Please enable JavaScript in your browser to complete this form.If you have any questions, please send an email to: info@HCBSprovider.comSelect Month/Year: *FEBRUARY 2024MARCH 2024APRIL 2024MAY 2024JUNE 2024JULY 2024AUGUST 2024SEPTEMBER 2024Please 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: *FirstLastStaff Email *Name of CLIENT: (Make sure client name and staff name are not the same) *FirstLastLOCATION(s) *Client HomeCommunityStaff HomeOtherLocation: (Other)MPI:#1. Did your client attend any health/medical appointment during the last 30 days? *YESNO(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. *(H2023 Job Finding & Development)2. Did you use this information to identify types of jobs in the community that match the individual’s interests, strengths, and skills? If so, please explain? *(H2023 Job Finding & Development)3. Did you help you client to develop a resume or add to an existing one? Please explain. (copy) *(H2023 Job Finding & Development)4. Did you assist your client in using job seeking websites, (Indeed, monster etc.) and/or employer websites to search for a job? Please list as applicable. *(H2023 Job Finding & Development)5. Did you assist your client in preparing for an interview? What methods did you use? Modeling? Role play? Video assistance or another. Please explain. *(H2023 Job Finding & Development)6. Did your client interview for a job? Did you attend the interview and what assistance did you provide? *(H2023 Job Finding & Development)7. Have you experienced problems with client and their commitment to finding a job? Please explain. *(H2023 Job Finding & Development)8. Was your client successful in securing a job? If so, will be supporting them, did you request change in services from Job Finding to Job Coaching and Support? If not, please explain. *(H2023 Job Finding & Development) 1. Did you provide on-the-job training to the client regarding new or existing tasks? Please explain. *(W9794 Job Coaching & Support)2. Did you communicate regularly with management regarding client performance? If so, what is discussed? *(W9794 Job Coaching & Support)3. Is your support necessary for individuals to maintain acceptable job performance and work habits? Please explain. *(W9794 Job Coaching & Support)4. Do you have a plan in place to fade supports over time? Please explain. *(W9794 Job Coaching & Support)5. Did you participate in team meetings? If so, please explain how you supported your client. *(W9794 Job Coaching & Support)6. Did you participate in any performance evaluation? How did you assist your client and what was the outcome. Please explain. *(W9794 Job Coaching & Support)7. Please describe any difficulties your client has encountered this month and how you may have assisted them. *(W9794 Job Coaching & Support)8. Please provide any additional information you may have or any input regarding your role as a Job Coach. *(W9794 Job Coaching & Support)IN-HOME & COMMUNITY SUPPORT: Activities of Daily Living: personal grooming and hygiene, dressing, making meals, maintaining a clean environment, laundry. Healthy Lifestyle: nutritious meal planning, regular exercise, working on prescribed therapies and exercises; medical care; mental health care. Financial Management: managing personal resources, general banking and balancing accounts, record keeping. Communication/Social Skills. Community Life Activities: accessing the community and developing personal interests. Within the last 30 days, which skills did you and your client work on? How did you help? *(In-Home & Community Support - Code:7060, 7061) Are you able to tell if your client wants to work on obtaining other skills? If so, which skills? Do you have ideas of goals that may benefit your client? *(In-Home & Community Support - Code:7060, 7061) Within the last 30 days, which skills did your client maintain? Which skills have been improved? Which skills need to be improved? *(In-Home & Community Support - Code:7060, 7061) Any other comments that you want to share? *(In-Home & Community Support - Code:7060, 7061) Signature of Authorization * Clear Signature Please provide your signature above.If you experience difficulty submitting your monthly report, please email Reports@HCBSprovider.com immediately and explain what happened so that we can assist you.SUBMIT MONTHLY REPORT