Fla. Admin. Code Ann. R. 58A-1.010 - Program Forms

The following forms shall be used for programs regulated by this chapter. These forms are hereby incorporated by reference, and are available from the Department of Elder Affairs, 4040 Esplanade Avenue, Tallahassee, Florida 32399-7000.

(1) For purposes of assessment:

(a) DOEA Form 701A, Department of Elder Affairs Condensed Assessment, April 2013.

(b) DOEA Form 701B, Department of Elder Affairs Comprehensive Assessment, April 2013.

(c) DOEA Form 701C, Department of Elder Affairs Congregate Meals Assessment, April 2013.

(d) DOEA Form 701S, Department of Elder Affairs Screening Form, April 2013.

(e) DOEA Form 701T, Department of Elder Affairs Non-Community Placement, April 2013.

(2) For purposes of documenting planned services of care, a case management agency must develop a care plan format that includes at least the following information:

(a) Client name and identification number;

(b) Case management agency name and identification number;

(c) Client's assessed service needs;

(d) Types, units, frequency and duration of planned DOEA and non-DOEA services;

(e) The provider and associated costs of each planned service;

(f) Initiation, revision and termination dates of the care plan;

(g) An acknowledgement that the client or client's representative is involved in the development of the care plan; and,

(h) Client or representative and case manager signatures and date of signatures.

Notes

Fla. Admin. Code Ann. R. 58A-1.010

Rulemaking Authority 430.08 FS. Law Implemented 429.69, 430.101, 430.04 FS.

New 8-20-00, Amended 8-6-01, 9-24-08, 7-1-13.

New 8-20-00, Amended 8-6-01, 9-24-08, 7-1-13.