Care Plan Version of Multnomah County
ACHP Classification Level Worksheet for Adult Care Home Operators

Operators shall complete this worksheet as part of the Care Plan once the resident has been in the home for up to 14 days.                              (Initial class worksheet is completed as part of the screening.)

Resident Name:					    	DOB: 					Date: __________________________

Definition                                    Independent	                   Assist         		                        Full Assist
Eating

Feeding and eating; may include using assistive devices.	Needs no assistance

Considered independent even if set-up, cutting up food, or special diet needed.

	Requires another person to be immediately available and within sight. Requires hands-on feeding or assistance with special utensils, cueing while eating, or monitoring to prevent choking or aspiration.

	Requires one-on-one assist for direct feeding, constant cueing, or to prevent choking or aspiration. Includes nutritional IV or feeding tube set-up by another person. Needs assistance through all phases, every time.

Dressing and Grooming

Dressing and undressing; grooming includes nail care, brushing and combing hair.
	Needs no assistance

	q	q	Needs assist in dressing, or full assist in grooming (cannot perform any task of grooming without the assistance of another person.)

	Needs full assist in dressing. (cannot perform any task of dressing without the assistance of another person.)

Bathing/Personal Hygiene

Bathing includes washing hair, and getting in and out of tub or shower. Personal hygiene includes shaving, and caring for the mouth.
	Needs no assistance

	Needs Minimal to			Unable to do Any Activity	Requires assist in bathing, or full assist in hygiene. (needs hands-on assist through all phases of hygiene, every time, even with assistive devices.)

	Requires full assistance in bathing. (needs hands-on assist through all phases of bathing, every time, even with assistive devices.)

	

Mobility

Includes ambulation and transfer. Does NOT include getting to/from toilet or in/out of shower/tub or motor vehicle.
	Needs no assistance

	Must require assistance of another person with ambulation, or with transfers, or with both.

	Must need full assist with ambulation or with transfers or both. Unable to ambulate or transfer without the assistance of another person throughout the activity, every time, even with assistive devices.
	
Elimination

Toileting, bowel & bladder management includes getting on/off  toilet, cleansing after elimination,  and clothing adjustment; catheter and ostomy care, toileting schedule, changing incontinence supplies,
digital stimulation.
	
Needs no assistance. Continent, or manages own incontinence.

	
Requires assist with bladder care or bowel care or toileting. Even with assistive devices, the individual is unable to accomplish some tasks of bladder care, bowel care, or toileting without the assistance of another person.

	
Requires full assist with bladder care or bowel care or toileting.  Full assist means that the individual is unable to accomplish any part of the task and assistance of another person is required throughout the activity, every time.

	
Cognition/Behavior
8 components: Functions of the brain (5) : adaptation, awareness, judgment/ decision-making, memory, orientation.
Behavioral symptoms (3): demands on others, danger to self, wandering	
Needs no assistance

	
Needs assist in at least 3 of the 8 components of cognition and behavior.

Assist implies that the need is less than daily, or if daily, impairment is not severe.

Needs full assist in at least 3 of the 8 components of cognition and behavior.

Full assist implies that the need is ongoing and daily. The level of impairment is severe.

        Independent	                  Assist	                                               Full Assist
                                        Total: 			                  				                         		
Class Level: __________

Class I =   Assist with 4 or fewer ADL and not full assist in any ADL
Class II = Assist with all ADL, full assist in no more than 3.
Class III = Full assist (dependent) with 4 or more ADL. 

Name of RN or Physician responsible for monitoring client care in the home: 								
Phone: 					
Frequency of visits: 			
     Multnomah County

$

Adult Care Home Care Plan

Resident Name:                                            Date of annual plan:                       Update:                     
Operator:                                                

 Eating
 Special diet: 

 
 General appetite:

 Allergies:

 Special equipment:

 Preferences:

	
    What resident does:	
  What caregiver does/when:	

 Dressing
 Equipment:

 Day preferences:

 Night preferences:

 Other:

 	
  What resident does:	  
 What caregiver does/when:	

  Grooming
  Nail care
  Fingernails: 	
   
  Toenails:

  Brushing/combing hair
  
  Preferences:

  Other:	

 
Bathing 
Frequency:

Schedule:

Time Required: 

Equipment:
 
 Transfer:

 Preferences:   

 What resident does:
	
 What caregiver does/when:	

  Personal Hygiene
    Shaving
  Frequency:

  Schedule:
 
  Caring for the mouth
  Frequency:

  Dentures:

  Schedule: 

  Preferences:

 Mobility
 Ambulation
 Equipment :

 Transfer
 Equipment:
 
 Preferences:

 Special Transportation Needs:	 What resident does:	 What caregiver does/when:	

  Elimination
 Toileting:
 
 Transfer:

 Other assist:
 
 Bladder management:

 Bowel management:
 
 Equipment/supplies:

 Schedule:	

 	
 
 Cognition
 Adaptation:
 
 Awareness:

 Judgment/decision making:

 Memory:

 Orientation:	
What resident does:	
 Interventions: 
 What caregiver does/when:	
 
 Behavior (describe)
 Demands on others:

 Danger to self:

 Wandering:	

  Night Needs 
 Toileting/Incontinence care:

 RN consultation:
 
 Medication:

 Equipment:

 Other needs:

 Resident’s preferred bedtime:

 Other preferences:                                          	  
 What resident does:	
  What caregiver does/when:	

 Communication Needs
 Glasses:

 Hearing Aids:

 Interpreter:

 Other:	

 Medical Concerns
 Health Issues to Monitor: 

Treatment/Therapies/Procedures: 

 RN Consultation:

 RN Delegation: 

 Physical Restraints:

 Allergies: 

 Other:

	

 
 Social/Spiritual/Emotional
 Activity Needs:

 Church affiliation: 

 Clubs:

 Social Contacts: 

 Activities Preferred:	 
 What resident does:	 
 What caregiver and/or
  significant others do:	

 Exiting in an Emergency
 
 Equipment needed:

			

Care Plan Signature Page

Name of Resident:                                                         Date of annual Plan:                                     

Signatures:                                                      Dates:                                          

																			
Operator							     annual plan		 6 month review 	       change of condition 

																			
 Resident 						              annual plan		 6 month review	       change of condition  

																			
Resident  Representative		                       annual plan		 6 month review         change of condition

Signature:                                                        Dates:  

								 		        	           							    
 Caregiver							 annual plan                   6 month review           change of condition

								 		        	            							__
 Caregiver                                                           annual plan                  6 month review           change of condition

 Caregiver                                                           annual plan                   6 month review          change of condition

Caregiver                                                            annual plan                   6 month review          change of condition

Caregiver					                    annual plan                   6 month review          change of condition

Caregiver                                                            annual plan                   6 month review          change of condition

Caregiver                                                            annual plan                   6 month review          change of condition