Monthly Report Forms – HCBS | Home and Community Based Services

If you have any questions, please send an email to: [email protected]

Select Month/Year: *

Please choose the correct month for the Report.

Please select a Monthly Report Form *

In-Home & Community Support (Code:7060,7061)
Companion (Code:1726)
Job Finding & Development (H2023)
Job Coaching & Support (W9794)
(CPS) Community Participation Support (Code:5996)

You will see blank templates for the services that require monthly reports: Companion (Code 1726), In Home & Community Supports (formerly known as Hab - Code 7060, 7061), Supported Employment (Code 2023, 9794), Community Participation Supports (Code 5996). Respite services do NOT require a monthly report. You will fill out a template for each client and each service. The administrative team will fill out some sections.

Name of STAFF: *

First

Last

Staff Email *

Name of CLIENT: (Make sure client name and staff name are not the same) *

First

Last

LOCATION(s) *

Client Home
Community
Staff Home
Other

Location: (Other)

MPI:

#1. Did your client attend any health/medical appointment during the last 30 days? *

(Dental, medical, physical therapy, psychiatry/mental health, occupational therapy, podiatry, nutritionist, etc.)

List the dates of appointments and follow up appointments. *

COMMUNITY PARTICIPATION SUPPORTS: Service is expected to result in the client developing and sustaining a range of valued social roles and relationships; building resources and experiences in the family and community; increasing independence; increasing potential for employment; transportation; experiencing meaningful community participation and inclusion.

#2. What activities do you and your client participate in during your time in the community? Which ones does he/she really enjoy? How often do you and your client do these activities per month? *

(Community Participation Support - Code:5996)

#3 Other than your regular activities what special community outing, activities, or events has you and your client participated in? *

(Community Participation Support - Code:5996)

#4. How does your time in the community create opportunities for your client to develop or maintain peer relationships? *

(Community Participation Support - Code:5996)

#5. What behavioral, physical and/or other challenges has your client displayed while out in the community this month? How often have these challenges happened? *

(Community Participation Support - Code:5996)

#6. What goals that are listed in your client’s ISP have been working on? Is he/she improving or maintaining their skills? If no goals are listed in the ISP what skills that you are assisting your client with? *

(Community Participation Support - Code:5996)

#7 How do you communicate with your client’s family/provider/group home about his/her activities in the community, his/her behaviors or health concerns? Do you have a good relationship with your client’s family/provider/group home in which you regularly interaction and notify each other of schedule changes? *

(Community Participation Support - Code:5996)

#8. What goals are you working on that are beneficial for employment? For example: Working independently, problem-solving, social interaction, or public transportation? *

(Community Participation Support - Code:5996)

#9. Any other comments that you want to share? *

(Community Participation Support - Code:5996)

COMPANION: Health and Safety needs are the only goals/outcomes for this service: supervision and monitoring of all activities, during awake and sleep hours, to ensure that the health and safety of the client is maintained.

Within the last 30 days, what did you do to ensure this client’s health and safety? (ie. healthy lifestyle activities, medication, transportation?) *

(Companion - Code:1726)

Within the last 30 days, did you encounter any problems related to this client’s health and safety needs? *

(Companion - Code:1726)

Any other comments that you want to share? *

(Companion - Code:1726)

SUPPORTED EMPLOYMENT: services consist of 3 components: career assessment, job finding or development, and job coaching/support. May include: direct intervention with employer, personal skills instruction, support to re-learn job tasks, training in use of transportation, practice with a fade plan, maintain appropriate work and interpersonal behaviors while on the job.
- Job Finding and Development - Code 2023: includes employer outreach and orientation, job searching, job development, resume preparation and interview assistance.
- Job Coaching and Support - Code 9794: includes training the client on job assignments, periodic follow-up, or ongoing support with client and their employer(s).

1. Did you spend time assessing your client's interests? This includes gathering and conducting a review of the individual’s interests, skills, and work or volunteer history. This may also include conducting situational assessments to assess the individual’s interest and aptitude in a particular type of job. Please explain. *