Definition of Services - clayccoa.comclayccoa.com/images/master admit pkt gcs print 2017.pdfAdult Day Health Care Program 604 Walnut Street ... individuals at risk for nursing home

Adult Day Health Care Program 604 Walnut Street Green Cove Springs, FL 32043

Definition of Services

Adult Day HealthCare (ADHC) is an alternative for elderly or individuals at risk for nursing home placement with cognitive impairments such as Alzheimer’s and other forms of Dementia, Traumatic Brain Injury and physical impairments such as Parkinson’s or partial paralysis.

ADHC provides a therapeutic, protective, structured and supportive environment up to five days a week - Monday- Friday 8 am – 4 pm. Participants are offered social interaction, professional and peer support, exercise, mental stimulation, health monitoring, assistance with eating, walking, toileting, and medication administration as well as structured activities such as music, art, and reminiscence therapy.

Caregivers benefit as the ADHC program provides respite or a break from caregiving responsibilities so that the caregiver may meet other family obligations, work or enjoy some much needed rest and relaxation.

Breakfast is served between 8 - 9 am along with lunch that meets 1/3 minimum of recommended dietary allowance requirements and an afternoon snack. Transportation may be provided to and from the ADHC facility dependent on location in the county.


Eligibility/Discharge Requirements

Eligibility Requirements for ADHC attendance:

The following are examples but are not limited to: • Ability to participate in group activities as determine by individual’s limitations from

disease process, age or physical disability. • Eat meals with some assistance such as cutting up food, verbal encouragement. • Toilet with some assistance, able to walk or ride in wheelchair to toilet, transfer if

needed with assistance, sit on the toilet without difficulty, follow simple commands for standing and washing hands with verbal encouragement and assistance if needed.

• Able to follow simple instructions regarding sitting in recliner chairs, standing or transferring into assistive device to go to lunch or bathroom.

Discharge from the Program under the following circumstances:

The following are examples but are not limited to: • Aggressive behavior to staff or other clients such as biting, hitting,

spitting, throwing items, pulling hair. • Progression of disease process or physical limitations requiring 1-1 care for eating,

toileting, transferring to assistive devices as client is unable to assist with any of the above items.

• Any medical condition requiring monitoring beyond simple administration of oral medication or checking blood pressure or blood glucose levels.

• Continuous disruption of activities due to behavioral issues such as repeated attempts to undress, inappropriate touching of staff or other clients, inability to stay seated when appropriate, even with verbal encouragement.

____________________________ _____________ Caregiver’s Signature Date


Evaluation Period

There will be a 30 day evaluation period after client begins

attending the Adult Day Health Care Facility to assess suitability for continued attendance. Please note that changes at a later time may

also result in being discharged from the program. Clients will be assessed on a variety of factors including participation to level of ability,

the individual’s behavior in a group setting and behavioral issues such as compliance with simple instructions.

Behavioral issues which will result in discharge from the Program,

including but not limited to: combative or disruptive behavior, aggression towards other clients or staff, safety issues such as fall risks

not managed by medication or assistive devices or a worsening of medical/mental condition resulting in an increase in one-to-one care.

_____________________________ Client Name Date _____________________________ ______________________ Caregiver Name Date


Agreement Contract for Admission

COUNCIL ON AGING OF CLAY COUNTY and _____________________________ Client Name Hereby agree to the following terms regarding the responsibilities pertaining to participation in the Council on Aging of Clay County Adult Day Health Care Program. The Council on Aging of Clay County agrees to:

1. Provide a safe, supervised environment designed to offer the client quality care in the areas of health, nutrition, therapeutic programs, and provide the client and his/her family with a holistic approach to the treatment of his/her disorder in accordance with the provisions mandated by the state of Florida for Adult Day Health Care Centers.

2. Administer medication to the client in accordance with the following criteria:

a. Medication prescribed for administration during the Day Care hours of service must be properly labeled with name of medication, pharmacy number, prescribing physician, dosage and times of administration.

b. Medication to be administered will remain on the premises for duration of client’s participation in the program.

c. Medication renewals will be the responsibility of the client or responsible party. d. Client acceptance of medication; if the client refuses medication, the responsible

party will be notified.

3. Arrange for the client’s transfer to an acute-care facility (of the client’s choice when possible) in the case of an emergency and notify the client’s family or responsible party as soon as possible regarding said transfer.

4. Give the client (or responsible party) at least 15 days’ notice prior to discharging the

client should his/her behavior or physical limitations be deemed hazardous to his/her safety, safety of the staff, or safety of other participants after reasonable alternatives have failed, and emergency safety situations may require more immediate action for discharge.

5. Provide breakfast and a hot noon meal that meets 1/3 of the recommended daily

diet and assist/encourage the client in his/her nutrition.

Contract Agreement | Page 2



The Client or Responsible Party Agrees to: 1. Complete or provide all necessary client-related forms prior to admission. 2. Notify the Council on Aging of Clay County at least seven days prior to the client’s

intended date of discontinuance in the program.

3. Provide changes of labeled clothing and undergarments to be stored at the center should it be deemed necessary for the client’s hygiene (any personal items left will be listed on the clothing list). If the client’s utilize incontinence diapers, an adequate supply should be provided each day.

4. Absolve the Council on Aging of Clay County of liability for any loss or damage to the

client’s personal property or valuables due to fire, theft, or other mishaps.

5. Absolve Council on Aging of Clay County officials, employees, and/or any other person, firm, or corporation charged or chargeable with the 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 act or occurrence, and particularly on account of personal injury sustained by the said participant, while the participant is on the premises of the Council on Aging of Clay County or vehicle arranged by the Council on Aging of Clay County

6. Authorize the Council on Aging of Clay County to transport the client off the

premises for planned outings, neighborhood walks, or community events, etc. as part of the therapeutic programming.

7. Accept the decision of the Council on Aging of Clay County regarding discharge of

the client due to concerns for his/her safety or that of others.

8. Authorize the Council on Aging of Clay County to: a. Use pictures or identifying information regarding the client for publicity purposes

or use in an emergency. b. Release information regarding the client to authorized agencies if deemed legally

or medically necessary. c. Transport clients to the nearest emergency facility in the event of an acute

illness if the family or responsible persons cannot be reached.

Contract Agreement | Page 3



9. Client or responsible party agrees to accept financial responsibility for emergency medical services required and to accept financial responsibility for transportation of the client to the nearest emergency facility in the event of an acute illness if family or responsible persons cannot be reached. a. To pay the fee of $12.00 per hour for private pay for the client. The invoice for

hours served will be billed at the end of each service month and is due upon receipt.

b. Allow Council on Aging of Clay County to submit third party billing monthly for services rendered if necessary.

c. Adult Day Health Care hours are from 8:00 A.M. until 4:00 P.M. A late fee of $6.50 will be charged for each 15 minutes past 4:30 P.M. if a family member or responsible party is picking up the client. Daycare clients go home at 4:00 P.M. and it is the caregiver’s responsibility to be home at the time of the van’s arrival at the home. Since the driver deals with four to twelve persons on the delivery schedule, the driver cannot wait for someone to arrive at the home.

10. Client will attend ADHC _____________days per week ______________. I have read and understand the above and agree to abide by it. ______________________________________________ Date________________ Caregiver Name Client’s Name

Contract Agreement | Page 4 Updated: January 2, 2016


Participant (Client)/Caregiver

Policies and Procedures

1. Participant and their caregivers are informed of provisions for services identified as evidenced by written acknowledgement from the responsible party prior to or at the time of admission, and given a statement or summary statement of the center’s policies and procedures, and an explanation of the participants’ responsibilities to meet these requirements. Participants and their caregivers are given the opportunity to participate in the planning of their care. 2. Participants and their caregivers are informed, and are given a written statement prior to or at the time of admission of services available at the center and for any related charges including those for services not provided free or not covered by sources of third party payments or not covered by the facility’s basic per diem rate (hourly fee). 3. Participants and their caregivers are promptly informed of any substantive changes in policies, procedures, services and rates. 4. Participants and their caregivers are informed during the intake process, in writing, of the center’s Emergency Management Plan. 5. Participants and their caregivers are informed during the intake process and with the application process, of the local emergency management agency registry for disabled persons who need assistance during evacuations or when in shelters because of physical or mental handicaps and the paperwork provided to register such persons with the local emergency management agency.

Clay County’s Emergency Shelter is at the Thrasher Horne Center located at: 283 College Dr., Orange Park, FL 32065.


Participant (Client)/Caregiver Policies and Procedures

6. All participants may expect no abuse, neglect, exploitation or use of restraints. Only medications prescribed by a licensed physician may be given while at the facility. Over-the-counter medications must have a written prescription in order to be given – caregivers may not simply request that such medication be administered. 7. Participants are assured privacy in the treatment of their personal and medical records. 8. Participants are treated with consideration, respect, and full recognition of their dignity, individuality, and right to privacy. 9. Participants or their caregivers are not required to perform services for the center. 10. Participants are assured of the opportunity to exercise civil and religious liberties including the right to independent personal decisions within the limitations of their mental capacity and safety concerns. No religious beliefs or practices or any attendance at religious services will be imposed upon any participant. 11. Participants are not the discriminated against with respect to participation in all offered activities, which includes social and meals, because of age, race, religion, sex or nationality as defined in Title VI of the Civil Rights Act of 1964, or Americans with Disabilities Act of 1990. 12. The participants are informed of the right to report abusive, neglectful or exploitative practices. The number to report such concerns is 1-800-962-2873 (1-800-96-ABUSE) and is posted on the program bulletin board where participants and caregivers can clearly see it.


Participant (Client)/Caregiver Policies and Procedures

Acknowledgement

I hereby acknowledge receipt of a copy of this statement of the Participant/Caregiver Care Policies and

Procedures, and have been fully informed of such rights.

Participant (Client) Name Caregiver name Relationship Date


CLIENT DATA SHEET

CLIENT NAME: Admission Date: ADDRESS: PHONE: ZIP CODE: DOB: Days of Attendance: SSN#: MCaid#: MEDICARE #: DNR/Advance Directives or Living Will: Contact EMAIL of Caregiver/Family: PRIMARY CAREGIVER: HM PHONE: CELL #: WK #: Address if different than client: #2 Emergency Contact: Phone: Address if different: Physician Name: Phone: Preferred Hospital: Diagnosis: Allergies/Diet (Regular, Cardiac, Diabetic): Please check assistance needed: ____ toileting; ____ eating; _____ drinking; _____ fall risk; ____ wandering; ____ food pureed; ____ thickener added to fluid Special Services: Transportation/Medication Administration Short-Term Goals: To provide respite for family/socialization & safe environment for client Long-Term Goals: To maintain bio/psycho/social integrity & independence as long as possible


Social Assessment

Welcome to the Adult Day Health Care at the Clay County Council on Aging, Inc. Senior Center. We wish to make your family member’s visit to our Day Care a pleasant experience. The answers to the following questions regarding your

loved one will assist us in providing a positive and enjoyable day.

Name of Client: Name of Spouse (including deceased): Names of Children (if applicable): No. of Grandchildren (if applicable): Previous Occupation(s): Hobby(s): Special Talent (s): Reading Preferences: Describe current eating habits – good appetite, picky eater, etc.:-____________________________________________________ Does Client have Dentures: Upper _______ Lower __________ Do they wear them comfortably_________ Does Client have Specific food/drink they like:______________________________________________ Does the Client have: Eyeglasses? _____ Hearing Aid? _____ Wheel Chair? _____ Cane? _____ Walker_____

13 Adult Day Health Care Program 604 Walnut Street Green Cove Springs, FL 32043

Social Assessment

Page Two

Activities & Interests:

Information that will help the staff make the day EXTRAORDINARY for your family member:

Does Client Enjoy: No Yes Comments

Animals

Arts/Crafts

Cards

Magazines

Books

Board Games

Enjoy looking at Pictures

Music

Types of Music:

50s – 60s

Swing

Jazz

Country


Proper Completion of 3008 Form for Admission Into Adult Day Health Care Program

To be complete by your Primary Care Physician Only:

Name and DOB on both sides – very top

A. All Patient Info B. Sight and Hearing C. Decision Making Capacity D. Emergency contact E. Medical Condition - Primary Dx is primary Dx at this time: DISREGARD THE PHRASE

DISCHARGE ** - ALSO INCLUDE ICD-10 CODE WITH EACH DIAGNOSIS F. Infection Control Issue

**MUST SELECT NEGATIVE UNDER PPD – IF UNKNOWN MUST ADMINISTER A NEW PPD AND INDICATE READING - MAY NOT SELECT UNKNOWN – PT WILL NOT BE ADMITTED INTO PROGRAM WITH AN UNKNOWN SELECTION.

G. Patient Risk Alerts – indicate elopement (wandering), Falls, Difficulty Swallowing, Seizure if appropriate. We do not use restraints. Indicate allergies or NKDA as appropriate including Latex Allergies.

H. Advance Care Planning – Please attach any copies of indicated documentation - DNR I. May indicate N/A J. May indicate N/A K. Physician Contacts – Fill out at least Primary Care Name and Phone L. Time Sensitive Condition – N/A M. Pain Assessment – If relevant N. Following Reports – May attach Current History & Physical and/or Medication List O. Vital Signs – current from date of office visit P. Patient Health Status – Bladder/Bowel status to continence. – Foley info only if indwelling.

Please complete Immunization Status as appropriate Q. Nutrition/Hydration – Any Dietary Restrictions – ADA, Low Sa+, Diabetic, etc. and eating

assessment R. Not required unless currently receiving services S. Physical Function – Please indicate appropriate information for each of the 4 sections T. Not needed unless currently treating a pressure ulcer U. Mental Status/Cognitive Status – this is CURRENT status as witnessed by physician V. Treatment Device – Only indicate if appropriate – i.e. Oxygen or nebulizer treatments W. Personal Items – only items that are relevant Y. Last block should be marked – I certify the individual is in need of Medicaid Waiver Services in

lieu of nursing facility placement. Please sign all 4 blocks clearly and legibly or use office stamp – must be able to read signature

and have a contact phone number to be completed.




Medication Form

Date: DNR: Client Name: DOB: Allergies:

PLEASE LIST ALL MEDICATIONS:

1. 6. 2. 7. 3. 8. 4. 9. 5. 10. PLEASE SEND IN UPDATED INFORMATION IF MEDICATIONS ARE DISCONTINUED

OR NEW MEDICATIONS ARE ADDED.


Medication Policy

The following information explains our guidelines regarding medication administration at our facility:

All medications must be in labeled prescription bottles with a current date.

Medications will be kept at our facility. They may not be transported back and forth on the bus.

We will inform you when the supply is getting low so that you may come in with additional medication.

If your loved one requires over the counter medication, i.e. cough syrup, Tylenol, you must have a written prescription from a physician with complete

instructions of how the medication is to be administered.

***NOTE – MEDICATIONS WILL BE DESTROYED AFTER 15 DAYS FROM DISCHARGE IF NOT PICKED UP BY

FAMILY.

Please keep us informed of all changes to your loved ones medications so that our

records are up-to-date. Your assistance in this matter is most appreciated and will help us provide the best possible care for our cherished seniors.

Caregiver Name Date


MEDICATION ADMINISTRATION

INFORMED CONSENT

is aware that medication may be administered (Caregiver Name)

to my family member by an RN/LPN or an unlicensed but trained employee of the Clay County Council on Aging, Inc. Unlicensed personnel work under the direct Supervision of the RN/LPN and have successfully completed the 4 hour course “Medication Technician” per Department of Elder Affairs (DOEA) requirements. They are required to do yearly update training. These employees are full time employees of the Adult Day Health Program and may only assist with administering oral medication, breathing treatments or checking blood glucose. They do not administer injections or give medications via tubing. Client’s Name Caregiver Date


SICK POLICY Please be aware of the following sick policies. If your family member is sent home for any of the following symptoms, they must be absent for at least 24 hours from the time they go home and must be symptom free for 24 hours before returning.

We appreciate your cooperation in this matter. It is important that we try and prevent germs spreading to other clients and staff members.

Vomiting Your family member will be sent home after they throw up for the second time. They must be kept at home until they are vomit free for 24 hours. Diarrhea Your family member will be sent home if they have 2 or more liquid stool movements. They must be kept at home until they are diarrhea free for 24 hours. Fever This is very important. Any client with a fever of 101 or higher will be sent home. They must remain out of the facility until they are fever free for 24 hours. We will not administer Tylenol/Motrin to depress a fever. Fevers may be indicative of a more serious illness that can only be determined by the client’s physician. Pick Up Policies We require clients to be picked up within one hour of notifying the primary caregiver. If you cannot make the one hour timeframe; you will need to make alternative arrangements to pick up your family member as soon as possible. Signature (Caregiver) Date


Release Form for Emergency Treatment

I understand that in the event that emergency treatment is necessary and a family member or responsible party cannot be contacted, the participant(s) will be transported to the nearest hospital for emergency treatment.

I have read the above and agree to abide by it.

Client Name ____________________________ Caregiver Name Date


Release of Information Form (Client’s Name) authorize the Clay County Council on Aging, Inc. to obtain and/or release information regarding me in order to provide services to me. This may include the following:

A. Information from physicians, clinics or hospitals regarding my medical condition, as it may relate to may plan of services.

B. Information on other agencies from which I receive assistance so that

services may be coordinated. C. Information from authorized family or significant others needed to

assess my need for services. I understand that the above information may be necessary in order to provide services to me, and will only be used by the Clay County Council on Aging, Inc. to assist in delivering services to me. I understand that no information about me will be released to any other agency or person, unless such release is necessary to assist in securing needed services for me. I further understand that I will be notified of all information released about me. I also understand that if I feel I have been treated unfairly or denied services wrongly, I have the right to a fair hearing.

Client Name

_______________________________ ________________________ Caregiver Name Date


Authorization of Photo Release Form

Client Name: ________________________________

I, DO DO NOT

AUTHORIZE THE CLAY COUNTY COUNCIL ON AGING, INC. TO USE MY FAMILY MEMBER’S PHOTOGRAPH ON THE COUNCIL ON AGING

WEBSITE UNDER THE ADULT DAY CARE SECTION. I UNDERSTAND THIS WILL NOT BE USED IN ADVERTISEMENTS OR BROCHURES BUT RATHER

A SITE THAT FAMILY AND FRIENDS CAN GO AND SEE PICTURES. I UNDERSTAND I HAVE THE RIGHT TO REQUEST A PICTURE TO BE

REMOVED FROM THE SITE. Caregiver Name Date

I, DO DO NOT Authorize use of my family member’s photo in newspaper articles regarding the Clay County Council on Aging, Inc. Adult Day Health Care Program.


Change of Clothes Policy

Please bring in at least two changes of weather appropriate clothing that can be left here in a locker that will be provided. Include outer

clothes such as slacks, shirts as well as underwear, socks, etc.

Please label all items.

Clothing will be washed and replaced in their locker.

If you receive a bag with soiled clothing (pants or shirt) – usually on Friday’s or at end of day, please send a fresh replacement in with your

loved one the next time they come into the program.

**NOTE** - Clothing left over 2 weeks from discharge from our program will be considered abandoned.

Caregiver/Guardian Date


Check-Out Policy

In order to ensure the safety and well-being of all our clients, and to increase accountability of Adult Day Care staff, CCOA has instituted a firm requirement that all Day Care clients will be signed out of Day Care. The caregiver who signs out any client must also provide positive picture identification and specify their relationship to the client. Persons signing out a client must be listed on the Participant Data Sheet as authorized to pick client up (Emergency Contact). Exceptions may be granted only by the Day Care Administrator or Executive Director. Once a client is signed out by the responsible party, he or she assumes responsibility for that client. I have read and understand the above policy. Client Name Caregiver Signature Date


Change in Funding Form

I, Caregiver Name (Please Print) understand that the services offered by Clay County Council on Aging at

the time may be temporary, contingent upon the availability of services/funding.

I have read and understand the above policy. Client’s Name Caregiver Signature Date


VEHICLE PARKING PASS

PET PASS

If you will be providing transportation in your personal vehicle you will need a parking pass to access the Moosehaven Community Grounds. You will need to provide your Driver’s license, car registration and insurance. The pass is non-transferrable. It is assigned specifically to the car and person to whom it is registered. You will keep it on your dashboard so the guard at the gate and see it. To access the Moosehaven property you will enter through the gate marked North Gate located on Hwy 17 across from the Geico/Vita Hot Tub shopping Center. You will make the first left hand turn once pass the guard gate and our building is located on your left. **NOTE – THE MOOSEHAVEN COMMUNITY HAS MANY RESIDENTS WHO WALK AND RIDE THEIR BICYCLES. THE SPEED LIMIT OF 15 MPH, COMPLETE STOPS AT STOP SIGNS AND NO CELL PHONE USAGE WHILE DRIVING IS STRICTLY ENFORCED. IF YOU ARE FOUND TO BE IN VIOLATION OF ANY OF THESE RULES, YOUR PASS WILL BE REVOKED AND YOU MAY NOT DRIVE YOUR VEHICLE ONTO THE GROUNDS. In order to have a pet in your vehicle with you, you must provide a current shot record the first time you bring them to the Moosehaven property. You will be given a business size card that is a Pet Pass. This must be with you whenever you have your pet in your car. The pass will be valid until the date the shots need to be redone. It doesn’t matter if you do not intend to let your pet out of the car, you must have a Pet Pass to bring them onto the Moosehaven property. I have read the above rules and regulations and understand the guidelines for driving my personal vehicle and/or bringing any animals onto the Moosehaven Retirement Community grounds. Caregiver Name Date


Emergency Management Plan Acknowledgement

I have been informed of the Clay County Council on Aging, Inc. Adult Day Care Emergency Management Plan and that a copy is available upon request. I have been informed that in the event of an emergency, the plan will be implemented which will consist of evacuating the facility and if needed transferring staff and clients to the nearest available Clay County Council On Aging, Inc. Senior Center – either in Orange Park or Middleburg. Families will be notified of the evacuation and will either need to come get their loved one or transportation will be provided home as usual. Caregiver Date


Clay Transit

Adult Day Health Care Assessment Screening Form 2016

All Items must be completed and TYPED or PRINTED legibly or form will be denied

SECTION I – IDENTIFYING INFORMATION

Medicaid No.:______________________ S.S. #__________________Phone#:_____________________

Last Name: ____________________________________First Name:_____________________________

Home Street Address: ________________________________________________Apt.#:____________

Name of Sub-division or Apartment Complex: ______________________________________________

City: ______________________________ County: ______________________ Zip Code: ___________

Is this a: _____ House ____ Apartment _____ Nursing Facility _____ ALF ____ Boarding Home

Date of Birth: ____/____/______ Your Current Age: ________ _____ Male _____Female

Optional: ___ White ___ Black ___ Hispanic ___ Native American ___ Asian ___Other_________

SECTION II – DISABILITY

NEED TO KNOW FOR TRANSPORT: ___ Blind/Legally Blind ___ Wheelchair User ___ Difficulty Walking ___ Arthritis ___ Cerebral Palsy ___ Multiple Sclerosis ___ Neuromuscular Disease ___ Alzheimer’s disease ___ Stroke ___ Epilepsy ___ Mentally Challenged ___ Muscular Dystrophy ___ Respirator or Oxygen Dependent Do you have portable oxygen dispenser? ___Yes___No ___ Other: ___________________________________________________________________________ Please check or list any special needs, services of modes of transportation you will be using during transportation (Check all that apply) ___ Walker ___ Guide Dog ___ Scooter ___ Cane ___ Other ____________________________________________________________________________

SECTION III – SIGNATURE, PREPARER AND WITNESS I affirm that the information provided in this application for services is true and correct and understand that making false statements, having others make false statements, or making false statements on behalf of others constitutes welfare fraud and is considered a felony under the laws of the State of Florida. Medicaid and/or Transportation Disadvantaged Recipient’s Signature: _____________________________________________ Date: ______/_____/______ Preparer’s Signature: ___________________________________ Date: ______/_____/______

Do not Write In Space Results of Interview Office Use Only NEW ELIGIBILITY______REDETERMINATION______DATE REC’D____/___/___REVIEWED BY:_________________ APPROVED DATE_____/_____/_____DENIED DATE____/____/_____REASON FOR DENIAL______________________


SPECIAL NEEDS DISASTER PLANNING GUIDE

Pre-planning what you will do in the event of a disaster will allow you to be ready to respond quickly and safely. You should plan now to determine if you need to evacuate when a disaster strikes and, if so, what supplies, equipment or assistance you will need.

Depending upon the type of disaster and other conditions, evacuation from the area may be necessary. If you are asked to evacuate, your safest choices may include staying with relatives or friends out of the area, checking into a hotel/motel, or admission to a medical facility. The decision about where you should go should be made jointly with your physician, home health agency, care giver, family and yourself. To assist in making the best decision concerning your care, the following information is provided:

PUBLIC SHELTERS

Because we realize a portion of the population does not have the option of independent evacuation out of the area; the American Red Cross operates public shelters as a refuge of last resort. A shelter is generally located in a school and may be noisy, crowded and have few comforts. It is not a hospital, nursing home or hotel. Plan ahead to stay with relatives or friends out of the area if possible.

SPECIAL NEEDS SHELTER

In the event of a disaster, Clay County sponsors a Special Need shelter. This shelter is available for those individuals who require assistance with activities of daily living. You must bring all medical equipment, supplies and medications you use with you, and a caregiver must accompany you to the shelter. Shelter volunteers will be unfamiliar with your medical condition and treatment. If volunteers are unable to report to the shelter, there will be no hands-on care other than your caregiver and the shelter manager to assist should an emergency arise. Basic medical assistance and monitoring will be available. The Special Needs shelter is not equipped with advanced medical equipment or medications, or staffed to provide this type of care. If you need 24 hour skilled nursing care, dialysis 3 or more times a week or are electricity-dependent for life support you are not a good candidate for the Special Needs shelter.

HOSPITAL/NURSING HOME

If your physician has decided that you need to be cared for in a skilled nursing facility such as a Hospital or nursing home during an emergency, he/she needs to arrange pre-admittance prior to evacuation. You will need a letter from your doctor’s office stating you are to be taken to a specific (in-County) hospital or nursing home and that arrangements have been made with the facility for admittance. This letter must accompany you when you are evacuated.

Medicare will only pay for hospitalization claims that are deemed medically necessary and therefore arrangements must be made in advance.


Special Needs Evacuation Acknowledgement I have been informed of the local emergency management agency registry for persons needing special assistance such as power for oxygen tanks or Alzheimer’s during evacuations or when in shelters because of physical or mental handicaps and the assistance provided by center staff to register such persons with the local emergency management agency. After completing the Personal Survey form: YOU MUST MAIL IT TO : Clay County Emergency Management, ATTN: Special Needs Registry, P.O. Box 1366, Green Cove Springs, FL 32043. A nurse for the Emergency Management Agency will review the paperwork and you will receive notification if your loved one qualifies to go to the Special Needs Shelter in Clay County. Note: Registration must be done on a yearly basis so please note this on your calendar. This shelter is located at the Thrasher Horne Conference Center at St. John’s Community College at 283 College Drive, Orange Park, FL 32065. Client’s Name Caregiver’s Name Date








Documents

Definition of Services - clayccoa.comclayccoa.com/images/master admit pkt gcs print 2017.pdfAdult Day Health Care Program 604 Walnut Street ... individuals at risk for nursing home