The Salvation Army Serendipity Adult Day Services PIN: 1005116 Admission Application Guest/Participant Information Name: (First/MI/Last) SSN: Sex: M F Date of Birth: (mm/dd/yyyy) Ethnicity: Caucasian Asian Black/African American American Indian/Alaska Native Hispanic/Latino Hawaiian/Pacific Islander Marital Single Married Separated Divorced Widowed Status: Primary Language: English Other: Medicaid #: Medicare #: Other Insurance: Payment Source: Preferred Name Place of Birth: Longest Place of Residency: Name of Spouse & Years Married: Names of Children: Medicaid Waiver Private Pay Grant Other: Highest Education Level Completed: Past Interests/Hobbies: Primary Career & Year Retired: Religion (if applicable): Favorite Current Pastimes: Expectation for Attending? Elementary School Vocational School College - BA (4yrs) High School College AA (2 yrs) College MA/PHD 10/31/16 Serendipity Admission Application 1
Residence Information: Lives: At Home In An Assisted Living Home Other: PIN: 1005116 Primary Care Giver: Relationship: Name of Assisted Living Home or Group Home (if applicable): Street Address: City State Zip Code Home Phone: Cell Phone: Work Phone: Email Address: Next of Kin and/or Legal Representative: Legal Representative Type: Self Power of Attorney Guardian Public Guardian Other: Name: (Provide Serendipity a copy of POA assignment/guardianship.) Relationship: Same as Primary Caregiver Above? Agency (if applicable): Mailing Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Email Address: 10/31/16 Serendipity Admission Application 2
Care Coordinator (if applicable): Name: Organization: PIN: 1005116 Mailing Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Email Address: Emergency Medical Contact Information: Name: Relationship: Mailing Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Email Address: Additional Emergency Medical Contact: Name: Relationship: Mailing Address: City: State: Zip Code: Home Phone: Cell Phone: Work Phone: Email Address: 10/31/16 Serendipity Admission Application 3
Health Assessment: Primary Physician Name: Physician: PIN: 1005116 Address: Phone: Fax: Preferred Hospital: Allergies: Drug: Food: Comfort One or Advanced Directive: Diet Modifications: (Provide Serendipity with a copy of the document.) Health Lung Disease Urologic Disease Diabetes Other Issues: GI Disease Hypertension Heart Disease Stroke Dehydration Dementia Brain Injury Seizure Mental Illness Neurologic Disease Eye Disease Arthritis Overall Health: No chronic health conditions. Chronic health conditions but stable (quarterly or less physician visits, minimal medication changes, no emergency room visits in the last year). Health conditions that require frequent, on-going treatment. None 1-3 4-6 6+ ER Visits in The Last Year Assistance or Adaptive devices necessary for any of the following? Balance/ Wheelchair Walker Cane Paralysis Other: Vision Eyeglasses Other: Hearing Right Hearing Aid Left Hearing Aid Both Dentures Upper Lower Other What participant behaviors or impairments have been the most difficult? What participant health conditions have the greatest impact on quality of life? Additional Comments: 10/31/16 Serendipity Admission Application 4
Physical Assessment: Mobility: Walks Independently Walks with Stand-by Assistance Walks with 1-Person Assistance Walker Wheelchair Independently Wheelchair with Assistance Standing: Stands Independently Stand-by Assistance 1-Person Assistance Cannot Stand Falls in the Last 6 months: None 1-3 4-6 6+ Wandering: Does not wander Wanders in confined areas Leaves home, but is easily redirected. Leaves home, does not accept redirection easily. Wandering occurs: Never Seldom Frequently Additional Comments: PIN: 1005116 Functional Assessment: Circle the letter that best describes how the guest performs the following tasks: Activity (a) No Assistance (b) Verbal Cues (c) Some Assistance (d) Full Assistance Bathing a b c d Eating a b c d Dressing a b c d Hygiene a b c d Toileting a b c d Walking a b c d Bladder Control: Bowel Control: Continent Occasional Frequent Total Incontinence Incontinence Incontinence (2x per week) (daily) Indwelling Catheter Continent Occasional Frequent Total Incontinence Incontinence Incontinence (2x per week) (daily) Colostomy Prolapse: Bladder Uterus Anus Urinary Tract Infections: Frequency: Continence Supplies Used: 10/31/16 Serendipity Admission Application 5
PIN: 1005116 Activities of Daily Living: Circle the letter that best describes how the guest performs the following tasks: Activity (a) No (b) Verbal Cues (c) Some Assistance (d) Full Assistance Assistance Preparing Meals a b c d Housework a b c d Laundry a b c d Personal Business a b c d Transportation a b c d Shopping a b c d Using Telephone a b c d Comments: Psychosocial Behavioral Assessment: Alcohol Use: None Occasional Frequent Never Does the guest recognize (mark all that apply): Themselves Family Members & Care Providers Month/Day Time of Day Does the guest experience restlessness or hyperactivity: If yes, are there certain instances when these behaviors occur? Does the guest experience agitation or anxiousness? If yes, are there certain instances when these behaviors occur? Does the guest experience hallucination or paranoid thought? If yes, are there certain instances when these behaviors occur? Does the guest experience isolation or withdrawal? If yes, are there certain instances when these behaviors occur? Does the guest display verbally abusive behavior? If yes, please explain. Does the guest display physically combative behavior? If yes, please explain. Has the guest been convicted of a sexual offence? If yes, please explain. Participant or Legal Representative: Printed Name: Signature: Date: 10/31/16 Serendipity Admission Application 6
The Salvation Army Serendipity Adult Day Services Medication Information PIN: 1005116 Name: Date: Please list all current prescription medications including the dosage and administration. Medication Reason for Taking Dosage Doctor Please list all current over the counter products that are used including reason, dosage, and administration instructions. This list should include herbs, vitamins and any medication administered on an as needed basis. Product Reason Dosage MD name if product Allergies to Medications: Allergies to Food: Diet Restrictions: Food Intolerances: Serendipity Adult Day Services 3550 E. 20th Avenue, Anchorage, AK 99508 Phone: 279 0501 Fax: 279 0502
(fax) Serendipity Adult Day Services 3550 East 20 th Avenue Anchorage, AK 99508-3414 Phone (907) 279-0501 Fax (907) 279-0502 Serendipity 2018 Financial Information & Agreement Form Adult day services at Serendipity for are to be paid by the following funding source: Medicaid Waiver - Older Alaskans (ALI) Medicaid Waiver - Intellectual & Developmental Disabilities (IDD) Grant Private Pay VA Name Signature Date
Serendipity Adult Day Services 3550 E 20 th Ave. Anchorage, AK 99508 (907) 279 0501 (907) 279 0502 (fax) Serendipity Private Pay Discount Policy & 2018 Financial Information and Agreement Form For our private pay participants, we offer a sliding fee discount based on the US Department of Health and Human Services, Health Resources and Services Administration Guidelines for Medical Practices. Eligibility for discount is determined annually coinciding with Alaska Medicaid Waiver annual rate changes. All participants are able to apply. The discount is based on the participant (and spouse s) income determined by total income sources and based on Federal Poverty Guidelines for Alaska. Sliding Scale Discount Breakdown: Monthly Income Federal Poverty Level Discount $5,061.00 Above 0.00% $3,796.00 $5,060.00 400% 25.00% $2,531.00 $3,795.00 300% 50.00% $1,266.00 $2,530.00 200% 75.00% $0.00 $1,265.00 100% 100% Participant Name: Please provide the following financial information to determine the level of discount. Income Sources: Social Security $ Year Month Supplemental Security Income (SSI) $ Year Month Adult Public Assistance (APA) $ Year Month Alaska Senior Benefits $ Year Month Retirement Accounts $ Year Month Pensions $ Year Month Annuities or Insurance $ Year Month Interest & Dividends $ Year Month AK Permanent Fund Dividend $ Year Month Other Incomes Sources: $ Year Month VA $ Year Month Name (Legal Representative) Signature Date
Serendipity Adult Day Services 3550 East 20 th Avenue Anchorage, AK 99508 3414 Phone (907) 279 0501 Fax (907) 279 0502 Hours: 7:30 am 5:30 pm, Monday Friday Serendipity 2018 Private Pay Discounts Gross Monthly Gross Monthly Discount *Cost per Cost per hour / 4 Meals Income Low Income High 15 minutes hours $5,061.00 Above 0.00% $5.25 $21.00 / $84.00 $21.15 $3,796.00 $5,060.00 25.00% $3.94 $15.76 / $63.04 $15.86 $2,531.00 $3,795.00 50.00% $2.63 $10.52 / $42.08 $10.58 $1,266.00 $2,530.00 75.00% $1.31 $5.24 / $20.96 $5.29 $0.00 $1,265.00 100.00% $0.00 $0.00 $0.00 *(4) hour minimum charge per day. Based on participant (and spouse s) income. Meals are prepared to meet specific dietary needs (eg, diabetic, heart healthy, etc.). What it looks like: Example of Cost per 4 hour stay at the 75.00% discounted rate 9:00 9:59 am $5.24 10:00 10:59 am $5.24 11:00 11:59 am $5.24 (4 hour stay plus lunch of $5.29 = $26.25.) 12:00 12:59 pm $5.24 $20.96 Example of Participant Activities Tuesday: 7:30 10:00 Crafts, Games, Snack 10:00 Blues Music 11:00 Exercise Class 11:15 What am I? 12:00 Lunch 12:30 Relaxation 1:15 Bingo 2:00 Velcro Golf 2:45 Trivia/Word games 3:30 Snacks 3:45 Games Lunch: Meatloaf Mashed Potatoes Green Beans Fruit Cocktail Orange Jello Snacks: Peanut Butter and Crackers Pudding with Vanilla Wafers
Services and Activities Serendipity Adult Day Services Hours of Operation Monday through Friday, 7:30 to 5:30 Serendipity is closed for Salvation Army approved holidays, quarterly for staff training and weather emergencies. The dates, other than emergencies, are announced in the monthly newsletter and calendar. Activities Serendipity offers the following categories of activities. Examples are listed but not meant to be inclusive of all activities. Serendipity staff creates a monthly activity calendar, incorporating suggestions and ideas from participants and their caregivers. All activities are designed to be meaningful, enjoyable and to help participants maintain mental, physical and emotional health. They are meant to be meaningful occupations of time which the participants choose according to their interests and lifelong skills. All activities are supervised by Serendipity staff. Serendipity participates in research studies with UAA. These include Enhanced Mobility with The Center for Behavioral Health Research & Services looking at a prescribed program of exercise and walking and how it affects the individual s wellbeing and physical function as well as effects on care givers. Also, the Java Music Club with the Department of Social Work assessing the effects of participation in a peer support group allowing the participants to provide social and emotional support to one another within a structured setting including discussion themes, music, photos, sayings, poetry etc. The goal is increasing well-being via helping others, strengthened relationships, focus inner beliefs, better coping skills and such. A variety of activities are offered simultaneously. Large group, small group and individual programs are all possible. Activities are planned monthly and include community volunteer groups and special day trips. An activity calendar and monthly newsletter are published, copies sent to participants/legal representatives, caregivers, Care Coordinators, Serendipity friends, volunteers or any other interested party. Copies are also available at the front door. Social: Music, singing, dancing, devotional programs, book reading, picnics and field trips, from 1:1 to large group gatherings, Holiday planning, multigenerational activities, afternoon teas and more Therapeutic: Daily exercise and walking program, art, physical and mental games, cards, table games, sewing, knitting, cooking, wood crafts. Ladies tea party, Spanish club and more Personal Care: Assistance with eating, hygiene, toileting, transferring, walking and interaction Health Related: Assistance with medication and collaboration with family, other care providers and health professionals on care needs Nutritional: Freshly cooked meals and snacks, tailored to meet individual nutritional needs. The menu has been approved by a Registered Dietician and provides minimum of 1/3 of the Dietary Reference Intakes established by the Food Nutrition Board. We comply with the State of Alaska s Senior and Disability Meals Services Condition of Participation. Special dietary needs will be accommodated if possible. Ancillary Services: Hair care and podiatry services are available monthly on site by independent providers. Caregiver Support: social gatherings, educational materials and resource assistance 12/28/2017 revised, 3/15/2014 Serendipity Adult Day Services
Transportation Secure Care 222 6683 Anchor Rides 343 2550 Anchor Rides https://www.muni.org/departments/transit/anchorrides (Obtain an assessment for Anchor Ride transport, please contact Paris Butler at (907) 343 6332 or, ButlerPD@ci.anchorage.ak.us.) Quick Rides 332 0261