2-Personal Care Monthly Report Template.pdf
PDF 243 KB Posted
- Attached to
- PROMISE Personal Care Services
- Solicitation number
- HSS-26-048
- Issued by
- Delaware
About this file
This is a Personal Care Monthly Report Template document for the Delaware Department of Health and Social Services, Division of Substance Abuse and Mental Health (DSAMH), related to the Promoting Optimal Mental Health for Individuals through Supports and Empowerment (PROMISE) program. The template is designed to track monthly performance metrics for personal care service providers operating across three Delaware counties: New Castle County (NCC), Kent, and Sussex. Providers are required to report the number of active consumers served, new intakes, total hours of service provided, and hours allocated to specific service categories including cleaning, shopping, meal preparation, laundry, bathing, dressing, personal hygiene, medication prompting, mobility assistance, and transportation. The template also requires documentation of consumer discharges and involuntary disenrollments, with data reported on a monthly basis throughout the reporting year.
The template includes sections for providers to document narrative information regarding innovative or promising practices implemented, program challenges such as referral difficulties, staffing shortages, and waiting lists, program successes including specific case examples, and steps taken to address identified obstacles. The form requires provider identification including name, program name, county of service, treatment unit ID, and reporting year. All data fields are presented in a standardized format with monthly columns and totals/averages columns, enabling DSAMH to aggregate and analyze performance data across multiple providers and service regions to support program monitoring and evaluation of personal care services delivery within the PROMISE program.
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Text version
Number of Active Consumers:
Total NCC Kent Sussex
NAME MCI Number Admission Date Total # of Hours of Service Provided
Cleaning Shopping Meal Prep Laundry Bathing Dressing Personal Hygiene
Medication Prompting
Mobility Assistance
Transportation Discharged
(Y/N)
Involuntarily Disenrolled
(Y/N)
Total 0 0 0 0 0 0 0 0 0 0 0 0
Describe any innovative or promising practices that your program has implemented.
Describe challenges related to the program, including lack of referrals, difficulty contacting new referrals, staffing challenges, waiting lists, etc. Include county-specific challenges as applicable.
Describe successes of the program, including specific cases, increased ability to manage tasks independently, etc. Include county-specific successes as applicable.
What steps have you taken to address the above noted challenges or other obstacles encountered by the program?
Personal Care Monthly Report Template
Name of Provider Program Name County of Service Treatment Unit ID Reporting Year
JAN FEB MAR APR MAY JUN JUL AUG SEP OCT NOV DEC Totals/Avg Total number of active consumers at end of month: 0 0 0 0 0 0 0 0 0 0 0 0 0 Total number of active consumers in NCC: 0 0 0 0 0 0 0 0 0 0 0 0 0 Total number of active consumers in Kent: 0 0 0 0 0 0 0 0 0 0 0 0 0 Total number of active consumers in Sussex: 0 0 0 0 0 0 0 0 0 0 0 0 0 Number of intakes: 0 0 0 0 0 0 0 0 0 0 0 0 0 Total # of Hours of Service Provided: 0 0 0 0 0 0 0 0 0 0 0 0 0 Cleaning: 0 0 0 0 0 0 0 0 0 0 0 0 0 Shopping: 0 0 0 0 0 0 0 0 0 0 0 0 0 Meal Prep: 0 0 0 0 0 0 0 0 0 0 0 0 0 Laundry: 0 0 0 0 0 0 0 0 0 0 0 0 0 Bathing: 0 0 0 0 0 0 0 0 0 0 0 0 0 Dressing: 0 0 0 0 0 0 0 0 0 0 0 0 0 Personal Hygiene: 0 0 0 0 0 0 0 0 0 0 0 0 0 Medication Prompting: 0 0 0 0 0 0 0 0 0 0 0 0 0 Mobility Assistance: 0 0 0 0 0 0 0 0 0 0 0 0 0 Transportation: 0 0 0 0 0 0 0 0 0 0 0 0 0 Number of consumer discharges: 0 0 0 0 0 0 0 0 0 0 0 0 0 Number of consumers involuntarily disenrolled from program: 0 0 0 0 0 0 0 0 0 0 0 0 0
Monthly Overview
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