Attach B_DSS Form 30141.pdf
PDF 430 KB Posted
- Attached to
- APS - ETPS - HOMEMAKER - CNAS -PCAS
- Solicitation number
- 5400029256
- Issued by
- Richland County, South Carolina
About this file
DSS Form 30141 is a verification of care document used by the South Carolina Department of Social Services for the Adult Advocacy program to document Personal Care/Certified Nursing Assistant (Sitter) services provided to Adult Protective Services (APS) clients. The form must be completed by the sitter and submitted by the contractor along with a detailed invoice for each APS client receiving sitter services to process payment. The form requires complete, legible, and signed documentation and covers services provided for a one-week period, with the sitter recording total hours worked and providing a general overview of the client's overall condition, attitude, and interactions with the sitter.
The form includes detailed tracking sections for each day of service where the sitter must document personal care services provided (such as bathing, diaper changes), medication monitoring with times and client compliance, behavioral observations including any outbursts or disruptive behavior, relevant client comments pertaining to case planning, nurse services rendered (such as blood pressure monitoring or insulin injections with dosages), and meals and snacks provided with times and food items. The sitter must certify the accuracy of all information by signature and date, and additional pages may be used as necessary to provide more in-depth information with specific notation of day, date, and category.
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Other files
| File | Type | Posted |
|---|---|---|
| Attach A_ DSS Form 2433.pdf | ||
| Attach C_ DSS Form 1580.pdf | ||
| Amendment 1.docx | DOCX document | |
| Attach D_DSS Form 3797.pdf | ||
| 5400029256.pdf |
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Text version
DSS Form 30141 (3/23/26)
Adult Advocacy
PERSONAL CARE/CERTIFIED NURSING ASSISTANT VERIFICATION OF
CARE
To be completed by the Personal Care/Certified Nursing Assistant (Sitter) and submitted by the Contractor along with a detailed invoice for each APS client receiving Sitter services in order for payment to be processed. Form must be complete, legible and signed.
Client’s Name: __________________________________ Sitter’s Name: _______________________________
PRINT NAME PRINT NAME
Services Provided for the Week Ending: _________________________
DAY Date Month/Date
Time (Circle AM/PM) Total
Hours General Overview of Client’s Day
(Client’s overall condition, attitude, interactions with the Sitter) In Out
SUNDAY /
AM AM
PM PM
MONDAY /
AM AM
PM PM
TUESDAY / AM AM
PM PM
WEDNESDAY / AM AM
PM PM
THURSDAY /
AM AM
PM PM
FRIDAY / AM AM
PM PM
SATURDAY / AM AM
PM PM
Total Hours for the Week
When date/time in/out goes over midnight, show time as:
For each care day, please use the next section to indicate:
• Personal care services provided to the client, (shower, bath, change diaper, etc.)
• Medication monitoring, i.e. what time the client took medication and what medication was taken - Did the client take the medication or refuse?
• Any occurrences of outbursts or other disruptive behavior
• Anything the client may say that is pertinent to case planning
• Visit with nurse-services received for high blood pressure, insulin injections (how much), changing bandages
(time), etc.
• Meals and snacks that are provided to the client (time and food items)
Signature of Sitter: ________________________________________ Date: _____________________ By signing, I certify that all information provided is accurate.
Page 1 of ____ pages
Client’s Name: __________________________________ Sitter’s Name: _______________________________
PRINT NAME PRINT NAME
Day of Week & Month/Date Care Item Sitter’s Notes – include times as appropriate
Day of week:
Month/Date:
Personal Care
Medication Monitoring
Behavioral Observations
Client’s Comments
Nurse Services
Meals/Snacks
Day of week:
Month/Date:
Personal Care
Medication Monitoring
Behavioral Observations
Client’s Comments
Nurse Services
Meals/Snacks
Use additional pages as necessary to provide more in-depth information. Specify day/date/category.
Page ____ of ____ pages
Client’s Name: __________________________________ Sitter’s Name: _______________________________
PRINT NAME PRINT NAME
Day of Week & Month/Date Care Item Sitter’s Notes – include times as appropriate
Day of week:
Month/Date:
Personal Care
Medication Monitoring
Behavioral Observations
Client’s Comments
Nurse Services
Meals/Snacks
Day of week:
Month/Date:
Personal Care
Medication Monitoring
Behavioral Observations
Client’s Comments
Nurse Services
Meals/Snacks
Use additional pages as necessary to provide more in-depth information. Specify day/date/category.
Page ____ of ____ pages
| Clients Name: |
| Sitters Name: |
| Services Provided for the Week Ending: |
| Total HoursRow1: |
| General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow1: |
| Total HoursRow2: |
| General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow2: |
| Total HoursRow3: |
| General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow3: |
| Total HoursRow4: |
| General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow4: |
| Total HoursRow5: |
| General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow5: |
| Total HoursRow6: |
| General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow6: |
| Total HoursRow7: |
| General Overview of Clients Day Clients overall condition attitude interactions with the SitterRow7: |
| Total HoursTotal Hours for the Week: |
| of: |
| Clients Name_2: |
| Sitters Name_2: |
| Sitters Notes include times as appropriatePersonal Care: |
| Day of week: |
| Sitters Notes include times as appropriateMedication Monitoring: |
| Sitters Notes include times as appropriateBehavioral Observations: |
| MonthDate: |
| Sitters Notes include times as appropriateClients Comments: |
| Sitters Notes include times as appropriateNurse Services: |
| Sitters Notes include times as appropriateMealsSnacks: |
| Sitters Notes include times as appropriatePersonal Care_2: |
| Day of week_2: |
| Sitters Notes include times as appropriateMedication Monitoring_2: |
| Sitters Notes include times as appropriateBehavioral Observations_2: |
| MonthDate_2: |
| Sitters Notes include times as appropriateClients Comments_2: |
| Sitters Notes include times as appropriateNurse Services_2: |
| Sitters Notes include times as appropriateMealsSnacks_2: |
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| Sitters Notes include times as appropriateBehavioral Observations_3: |
| MonthDate_3: |
| Sitters Notes include times as appropriateClients Comments_3: |
| Sitters Notes include times as appropriateNurse Services_3: |
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| Sitters Notes include times as appropriatePersonal Care_4: |
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