Rcfe assessment form

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Form 602: What California Residents Need to Know | Elmcroft

When it’s time to transition your loved one to assisted living, there are many factors to consider and steps to take to ensure it’s a smooth experience that will ultimately benefit their safety and quality of life. From having conversations about why it may be the right time to move, to choosing a community with the location and amenities your loved one desires, to helping them sell their current house and move all their belongings – you’re sure to be busy. But if your loved one has chosen an assisted living community in California, there is another important step you must take.  a person writing with a pen A physician’s report, known as Form 602, must be completed for all residents, or prospective residents, of residential care facilities for the elderly licensed by the California Department of Social Services.

What Is Form 602? 

Form 602 is a state-required physician’s report that lets assisted living communities know what care, medication and other considerations the potential resident needs. It includes a patient history, results from a physical and mental medical examination, and results of a tuberculosis skin test or chest X-ray. 

Which Elmcroft Communities Require This Form? 

Those who wish to live in Elmcroft’s Las Villas del Norte, Grossmont Gardens, Elmcroft of La Mesa, Las Villas de Carlsbad, Elmcroft of Point Loma or Mountview Senior Living communities will need to present the physician-completed Form 602.

Your Loved One’s Primary Care Physician Completes the Form

A primary care physician should complete Form 602 because they will typically have the most familiarity with your loved one’s medical history, health status, current medications and capabilities. It can take some time for physicians to return these forms. That’s why it is important to make an appointment for a Form 602 assessment as early in your decision-making process as possible. 

When you make an appointment with your loved one’s primary care physician, mention that the purpose is to complete the physician’s report, Form 602, as these appointments can take extra time.  

Where Can You Find Form 602? 

You can download Form 602 from the California Department of Social Services website here. Then, bring it with you to your loved one’s physician for completion. 

Make Sure the Form Is Filled Out Accurately and Submitted on Time 

Having a complete, accurate Form 602 in-hand is essential for settling your loved one in a new community that fits their care requirements, personal preferences and budgetary needs. Once the Form 602 assessment appointment is complete, check in with the office on the form’s progress, emphasizing that you’ll need it back in a timely manner in order to move forward. 

Some items on the form need special physician clarification, such as a clear differentiation between mild cognitive impairment versus dementia, the patient’s capacity for elements of personal care and medication management, and whether the senior can safely leave the community with or without assistance. The form is designed to enlighten the residential care community about the resident’s current medical conditions and capabilities so that it can provide the best possible care and supervision for your loved one.  

All boxes and items on the form need to be filled out. If the physician makes a mistake on the form, they must correct it on the form, sign next to the correction and attach a new page explaining the change. 

Sours: https://www.elmcroft.com/blog/2020/october/california-form-602/

Form LIC602A "Physician's Report for Residential Care Facilities for the Elderly (Rcfe)" - California

STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE)
I. FACILITY INFORMATION (To be completed by the licensee/designee)
4. LICENSEE’S NAME
6. FACILITY LICENSE NUMBER
II. RESIDENT/PATIENT INFORMATION (To be completed by the resident/resident's responsible person)
III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
(To be completed by resident/resident's legal representative)
I hereby authorize release of medical information in this report to the facility named above.
1. SIGNATURE OF RESIDENT AND/OR RESIDENT'S LEGAL REPRESENTATIVE
IV. PATIENT'S DIAGNOSIS (To be completed by the physician)
NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of a
residential care facility for the elderly licensed by the Department of Social Services. The license requires
the facility to provide primarily non-medical care and supervision to meet the needs of that person.
THESE FACILITIES DO NOT PROVIDE SKILLED NURSING CARE. The information that you provide
about this person is required by law to assist in determining whether the person is appropriate for care in
this non-medical facility. It is important that all questions be answered.
(Please attach separate pages if needed.)
6. TUBERCULOSIS (TB) TEST
b. Date TB Test Read c. Type of TB Test
d. Please Check if TB Test is:
e. Results: mm _____________
f. Action Taken (if positive): ________________________________
_________________________________________________________________________________
g. Chest X-ray Results: ________________________________________________________________
h. Please Check One of the Following:
No Evidence of TB Infection or Disease
LIC 602A (8/11) (CONFIDENTIAL)
STATE OF CALIFORNIA - HEALTH AND HUMAN SERVICES AGENCY
CALIFORNIA DEPARTMENT OF SOCIAL SERVICES
PHYSICIAN'S REPORT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY (RCFE)
I. FACILITY INFORMATION (To be completed by the licensee/designee)
4. LICENSEE’S NAME
6. FACILITY LICENSE NUMBER
II. RESIDENT/PATIENT INFORMATION (To be completed by the resident/resident's responsible person)
III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION
(To be completed by resident/resident's legal representative)
I hereby authorize release of medical information in this report to the facility named above.
1. SIGNATURE OF RESIDENT AND/OR RESIDENT'S LEGAL REPRESENTATIVE
IV. PATIENT'S DIAGNOSIS (To be completed by the physician)
NOTE TO PHYSICIAN: The person named above is either a resident or prospective resident of a
residential care facility for the elderly licensed by the Department of Social Services. The license requires
the facility to provide primarily non-medical care and supervision to meet the needs of that person.
THESE FACILITIES DO NOT PROVIDE SKILLED NURSING CARE. The information that you provide
about this person is required by law to assist in determining whether the person is appropriate for care in
this non-medical facility. It is important that all questions be answered.
(Please attach separate pages if needed.)
6. TUBERCULOSIS (TB) TEST
b. Date TB Test Read c. Type of TB Test
d. Please Check if TB Test is:
e. Results: mm _____________
f. Action Taken (if positive): ________________________________
_________________________________________________________________________________
g. Chest X-ray Results: ________________________________________________________________
h. Please Check One of the Following:
No Evidence of TB Infection or Disease
LIC 602A (8/11) (CONFIDENTIAL)
Treatment/medication (type and dosage)/equipment:
Can patient manage own treatment/medication/equipment?
If not, what type of medical supervision is needed?
8. SECONDARY DIAGNOSIS(ES):
Treatment/medication (type and dosage)/equipment:
Can patient manage own treatment/medication/equipment?
If not, what type of medical supervision is needed?
9. CHECK IF APPLICABLE TO 7 OR 8 ABOVE:
Mild Cognitive Impairment: Refers to people whose cognitive abilities are in a “conditional state”
between normal aging and dementia.
Dementia: The loss of intellectual function (such as thinking, remembering, reasoning, exercising
judgement and making decisions) and other cognitive functions, sufficient to interfere with an
individual’s ability to perform activities of daily living or to carry out social or occupational activities.
10. CONTAGIOUS/INFECTIOUS DISEASE:
Treatment/medication (type and dosage)/equipment:
Can patient manage own treatment/medication/equipment?
If not, what type of medical supervision is needed?
LIC 602A (8/11) (CONFIDENTIAL)
Treatment/medication (type and dosage)/equipment:
Can patient manage own treatment/medication/equipment?
If not, what type of medical supervision is needed?
Treatment/medication (type and dosage)/equipment:
Can patient manage own treatment/medication/equipment?
If not, what type of medical supervision is needed?
13. PHYSICAL HEALTH STATUS
f. Substance Abuse Problem
k. Motor Impairment/Paralysis
m. History of Skin Condition
LIC 602A (8/11) (CONFIDENTIAL)
b. Inappropriate Behavior
f. Able to Follow Instructions
i. Able to Communicate Needs
j. At Risk if Allowed Direct
Grooming and Hygiene Items
k. Able to Leave Facility
15. CAPACITY FOR SELF-CARE
b. Able to Dress/Groom Self
16. MEDICATION MANAGEMENT
a. Able to Administer Own
b. Able to Administer Own
d. Able to Administer Own
e. Able to Administer Own
LIC 602A (8/11) (CONFIDENTIAL)
a. 1. This person is able to independently transfer to and from bed:
2. For purposes of a fire clearance, this person is considered:
Nonambulatory: A person who is unable to leave a building unassisted under emergency
conditions. It includes any person who is unable, or likely to be unable, to physically and mentally
respond to a sensory signal approved by the State Fire Marshal, or to an oral instruction relating to
fire danger, and/or a person who depend upon mechanical aids such as crutches, walkers, and
Note: A person who is unable to independently transfer to and from bed, but who does not need
assistance to turn or reposition in bed, shall be considered non-ambulatory for the purposes of a
Bedridden: For the purpose of a fire clearance, this means a person who requires assistance with
turning or repositioning in bed.
b. If resident is nonambulatory, this status is based upon:
Both Physical and Mental Condition
c. If a resident is bedridden, check one or more of the following and describe the nature of the illness,
llness: ____________________________________________________________________
Recovery from Surgery: ______________________________________________________
Other: ____________________________________________________________________
NOTE: An illness or recovery is considered temporary if it will last 14 days or less.
d. If a resident is bedridden, how long is bedridden status expected to persist?
1. __________ (number of days)
2. ______________________ (estimated date illness or recovery is expected to end or when
resident will no longer be confined to bed)
3. If illness or recovery is permanent, please explain: __________________________________
__________________________________________________________________________
__________________________________________________________________________
__________________________________________________________________________
LIC 602A (8/11) (CONFIDENTIAL)

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California's Form 602 for Residential Care Facilities

Families in California have an additional step when moving their loved ones into residential care facilities for the elderly (RCFE). They have to submit a physician’s report, called Form 602.

Read below to learn more about the form and get answers to commonly asked questions.

California’s Form 602 for Residential Care

A physician’s report, Form 602, must be completed for all residents, or prospective residents, of residential care facilities for the elderly licensed by the California Department of Social Services. The physician’s report requires the following:

  1. A patient history.
  2. A patient physical examination.
  3. A Tuberculosis skin test (normally takes 2-3 days to get a result) or a chest x-ray to rule out active pulmonary tuberculosis.

Since moves to these communities can happen quickly, it’s important to learn about the form, what’s needed and what your family might want to consider in preparation of admittance to the community of your choice.

Read commonly asked questions below to learn more about Form 602’s requirements and what your family can do to avoid potential hold-ups or problems that could arise that could delay the RCFE move-in process.

1. What is Form 602 and Why Do Families Need It in California?

Form 602 is a physician’s report, state-required form, that assists in the communities knowing what the potential resident needs pertaining to care, medication, assistance and more. This is a standard State of California/Dept. of Social Services form that will help determine the care needs, diagnosis and medical history of the senior. A recent TB test will be required (that is good for 6 months), or a chest X-ray (that is good for one year), to show negative results for TB. Please note that this form is required at any RCFE community in California.

2. Do Doctors Need to Complete the Form?

Yes, a senior’s primary physician needs to complete this form; or the attending physician, if potential resident is in a skilled nursing community or hospital. Physicians, especially geriatricians, are very familiar with these forms.

Please note that it is preferable to have the form completed by the potential resident’s primary care physician because they have a more in-depth knowledge of the potential resident. Also, that it can take a little time to get these forms returned, so the earlier in the process the form is submitted to the physician, the better.

3. How Do Families Get an Appointment with Their Elder’s Doctor to Discuss the Form 602?

Families would make an appointment like they would go about getting any other appointment. However, it’s important to mention when making the appointment that the purpose of the appointment is to the complete a physician’s report, form 602 (as this can take extra time and the office needs to be prepared). It’s important to note that, depending on the type of insurance or medical group, some require you to go through their member services, initially.

4. Where Can Families Access Form 602?

Families can find the form on the California Department of Social Services website.

A Place for Mom advisors also have the forms handy to send them to families in California who are in need.

A Place for Mom Senior Living Advisor

Talk with a Senior Living Advisor

Our advisors help 300,000 families each year find the right senior care for their loved ones.

5. Is There Anything Else We Need to Know About Form 602 for Residential Care Facilities for the Elderly?

There are multiple items that need specific attention on the form. For example, clarification of mild cognitive impairment (MCI) compared to dementia, or specifics about whether the senior can leave the community with or without assistance (meaning, this is physically, not with an assistive device like a wheelchair, cane or walker). The form is designed to properly inform the residential care community about the resident’s current medical and care condition so that they can receive the best possible care and supervision. 

It’s important to note that all boxes and items on the form need to be filled out to ensure there are no questions about care. If a mistake is made on the form, it should not just be crossed out and corrected on the form. There needs to be a new page explaining the change, with a signature of the physician next to the correction.

Families should be the biggest advocates when it comes to getting the forms filled out accurately and in a timely manner. They should contact the physician’s office to check the form’s progress and make sure they clearly communicate the importance of getting the form back in an expeditious manner as it assists in the assessment of not only cost of care, but also in helping the family make a well-informed choice when it comes to picking a new home with and for their loved one.

Does your family have experience with California’s Form 602? What questions do you have about California’s Form 602 for residential care facilities? Share them with us in the comments below.

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Sours: https://www.aplaceformom.com/caregiver-resources/articles/californias-form-602
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Forms Required for Moving Into RCFEs

Residential Care Facilities for the Elderly (RCFEs) include assisted living or board and care homes. These senior communities provide help with activities of daily living such as dressing and bathing, but do not provide skilled medical care (as a skilled nursing facility would, for example).

In California, RCFEs are licensed and monitored by the Department of Social Services. This means that senior housing staff are required to maintain specific documentation related to all residents. You will be asked to complete some of these RCFE forms before you move into one of these senior communities.

Here is an overview of these required RCFE forms. Some senior communities may have other documentation they will want you to complete as well.

Identification and Emergency Information

This includes basic information about you as well as contact information for family and others who help you with finances or should be contacted in an emergency.

Physician’s Report

This form is completed by your doctor and provides basic medical information. Because RCFEs do not provide skilled nursing care, this form is required to determine whether the facility is appropriate for you. You, or your legal representative, will need to sign to give your doctor permission to provide the information requested.

Resident Appraisal

You, or someone you authorize, will need to complete this form. Like the Physician’s Report, this form provides information about your health, but from your perspective, rather than your doctor’s. It also asks you to share information about your interests and activities, what you like and don’t like, the type of help you think you need, and any other information that will help the staff determine if the community is appropriate for you.

Release of Resident Medical Information

You, or someone you authorize, will need to complete and sign this form for each relevant medical professional who may have information to share with the senior community.

Personal rights

This RCFE form outlines your rights as a resident in the senior community. Staff at the community are required to review these rights with you, answer any questions you may have, and let you know who you should contact if you have any complaints or feel your rights have been violated. You, or someone you authorize, will need to sign this form to indicate that you have been told about and received a written copy of your personal rights.

Resident Personal Property and Valuables

Senior housing facilities are responsible for keeping any personal property or valuables you bring with you safe. This form is a list of these items. You, or someone you authorize, will be asked to sign next to each item listed and you will be given a copy. The list will be updated as needed when you get rid of or add items.

Appraisal of Needs and Services Plan

Senior communities are required to work with you and anyone else you wish to identify your needs and develop a plan to meet those needs. This is a detailed plan that covers social, emotional, mental, health, and functional skills. For each need, it includes the time frame for addressing the need, who will be responsible for helping you with that need, and how they will evaluate progress. You, or someone you authorize, will need to sign the form once the assessment and plan are completed.

Consent for Emergency Medical Treatment

You, or someone you authorize, will be asked to complete this RCFE form to give permission to the senior community to provide emergency medical treatment if needed.

Telecommunications Device Notification

Senior communities are required to provide you with equipment or services you may need to use the telephone if you are deaf or have a hearing impairment. You, or someone you authorize, will be asked to sign this form to acknowledge that you have been informed of this right and the steps you need to take to get the equipment if needed.

This may seem overwhelming, but you don’t have to tackle this process alone. In addition to the staff at the senior community, Seniorly is here to help. Our on-staff gerontologist is always available to speak with families about their concerns prior to moving into a community and can provide expert advice regarding the transition process.

Sours: https://www.seniorly.com/resource-center/senior-living-guides/forms-required-for-moving-into-rcfes

Form rcfe assessment

RCFE Preadmission Questionnaire 10.02

1 COMMUNITY care LICENSING DIVISION "Promoting Healthy, Safe and Supportive Community care " Self-Assessment Guide residentialcare FACILITY FOR THE elderlyPreadmissionQuestionnaire 2 TSP 10/02 TECHNICAL SUPPORT PROGRAM residentialcare FACILITY FOR THE elderlyPreadmissionQuestionnaire The following Questionnaire is designed to assist

2 Licensees in identifying specific medical and behavioral issues that may affect the placement of and/or services to be provided to prospective residents of residentialcare Facilities for the elderly (RCFE). The questions on this form should be reviewed with the applicant's responsible party prior to admission to the facility. If the answer to any of the questions on this list is yes; the licensee should gather information to determine whether or not the facility will be able to admit the resident and meet his/her needs. The information on this form supplements the Preplacement Appraisal Information form (LIC 603), but does not replace it.

3 While the information gathered from this form should assist licensees in making appropriate placement decisions, it is not a required form and does not constitute a Preadmission appraisal. Date: Applicant s Name: DOB: Current Residence: Own home With family Board & care SNF Hospital____ Reason for Placement in RCFE: Applicant s Physician: A. INCIDENTAL MEDICAL SERVICES ASSESSMENT YES NO 1. Oxygen Administration F F Does the applicant use oxygen? If yes, explain. (See 87703) F F Does the applicant need assistance? If yes, explain.

4 (Exception required. See 87703) F F Does the applicant use liquid oxygen? If yes, explain. (Exception required. See 87701(a)(12) policy) 3 TSP 10/02 INCIDENTAL MEDICAL SERVICES ASSESSMENT (Continued) YES NO 2. Intermittent Positive Pressure Breathing (IPPB) Machine F F Does the applicant use an IPPB?

5 If yes, explain. (See 87704) F F Does the applicant need assistance? If yes, explain. (Exception required. See 87704) 3. Colostomy/Ileostomy F F Does the applicant have a colostomy or ileostomy? If yes, explain. (See 87705) F F Does the applicant need assistance? If yes, explain. (Exception required. See 87705) 4. Enema/Suppository/Fecal Impaction Removal F F Does the applicant need enemas, suppositories or fecal impaction removal? If yes, explain. _____ (See 87706) F F Does the applicant need assistance? If yes, explain. (See 87706) (Procedures must be performed by an Appropriately Skilled Professional [ASP]) 5.

6 Catheter care F F Does the applicant have a catheter? If yes, explain. (See 87707) F F Does the applicant need assistance? If yes, explain. (Exception may be required. See 87707) 4 TSP 10/02 INCIDENTAL MEDICAL SERVICES ASSESSMENT (Continued) YES NO 6. Bowel and Bladder Incontinence F F Is the applicant incontinent of bowel or bladder? If yes, explain.

7 (See 87708) 7. Contractures F F Does the applicant have contractures? If yes, explain. _____ (See 87709) F F Does the applicant need assistance? If yes, explain. _____ (Exception required. See 87709) F F Do the contractures severely affect the applicant's ability to function? (If yes, not allowed in an RCFE. See 87709) 8. Diabetes F F Does the applicant have diabetes? If yes, explain. (See 87710) F F Does the applicant require assistance with performing or reading glucose tests, drawing up injectable medications or administering injections?

8 If yes, explain. (Procedures must be performed by an ASP. See 87710) 5 TSP 10/02 INCIDENTAL MEDICAL SERVICES ASSESSMENT (Continued) YES NO 9. Injections F F Does the applicant need any injections? If yes, explain. (See 87711) F F Does the applicant need assistance with drawing up and administering the injections? If yes, explain. (Procedures must be performed by an ASP.)

9 See 87711) 10. Healing Wounds F F Does the applicant have any healing wounds? If yes, explain. (Exception required. See 87713) F F Does the applicant have stage 1 or 2 dermal ulcers (bedsores)? If yes, explain. _____ (Exception required. See 87713) F F Does the applicant have stage 3 or 4 dermal ulcers? (If yes, not allowed in an RCFE. See 87713) 11. Bedridden F F Is the applicant bedridden? If yes, explain. (See 87582) F F Is the condition temporary (less than 14 days)? If yes, explain. (See 87582) F F Is the condition permanent or expected to last more than fourteen days?

10 If yes, explain. (Exception and bedridden fire clearance required. See H&S ) INCIDENTAL MEDICAL SERVICES ASSESSMENT (Continued) m NO o o D D D o 12. Gastrostomy o Does the applicant have a gastrostomy? (If yes, not allowed in an RCFE. See 87701) 13. Naso Gastric (NG) Tubes D Does the applicant have NG tubes? (If yes, not allowed in an RCFE. See 87701) 14. Staph Infection o Does the applicant have a Staph or other serious infection? (If yes, not allowed in an RCFE. See 87701) o o 15. Total care Does the applicant need total care (assistance with ALL activities of daily living - eating, bathing, dressing, grooming, toileting and transferring)?

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