Dhmh4658c 2026

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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 of tasks related to participant care, including personal hygiene, mobility, medication management, and household activities. The assessment includes a checklist for observations, comments on caregiver performance, and protocols for reporting health and safety concerns.

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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 identifying the assessment.
In the 'Activities Observed' section, assess each task by marking 'yes' or 'no' based on your observations during the visit. Ensure you evaluate all caregivers if multiple are present.
For each task, provide detailed comments regarding any concerns or findings in the comment section next to each activity. This will help in documenting specific caregiver performance.
Complete the nurse and caregiver signature sections at the bottom of the form, along with their respective dates, to validate the assessment.

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