Field Book Sheets/Forms

Field Book Sheets/Forms
(required for each consumer in the group homes)

Identification Page – includes the consumer’s personal information, diagnosis legal status, physicians, SSN, employment/Dayhab, emergency contact (s), nurse, Case Manager/Company Office contact name and phone number, Pharmacy, HCL Model (such as “SL”) and LON. This page should not be shared with unauthorized personnel. All information subject change. All provider/companies vary. (See "Information/Identification Page" post)

Letter of Guardianship – (Not for every consumer) This is typically put in place as legal method to protect individuals well being when they cannot protect themselves. The appointed person/entity that makes decisions on behalf of an incapacitated person. (This action simply means the consumer no longer makes decisions for themselves, the guardian does.)

Title III defines the laws. Each case varies. Contact office personnel for details in regards to guardianship.

Greg Abbott

IP-Implementation Plan – is used to indicate how services will be developed to support a consumer. Individual desired outcomes/purposes identified in the person-direct-plan (PDP).

Abuse Phone Numbers – required by the state of Texas/DADS/HHS . These numbers are used for filing in the field book and posting in the group home for consumer access. The numbers are used to report abuse, neglect and exploitation. THIS SHEET IS REQUIRED BY THE STATE OF TEXAS. If a Field Book does not have this sheet, please notify office personnel.

Field Book Cover/Insert Sheet – NOTE it states ‘CONFIDENTIAL’, includes the name of the consumer, consumer case#, location code of the group home, address in full, residential type. Again, if you are making more than one stop, please do not leave this book exposed in your car, meaning the names on the front of the book should not be visible.

Evacuation Plan – individualized, each consumer. The plan is constructed by the office through DADS. Please read and understand the individual’s need in the event a disaster occurs.

*The evacuation states – FCC/Staff should notify management after notifying 911.

Emergency Numbers, required – in the field book. Each home is customized as far as police/fire/hospital are concerned. Local authoritative agencies and or medical entities have to be within certain miles from the group home.

Hospital Locator

Law Enforcement Directory

Waiver Programs by State

Disaster Tab includes: Free Printable Group Home Fire Checklist

Fire, see the diagram below and click “fire” ink and the remainder links below

Fire Safety for Individuals with Disabilities
Terrorism
Winter Storms/Extreme Cold
Carbon Monoxide Danger
Thunder Storms/Lightening
Power Outage
Flu Symptoms/Treatment
Heat Wave
Earthquake
Flood Recovery
Drought
Chemical Emergency Preparedness
Poison

Local Texas Preparedness Sites

Fact Sheets

DADS Hurricane Information

Texas.gov Emergency Preparedness

Minimum TAC Requirements for Written Disaster Plans

Progress Notes/Delivery Log – Form 4122 - Must document services claims for the host home/companion care services component. Must be completed in a reasonable time frame if billable activities have been performed. It is very important to record accurate information-legal document. Though, this form is required some Pdovider/companies may use additional note sheets not including BMPs.

Community Awareness/Activity Sheet- This form is used to record outside activities including visiting friends/family, doctor’s appointment, MHMR appointments. Any event or activity outside of the group home. Exceptions are work, this is noted on the IP-implementation plan.

Objectives – This plan details interrelated (connected) activities supporting a responsive, consumer directed long-term services systems that the individual needs It require services to be targeted social/economic need in some instances. Note: date initiated, if it is weekly/monthly and what goals is.

MAR – medication administration record – legal document, this is used record medication administration daily. This form list all of the consumer’s medication and what they are used for. An assigned nurse must add new medications, indicate the start and end date and initial, unless otherwise instructed.

*ALL MEDICATION ON LABEL(S) MUST MATCH THE MAR SHEET.

Behavioral Plans (BMPs) – individualized (see their plan in their field book.) BMP’s is a tool to manage a behavior. This serves to teach and reinforce positive behaviors and are a way of documenting the success of the intervention. All are individualized.

Incident Reports – completed in event an incident occurs such as a fall, hospitalization, death and more as directed.

Critical Reporting Procedures, also ask Company/Provider what forms in the Consumer Field Book if applicable.

Photo (of the Consumer) - Some companies watermark or insert a photo of the individual for identification purposes. This could be for company new hire safety and precaution or residential review via state requirements. 

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