Dhmh4658c 2025

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The document outlines the Caregiver Assessment process for Medicaid Home and Community-Based Services Waiver Programs. It provides a structured format for nurse monitors to evaluate caregivers' performance in various tasks related to participant care, including personal hygiene, mobility, medication management, and household activities. The assessment requires detailed observations and comments on each task, with protocols for reporting health concerns or abuse.

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Click ‘Get Form’ to open the dhmh4658c in the editor.
Begin by entering the participant's name and service date at the top of the form. This information is crucial for accurate record-keeping.
In the 'Activities Observed' section, assess each task performed by the caregiver. For each task, mark 'yes' or 'no' based on your observations.
Use the comment sections next to each task to provide detailed feedback on any concerns or findings related to caregiver performance.
If necessary, attach additional pages for more comments or observations. Ensure all relevant details are documented.
Complete the form by having both the nurse and caregiver sign and date it at the bottom. This confirms that all assessments have been made accurately.

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