following
tlolldays. (see holiday insert for any differences)
New Year's Day
Memorial Day
Independence Day
Labor Day
5. ThankSgiving
6. Christmas
1.
2.
3.
4.
In case d indement weather, we will announce our closing on Channel 12
and 25 (First Coast News).
Director
Add To Ufe Adult Oay Care
51177 Okl1lrruqtlllf'l& Rooli
JarkionvTlle R, 32219
(904) 779"1717
Client/Legal Guardian
Updated 4/1/09
Attention; All Family Members of Add To life Adult Daycare Center's client
Re: Emergency Procedure
This memo is to inform you of the procedure that will be followed In case
of an emergency (hurricane, fire, terrorism, etc.)
1. Channels 12 and 25 (First Coast News) will be notified of any
closures and the length of any closures.
2. All clients, if at the daycare, will be escorted home as soon as
possible.
3. As a last resort, any clients who are unable to be transported
home will be transported to The Terrace at Fleming Island,
Orange Park, Florida. We have a mutual aid agreement to provide
this service for their facility as well.
This is simply to inform you of the procedure and to allow you to have this
information on hand in case of an actual emergency. Please make a copy
for your own records and return this one.
Thank You,
Cindy B. Dixon, Director Add To Life Adult Daycare Center
CllentjGuardian's SIgnature
Dale
Director's Signature
Date
Add To Life Adult Day CBre
5877 Old llmuquana Road
lac.l<sonville FI, 32n9
Appllt::ant Initlal
(904) 779-1777
_
The next page is for ADT clients only, if
you are applying for a senior citizen- please
disregard the following page only.
Mull,Day Training Contract
Adult Day Training funding covers six (6) hours of funded time at
ADD TO UFE ADULT DAY CARE CENTER. After this allotted time has expired
each day the consumer that remains at the center after 6 hours is no longer
within the Adult Day Training program. He/she Is then enrolled in the Adult
Day Care program, On the
days that this occurs the family/caregiver is then
financially responsible for
any overtime accrued after their allotted six (6)
hours.
Caregiver signature
Date
DIrector signature
Date
Add Til Life Adult Day Care
5"877 Old Tlmuquana Rlla~
l,,"nOlwilk! FI, 3n19
(904) 779-1777
Am;>IIi;<1nt rnltl~,l
_
To All Families of Add To Life Adult Daycare Center's Clients
If transportation is provided by]fA for your family member, It is of utmost
importance that you or someone at your home assists the driver in loading
the dient from the van. ITA drivers maintain a very tight schedule and are
on a very tIght time limit when providing this service to you and your loved
one. Any assistance you provide wi\! allow them to be more accurate on
their arrival times.
Transportation must be provided personalty or by ]fA, if so chosen.
If ITA is the means of transportation for your loved one please follow the
following:
1. £Ie ready 20"30 minl,Jtes before estimated pick-up time.
2. Have client dressed, groomed, and toileted before pick-up.
3. Driver is only able to wart 5 minutes for passenger to leave the house.
4. £Ie prepared for a delay dl,Je to traffic or weather.
5. If they have not arrived by the estimated pick-up or drop"off time,
please call and we can check on estimated arrival time or yOI,J may call
ITA at 265-6999_
YO\Jr cooperation in this matter would be greatly appreciated.
Add To Life Adult D~Y care
5"8?? (lId Tlmuquana R~ad
Ja~l<Sonl/l!Ie Fl. 32219
(904) 779"17n
Applicant
!nl~a,,
_
Drafted B-7~02
Adult Day Health (are (ADHC) is an alternative to nu~ing home placement. The
program is open to eldel"ly Individuals, including those with physical and memory
(Alzheimer's) problems, <IS well as to Individuals 18 years of age or older who
may have special needs. ADHC provides a therapeutic, protective, structured,
and supportive environment five days a week on a regularly scheduled basis.
One of the local orgi'mizations that provide ADHC Is Add To Life Adult Daycare
Cent:l?!l".
Add To Life is open for ten hours per day (7:30-5:30), five days a week. Sodal
inter<lction, professional ~nd peer support, exercise, mental stimulation, health
monitoring, assistance with eating, walk.ing, tolletlng, and med\c~tion are some
of the many services that are Offered to the participants every day at Add To
life. There are also structured activities such as music, art, and reminiscence
therapy. caregivers also benefit from the
progr~m.
Wh"e their loved one is
attending the program, caregivers can use the time to meet family obligations or
to enjoy some much needed rest and relaxation.
The lunch proVided meets 1/3 of the minimum r&Ommel1de.d dIetary allowance
requirements. lunch is provided, along with breakfast and an afternoon snack.
Tr;:m<;portatlon Is available to and from the Adult Health care Facility; see
director for contract information.
Add To Ufe Adult Day Care
5877 Old Timuqu~na Rood
JIld<sonvl»e fl, 32219
(~D4) 77Hm
Applicant InitiaL'
_
Adult Daycare Eligibility
1. Add To Life Adult Daycare is a prQ:lrarn provided for Adults with Special
Needs. The purpose of Adult Oaycare is to provide protective individual
supervision in a safe, and pleasant environment. Activities are prOVided,
which include arts and cr<lfts, puzzles, games,
discu~lon
groups, exercise,
hygiene classes, individual training programs, reality orientation, movies,
outings, etc. These activities help the dients remain as active and
independent as possible for a longer period of time. Consultant Referral
Services are provided upon request or as indicated.
Z. If a client 15 determined to be appropriate, physician crdets and a
current 1'8 test or chest x~ray must be completed to comply with
department rules. Physician orders and physical exams must be renewed
as medications change or there is a change in client health.
3. Partidpcmts are responsible to comply with these polides and
procedures and to respect the personal rights ad private property of other
participants.
Add To l((>, Adull Cay Care
5877 Old T1muquana Road
Jacksonville Fl, 32219
(90~)
nH777
A\JpUcant Inltlal
_
Program Policies
1. Hours of operatloll'l
The program is open from 7:30 am to 5:30 pm, Monday through Friday.
will occur promptly at 5:30 pm. A late fee will be assessed for
clients not pick;ed up by 5:30 pm. Respite care will be charged @ $12.00
Closing
per hour after 5:30p.m., a charge of $10.00 every 15 minutes.
Transportation of clients through
and
ITA service will be coordinated by staff
JTA.
2. Incontinence
Protective undergannents are acceptable for loss of bladder control. Please
send in at least two extra per day.
3. Spec;;ht' Assistance
The staff is always available
to provide assistance to dienl5. Persons
regularly requiring the simultaneous assistance of more than one staff
person are considered on an individual basis.
4. Hygienic Standards
It is very important that all clients have good hygiene. Good hygiene
means a clean body (including mouth and hair) and clothes. In case of
poor hygiene,
helping
staff will advise the client and/or caregiver and assist with
to solve the problem through referrals and/or educatIon and/or
individual attention.
Add To Life Adult Day care
S877 Old l1muQuona Rood
Jac'l<'lonvllie A, 32219
(904) 719-1777
Applicant Inililll~_~~_
s. Medklnes
Administer medication
to the dient In accordance with
the following
criteria:
~Medication
prescribed for administration during the day care hours
of servke must be properly labeled with name of medication,
pharmacy number, prescribing physician, dosage, and timp.5 of
administration. Medication should also come in a bottle directly from
the pharmacy.
~Medication to
be administered will remain on premises for duration
of client's participation in the program.
~Medlcation renewals will be the responsibility of client or responsible
party.
-If the client refuses medication, the responsible party will be
notified.
6. Bed Rest
A day bed is available for clients who become ill and need
to lie down.
Otherwise, comfortable easy chairs, couches, and recliners, are available
for recUning.
7. Activities
A variety of activities are schedUled and all dients are encouraged to
participate.
8. Wandering
To ensure clients' reasonable safety, determination of the appropriateness
of dlents who are prone to wandering will be made on an individual basis.
Alarms and fences are in place.
Add 10 "Ire Adult DilY Cilre:
5"877 Old nmuqua~a Road
Jilcksonvillp; A, 32219
(9(4) 779-1m
Applicant lnltla,,'.
_
9. Combative Behavior
The participation of persons who are routinely hostile, combative, or
verbally abusive to others (clients or staff) w\Il be terminated. The client
will be allowed
to remain as a client if behavior problems can be controlled
by mediations or behavior management.
10. Termination from the Program
These pOlicIes and standards were developed to ensure a healthy,
pleasant, stimulating environment for all clients and staff. A client who
does not meet these standards will be re·evaluated
to determine cause for
termination from the program. In such situations, an Individual conference
with the client, car~lverT and/or case manager may be scheduled
to
assess the situation. In all cases, the client and/or caregiver will be given a
minimum of one week. of prior notice to the termination date. When safety
is an issue due to progression of symptoms, these clients wiH be dealt with
on a one to one basis.
11. Volunteers
Adult daycare utilizes volunteers from the cnmmunity, local schools, and
universities. There are many volunteer opportunities.
12. The client or Responsible party agrees to:
·Complete or prOVide all necessary client·related forms prior to
admission.
"Notify the daycare at least seven (7) days prior to client's intended
date of discontinuance in the program
·Provide Changes of labeled clothing and undergarments to be stored
at the center.
If client uses incontinence diaper, an adequate supply should be
provi.ded for each day.
Add To Life Adult D"y Cue
5877 Old nmuqu"n" Ro"d
~B<:I<sOlwll\e
R, ~121g
(904) 779-17n
Applicant lnitial'
_
-Absolve the daycare of liability For any loss or damage to the client's
personal property or valuables to fire, theft, or other mishaps.
-Absolve Add To Life Adult Daycare Center, Inc.'s officials,
employees, and/or any other person, firm, or corporation charged or
chargeable with responsibility or liability from any and all claims,
damages, costs, expenses, loss of services, actions, and cause of
action, which could arise out of any occurrence, and particularly on
account of personal injury, sustained by the said participant, while
the participant is on the vehicles arranged/owned by th.e daycare.
-Authorize the daycare to transport the client off the premises for
planned outings, neighborhood walks, or community events, etc. as
part of the therapeutic programming.
-Accept the decision of the daycare regarding discharge of the client
due to concerns for his/her safety or that of others.
13. Authorize the daycare to;
-Use pictures or identifying information regarding the client for
publicity purposes or use in an emergency.
~Release information regarding the client for publicity purposes or
use in an emergency.
-Transport clients to the nearest emergency facility in the event of an
acute illness if family or responsible persons cannot be reached.
14. a. Pay the daycare the daily rate
at the beginning of the
week or month, plus transportation.
b. Allow the daycare to submit third party billings monthly for
services rendered, if necessary, if covered.
c. Add To life Adult Day Care center hours are from 7:30 am to 5:30
pm,
d. A late fee of $.10.00 will be charged for each fifteen minutes past
5:30 pm, or agreed time for client to be picked up.
e. Client will attend daycare
per week on the following days
I have read and understand the above items and agree to abide by them.
legal Caregiver/Client
Date
Add Ta Life Adult D~y C<lre
SBn ad Timuquanll Road
JlItksonvllle f!, 32219
(9ll4) /79-1777
Aprllcant lnltlal'
_
Emergency Preparedness Information
As part of the center's Emergency Management Plan to keep your loved Gne safe we
offer annual evacuation Information. We have the forms you need to complete If you
wIsh for specIal servia>.s
In the case of a dIsaster. There are two forms for those wlth
sped'll needs. One form Is to have eval;uatlon t@nSDOrtiltiqntoashelter, the
other fDrm Is for the Intent of staying In a shelter in the event of a disaster.
You may request one or both of these forms,
Please Inform the center if YOu have any Interest.
Add To LrfE Ml.llt o~y Care
5877 Old Tlmuqullnll Road
J~cksonville
Fl. 32219
(904) 779-1777
Applicant Inltllll
_
"", "' "'","
~•....iIi1i..&!iII,···liI
ELDERAFFAlRS
STATE OF FLORIDA
DEPARTMENT OF CHILDREN AND FAMILIES
DEPARTMENT OF ELDER AFFAIRS
INFORMED CONSENT FORM
CLIENT'S NAME: _ _
SOCIAL SECURITY # :
~
_
An assessment is required for all persons applying for or receiving assistance for
long term care. This Includes the Inslilulional Care Program (ICP) and Home
and Community Based Services (HCSS) waiver programs.
In order to evaluate my needs, I em giving my consent to the following:
.. I agree to an assessment to identity my need for long term care, and to
determine if my needs can be met in the community instead of a nursing
facility.
• I authorize DC&F and DOEA staff to access my medical records. I
understand and agree 111a1 DC&F and DOEA may need to talk to my doctor
and other health profe:,sionals. I also understand that they may nead to
Interview family members, CI038 friends and social services professionals
about my situation
Individual or Representative
Relationship (if representative signs)
Date
CF-F.S
~o~~.
S,p
2~M [1l.~I'"M Jan
IS'oo' "umbor: 3CF·QQ?71\
93
odltl~n "~ich
moy"" "oed)
~ient reGon!
ot'diSGIOSureSO
-In general, Ihe HrPM prlvecy rule give IndivfdufllG \he rtghllo request e I1lslrlr:\.(on on usee end
dleclrnlUf9B of Ihelr pmleC!Bd health intormatlon (PHI). The Individual Is elsD provIded the right
to ,squasl confidential eommunlcalions or [hilt e cDl'l1muniealion of PHl bill made by eUemeUve
meaT"le. SUd1IlB sending correspondence to the indIvidual's offlr:a IMtead oflhe Individual's home,
J wish to be contacted In the following manner (check all thai apply):
o
o
o
Home Telephone~
o
o
o
o
o
o
WrlllBfl COmmunlcalion
OK (0 leave meBsllgll\Vilh detailed irrrormlliion
Laave l'l1eesage with OlII1_beck numb~ only
o
O.K.tomllllmmytlomeeddrees
0.1<. To melllo",'1 wcrk:lofllc" address
O.K. To fax \0 Ihl8 numMr
WOr\( Telephone Number:
OJ( 10 la1M!' mSMBQe with detailed InIorme!ioll
D.olher
Laeve mE,,91l1ge .....Uh call-bsck number only
Pellenl Signalure
Print. Neme
Dele
.--- The privacy rule genemlly requires heBllhcam provldere 10 l6~e reB!ianeble Mepa 10 limit !he uspJ or dlef:losure
of, Bnd requeS\e ror p«ltec\Bd hesllh Informetlon 10 lhe minimum 1'lBCl'l9"'1ry to eccomplish lhe Inlended ~""l!'.
These provIsions do not apply to ueef; or dlsclosuree mede pursuenllo Iln Ilulhorlzellon requesllld by ll1e lndlvlduel
Heallhcal'll enlilles musl kellp reCOrde of Prolected Health Informellon dleclosure. Informellon proVided below. If
~ompleted properly, wtll CDnemule eo adequete record.
• Nate: UIl88 and dlacloaul'lll of PrutlIc1ed HeolttllnfoJTJ1lltlon mIlY be plImIlrtad wlttlotdprlor
Con.em In en emargency.
RECORD OF DISCLOSURE OF PROTECTED HEALTH INFORMATION
Pal.
lllllelOaad To
I, )
Purpose of Olacloaul'll
By Whom DisclOSed
t
1
2
3
Check thl~ box Itthe dlef:losure Is authorlzad.
Type Key; T" T!Belmenl ReC<lrds; p" Peymenl Inrormetlon, 0" HeellhclH'l'! Operations
Enlerhow dleclosure WBS lIIlldo: F" FElJ; p" Phone; 0" OIMr
1'1 I , )
•'
,
!}'
•
,
•
J? •
,
"Bill of Right.';"
This bill reaffirms all those
inall~nnhlp. rlght~
•
guaranteed in the
U.s. Bill of Rights while setting forth 12 speclftc right'5 ror all cltllens:
The right to digillty, prIvacy ana humane care
•
•
"
.,
The right to religious frl'!edom and practice
•
The unrestrIcted right I:n communication
• The right to personal possessIons and effecb;
o
The right to education arid training
• The right to prompt ami appropr1ate medical care and treatment
• The rigt1t to sodalilteraction
• The right to physical exercise
• l1\e r1ght ttl numan dlsdpllne
•
The right to minimum wage protection and faIr compensation
• The rIght to be free from phySical restraint
{to
• The right to a centra! record
*
Atld Ttl \jfu Adult Day Qlre
5877 Old Tlmuqullna R{'ad
Appllcart In\tlal,
_
Jacksonville Fl, 32219
(904) 779"1777
;
*
PRINCIPLES OF CHOICE
• All people have the right to make choices,
• People have the right to learn about choices through exposure
to
natural life experiences, making mistakes, naturally occurring
consequences, training and through seeking advice from others.
• All people with disabilities have the right to receive impartial
information concerning choices. Undue, Imbalanced or self-serving
influence Is not acceptable
• Factors that limit choIces for people with disabilities should not dIffer
from those for people Without disabilities.
• People have the right to choose from a varlflty of supports and
services and make changes based on their individual needs.
• People should be offered options which are free from threats to their
immediate t1ealtl, and safety or the immediate health and safety of
others,
• Consistent with other principles of cholce, people have the right to
make an informed choice of any qualified prOvider of any needed
service or support.
• Tile choices people make do not diminish the obligation to act in a
responsible manner and to accept the consequences of their choIces.
Add To
ur~ .~durt
D!JY Ore
5977 Old T1nllqu~na Road
Jacksollville Fl, 32219
(904) 779-1777
Applicant Initial
(I',alce and EmpoweflTlent
(stl'lnd'arc!1.B5,cite 15/lG-C.A.)
As l'I provider, I reccgnll:e
IndMdu~
~le
need fot IndMduBls to be encouraged to r""ake their own d...dsions. I view
I sel'VP. and their families as pl'lrtllf'!rs in meel1ng the perstln's service nf'!eds.
r am committed til creating
llpp~rtunitle"
for Individuals to make rnolces throughout the services I provll:!e.
The choice ml'lkl~g ~~lIlty of each imlMdualselYl:'11
the
pe~n,
by me will be revlewi!d at the time
crt rlrst mee~ng with
throughout the SUpport plan year, and annually thereafu!r during the Individual's support plan
meetlng. Training will be pl'Ovld\~d Ifl those 21f'B!l' that are Identff'led as a need.
The IndIVIdual Is encouraged to idenllfy his/her choic~ and ne...ds and til share them With me. Through
meetings with the pernon, and other IndiViduals they wish to inVite, priority outmmas are delEffillnad. An
impfement3lioo plan Is developed Within 30 daY' ~ beginning e new service am:! wltl1in 30 days
effective dale of saNlce authol1t3tion for ongoing servlm:;.
Thl~
crt the
plM directly relates with th" sl<l!l'd
olilrome from the suprurt plan ror the seNtee I provide. Tho': Irnpl"mentaHon plan will Indude specific plans
of how to a.l5l5t the person In llYleting their st3ted outr:omes as w...ll as those that ensure health and
slIfety. The implemelltation plan may be c11anged throughout the support Plan year as personal outr:ome
are
met, the pel'Son'~
0( the
preference~
change,
0'
If different appl'lach should be. i,iSed to ensure
~chlevement
outcome.
Ali indiViduals ro::cel'JlnQ services ~re elped:ed to fUlly participate in the development of the.1r ihdlvidualll>'rl
plan. Th" per50n d"termllleS the services ar,d how they arc ptovlded as well as the outmmes 10 be
addtt'5sed. n an Individual has iI hard time understanding and/of rnaklnQ choices or In understanding the
c01',seQuences of
m~\:ing
choices, I wW help them in trying to find an involved caregiver/friend to help wllh
this pn>t:ess.
To furtller encilUfagli'! ellolee mi:l'l.lng, individuals recelvlng se.TVI~!i participate In community training
actlvitle> and are given chances to choose whele they W<)uld like to go, what they would to purchase.
r fully Inform IndlYldullls that they haw a rlght to due pror::ess should they be UIlh"ppy wllh th" ~rvlces
b,,'ng provideD amI hav" the rig!lt to choO'le a new provider shOUld we not be able to work out any
prnblems between us. A person's abijity to ma""" dlol= as de~Clibed in
th!~
policy INiIi be reviewed wlth
the perilOl"I each year.
My right'; relared lD choice making hilVe been fully e:.:plllined lD me..
Tndlvldual/ Guardl8n
PtOYlde'
AddTo LlIl! Adult Day care
5877 Old TImllQuana Road
Jacksonville FI, J2219
(9O'l) 779-1777
Applicant InItJaI'~~~~~
Every person receiving services, caregiver, parent and/or guardian has a
right to express a grievance to the center staff. The staff member shall
attempt to address the problem.
If the grievance is not addressed to the satisfaction of the person receiving
services/caregiver/parent/guardian, he/she may take the complaint to the
Program Director.
A grievance form should be filed at this time.
The Program Director shall have 7 days to respond to the filed grievance.
If the grievance Is still not resolved to the satisfaction of the person
receiving servic:es/careglver/parent/guardian, he/she may make an
appointment to meet with the Program Director.
The Director shall have 20 days to resolve tile complaint.
If the grievar1ce Is not addressed to the satisfaction of the person receiving
services/careg;ver/parent/guardian he/she shall then request an
appointment with Support COordinator/Case Manager and/or Liaison,
Director; owner/operator. The owner/operator shall have 10 days to
resolve this complaint cmd the decision shall be flnaL
This form will be reviewed annually
Caregiver signature
Date
Director signature
Date
Add To Life AdUlt D~y CIlre
sen Old Trmuquana Road
Jact!!;[)l'wllle A, 32219
(904) 779-1177
AppllcantInitial
_