Bedingfield Assessment Report, blank

Developmental Services Waiver: HCBS Medicaid Provider No. 68 41783 96ABC Vendor ID No. F 593 754 678001

Family and Supported Living Waiver: HCBS Medicaid Provider No. 68 41783 98ABC Vendor ID No. F 593 754 687001

HOME MODIFICATION ASSESSMENT REPORT

DATE: December 26, 2005

Client Name D.O.B. Medicaid No. Soc. Sec. No.

Phone No. Cell/Pager No.

Address of Client Apt. No. City State Zip

FL

Address of Property Assessed Apt. No. City State Zip

FL

Parent/Guardian Name Phone No. Cell/Pager No.

Address (If other than Client’s) Apt. No. City State Zip

FL

Corporate/Fictitious Provider Name Phone No. Fax No.

Support Coordinator Cell No. Pager No.

Physical Address Apt./Suite City State Zip

FL

Mailing Address # City State Zip

FL

Provider No. E-mail Address

Billing Code Description Authorization Date

S5165U6SC Environmental Accessibility Assessment 12-22-05

Adaptive Home Modifications Consulting1951 72nd Avenue N.E.

Saint Petersburg, Florida 33702

Adaptive Home Modifications Consulting

Client:

Assessment Report Date: December 26, 2005

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CLIENT INFORMATION

Residence

Single Family HomeCondo Apartment

Owned Rented

x

Conditions Influencing Modifications:

The Bathroom is very small and the landlord does not want any removal or alteration,including holes, to the tile in the Bathroom.

Primary Diagnosis of Client:

Cerebral Palsy

Secondary Conditions:

Moderate impairments of fine motor skills and speech.

Client Capabilities / Limitations:

The Client uses a manual wheelchair. He does rely on the services of a caregiver forassistance with mobility, toileting, dressing, bathing, personal hygiene and grooming,meal preparation, transportation, laundry, cleaning, personal affairs, including groceryshopping and financial matters.


Client:


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DISCLAIMER

Walton D. Dutcher, Jr. d/b/a Adaptive Home Modification Consulting (Consultant) isnot licensed as any type of contractor with the Construction Industry Licensing Board,or as an architect with the Board of Architecture and Interior Design, or as anengineer with the Florida Board of Professional Engineers, all of which are under theDepartment of Business and Professional Regulation of the State of Florida, or anyother profession upon which reliance may be placed relative to expertise in thematters which may be involved in the design and specifications of renovation,remodeling or construction of the home addressed in this Report. Any design(s) orspecification that may accompany this Report are offered solely for the purposes ofplanning. Any such work that may be required for construction, and fields relatedthereto, which must comply with the Florida Building Code (Code) and specialtyVolumes thereunder, must be reviewed by a licensed architect, engineer, or otherprofessional familiar with the Code and with the authority to provide constructiondrawings that are compliant with the Code. This Disclaimer extends to the installationof any items recommended, specified or included in this Report that are a part of therenovation, remodeling or construction of housing. Consultant does not knowinglyhave any direct or indirect interest in any company that manufactures any of theproducts which may be suggested in this Report.

FINDINGS

1. There is a step up at the front entrance (4") and the rear entrance (2").

2. None of the doors have lever handles.

3. The fan/lights in the Living area and Front Bedroom, where the Client plans onsleeping, are operated by pull switches.

4. The Kitchen cabinet drawers and doors do not have handles and there are nopullout shelves in the lower cabinet.

5. There is one drawer to the left of the range which is not properly functioning

6. The side of the Kitchen sink base cabinet is missing and there was someattempt to provide one to support a half-shelf in the base cabinet to the right ofthe sink base cabinet.

7. The side of the Kitchen sink base cabinet is missing and there was someattempt to provide one to support a half-shelf in the base cabinet to the right ofthe sink base cabinet.


Client:


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8. The refrigerator door gasket is damaged and does not function properly whichcould result in improper temperatures for food stored.

9. The Bathroom door is only 2'-4" wide and swings inward.

10. The Hallway is only 3'-0" wide.

11. The Bathroom sink is mounted in a base cabinet making inaccessible.

12. The toilet is not ADAAG compliant by reason of its lower height.

13. The valve control for the tub/shower is on the same wall as the toilet and sink. Any typical slide transfer from the commode would result in placing the Client’sback facing the control and any hand-held shower head mounting that would beadded for bathing.

14. There is no gate at the east end of the front porch to provide access to theparking area.

Client’s Specific Request(s):

1. Install kickplates on both sides of the exterior doors.

2. Install slip resistant ceramic tile in Client’s Bedroom.

3. Provide a NuProdux multiCHAIR Model 4000

4. Install a Bidematic Hot and Cold Model

5. An ADA compliant toilet is not needed.

Scope of Work:

Based on the findings presented and the Client’s request, we have approached thedesign concept to provide the following goals:

1. Provide temporary landings and ramps at both exits.

2. Develop transfer devices for use in the Bathroom. These must be constructed insuch a fashion so as to be easily removable and without costly damage to thewalls or fixtures. The landlord emphatically instructed that there shall be nodamage to the wall or floor tile.

3. Install other items to achieve a higher level of accessibility and functionality.

4. Minimize any damage to the walls, floors, or fixtures and there mitigate anyexpense that may be incurred when the premises are vacated.


Client:


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Funding Limitations

$ 20,000

RECOMMENDATIONS

1. Construct and install temporary ramps and landings at each entrance asillustrated in the included designs. These items shall be constructed of PTlumber and marine grade plywood. The landings and ramps shall be coated withDuraback nonslip coating for outdoor applications or equivalent. The coveragerate is 65 sq. ft. per gallon. Total area for both installations is 100 sq. ft.

JUSTIFICATION: The premises is a rental apartment with limitations as to anypermanent installation.

2. Construct and install the transfer devices for the Bathroom as illustrated in theincluded designs.

JUSTIFICATION: The premises is a rental apartment with limitations as to anypermanent installation. The unique design solution for these transfer devices wasachieved through a collaboration of the company and the Client’s father. It wasimperative that the units must be easily removable and that no damage was to becaused to the wall or floor tile.

3. Change the swing of the Bathroom door to open into the Hallway as shown inthe included design. Install clear swing hinges to allow as much doorwayclearance as possible.

JUSTIFICATION: The Bathroom door is only 2'-4" wide which offers a clearance ofonly 2'-2" (26 in.). Changing the swing allows the door to be closed when the Clientis using the Bathroom. The additional clearance mitigates possible injury to theClient’s hands as well as provides better maneuvering.

4. Install handles on the kitchen cabinets.


Client:


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RECOMMENDATIONS

JUSTIFICATION: Handles are required since the Client has impairment of his finemotor skills.

5. Install lever handles in all doors.

JUSTIFICATION: Lever Handles are required since the Client has impairment of hisfine motor skills.

6. Install clear acrylic kickplates affixed with brass screws on both sides of theexterior doors.

JUSTIFICATION: The Client pushes the doors with his feet to open or close thedoors. The kickplates mitigate any damage to the doors.

7. The fan/lights in the Living area and Front Bedroom, where the Client plans onsleeping, are operated by pull switches. Request the landlord to wire theexisting wall switches that were originally used for a light to be rewired andswitches installed to operate the fans and the lights. If the landlord denies thisrequest, they will be required for the Client to operate them.

JUSTIFICATION: As stated, the fan/lights are operated by pull switches that hangfrom the fixture which renders them inoperable by the Client. The wall switches arerequired by the Client so as to make the operation accessible for the Client.

8. Provide and install slip resistant ceramic tile that is deemed to comply withADAAG requirements by the manufacturer in the Client’s Bedroom.

JUSTIFICATION: The Client prefers tile over glue down 28 oz. or better BCF Nyloncommercial carpet. The Client does use a manual wheelchair and tile offers asurface that is easier to maneuver than carpet. Additionally, the Client has concernover spillage of urine and the ability to easily clean it up.


Client:


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RECOMMENDATIONS

9. Provide and install a hand-held shower head and tub spout with diverter valveand outlet for hand-held shower head. Alsons provides a combination model asshown in the Sampling of Available Products section. If the Client prefers adifferent hand-held shower other than the Alsons, the tub spout with divertervalve and hand-held outlet and hand-held shower head can be purchasedseparately.

JUSTIFICATION: A hand-held spray is required by the Client to bathe. The divertervalve must be within Client’s reach.

10. Provide and install Bidematic Cold Water Model.

JUSTIFICATION: The Client does not have the ability to wipe himself. The Bidematicremoves the urine and fecal matter from the perineal area.

11. Provide a NuProdx multiCHAIR Model 4000 as specified in the Sampling ofAvailable Products section and requested by the Client including the optionalcommode pan for travel use.

JUSTIFICATION: The Client requires the ability to move toward and away from thewater control and hand-held spray. This product fulfills that requirement. The Clientalso travels from time to time and this product with it’s standard features plus thecommode pan offers the ability to have a means to accomplish toileting inunaccessible places.

12. Provide and install Sequoia model overhead lift structure manufactured byWaverley Glen or an equivalent that is acceptable to Client. The motor is notrequired since the Client will use a trapeze device.

JUSTIFICATION: The apartment is being rented by the Client and the installation ofa permanently mounted overhead track is not an option.


Client:


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RECOMMENDATIONS

13. Install shower track as specified in the Sampling of Available Products section inthe manner specified in the included designs.

JUSTIFICATION: The specified shower track allows the rotating arm to function thusproviding a means for the use of the bathtub. The existing shower rod would notallow the rotating arm to function.

CONSIDERATIONS DURING MODIFICATION PROCESS

Interruption of services

Electricity N/A Water N/A Sanitary X Heating / AC N/A

Interruption of functions

Ability to access each room X Ability to use appliances N/A

Ability to maneuver in any room X Ability to use AT equipment N/A

Environmental considerations

Removal of hazards; asbestos, lead based paint, etc. N/A

Dust control; a particular consideration when Client has breathing problems. N/A

Use of chemicals or installation of new fabrics; a particular consideration if Client haschemical sensitivities.

N/A

Need for continuous use of heating and air conditioning N/A

Other


Client:


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PICTURES OF APARTMENT


Client:


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Client:


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SAMPLING OF APPLICABLE AVAILABLE PRODUCTS

The following is a sampling of products that were discovered through internet researchand are offered as being possible solutions for a specific application referenced in anyof the recommendation(s) made herein above. Resources provided are for informationpurposes only. Walton D. Dutcher, Jr. d/b/a Adaptive Home Modification Consultingdoes not endorse or knowingly have any vested interest in any product presented. Selection of any and all products are left to the sole discretion of the Client or Client’sparent(s) or legal guardian.

Sequoia by Waverley Glenn

Lutron Skylark® Three Speed FanControl, Pushbutton Light Switch

Aubuchon Item # 683333

http://www.hardwarestore.com/

Box Track Hanger 450 Lb. (x 2)



Client:


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Box Trolley Track 450 Lb. 6' long


PEMKO RampProfile No. 259AA = Mill Finish Aluminum

Amerock Dulcet Pull 5-1/32 in. (PolishedChrome)

DURABACK™ Outdoor Textured Brown

DURABAK™ is a tough, single-pack, totallyflexible, slip-resistant, water-resistant protectivepolyurethane coating with self-contained recycledrubber granules for an attractive tough-texturedfinish. When exposed to atmospheric moisture,DURABAK™ undergoes a chemical curingprocess which changes it from a liquid to a toughpolyurethane membrane. It has excellent abrasionand chemical resistance.

Northern Tool, Twisted ClevisPin Size 3/4in. x 1/2in.Item No. 318016

Black powder-coated finish. Pins are yellow zincdichromate plated.

www.northerntool.com


Client:


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Alsons Add-A-Shower Deluxe all Brass5'' Diverter Tub Spout

Model 1000L

Alsons Push Button “Pause Control”Hand-held Shower and Tub Spout w/Diverter

Model 410SPB

Brookstone Handheld Shower

SKU 234716

Bidematic®

http://www.1800wheelchair.com/


Client:


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NuProdx MultiChair 4000

Standard features:

• Push handle back• Fold-back locking arms• Adjustable swing-away footrests• Total-lock brakes on 5" casters• Adjustable seat height• Seamless padded Ensolite™ back and 1½”

square seat cushion

Optional feature requested:

• Commode Pan

Schlage Elan Door Leverset

Full Mortise Swing Clear Hinge

Model 633 (US4) for 1d” doorSKU #219343

www.hardwaresource.com877-944-6437


Client:


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Keyless Interconnected Deadbolt LockItem 1794 $298

• Custom set codes from 4 to 6 digits• Stores up to 8 codes• Easy to program• Incorrect Code Warning Alarm - if incorrect

code is entered three times• Alarm is activated and flashing red light

indicates entry has been attempted with anincorrect code

• Long lasting battery life; 30,000 entries oroneto two years of stand-by life

• Easy to operate; just lift the lever handle to lockand press down to unlock

http://www.nokey.com/853111/keyelindeadl.html


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EXISTING APARTMENT


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PROPOSED BATHROOM MODIFICATIONS


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TRANSFER DEVICE STRUCTURE


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Documents

Bedingfield Assessment Report, blank