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Golden Hands Home Care
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Forms
Schedule Change
Child Attestation
Member Survey
Consumer Application
Agreement To Care
Home Visit Intake
Login
MEMBER AGREEMENT TO CARE & PCA CARE PLAN
Member Name:
Member Address:
Member Phone:
Clock In Time
Clock Out Time
Special Instructions
Complete each visit
Duties
Personal Care
Routine Functions
Tub Bath
Bed Bath
Shower
Transfer assistance from bed to chair - chair-bed
Assistance with dressing
Assistance with feeding
Medication reminder
House chores (member only)
Meal preparations (for client only)
Clean member area only
Laundry member items only
Infection control
Hand washing, use of gloves and clean working area
Documentation
Change of mental status
Report to RN
Change of condition
Suspect/witness abuse
Falls
Medical appointments/admissions
Client Signature:
Clear
Date:
Agency Supervisor Signature:
Clear
Date:
PCA Name:
Signature:
Clear
Date:
