AFHNA is providing the forms below for your use

Disclaimer:

AFHNA accepts no liability for the content of the forms provided or for any actions taken on the basis of the information provided. These forms are intended as samples only. Please review and modify the forms to reflect the needs of your residents. AFH providers are responsible for providing resident care according to State and Federal laws.

COVID-19 Related Forms

• CoronaVirus Policy Plan.docx
  
• CoronaVirus Infection Control Plan.docx
  
• CoronaVirus Policy Plan.docx
  
• Isolation Protocol updated 3-23-20.docx
  
• ISOLATION sign.docx
  
• Visitor Log-COVID-19.docx
  
• NO VISITOR SIGN COVID-19.docx
  

Administrative Forms

• New Resident QA Checklist
  
• Release of Information.doc
  
• Facility Transfer Facesheet-Checklist Page 1 (Copy in Sun Yellow!)
  
• Facility Tx Facesheet-Checklist 2-15 Sheet2.pdf (Copy in Sun Yellow!)
  
• Activity Log Sample
• Employee HCA Exemption Form
• AFH Medicaid Payment Policy

 

Dementia/Behavioral Related Forms

• Behavior Monitor Flowsheet
  
• Behavioral Approaches to Decrease Resistance to Bathing
  
• Caregiver Approaches to Decrease Resistive Behaviors in Residents
  
• Non-Verbal Cues for Pain and Anxiety Assessment Tool
  
• Managing Behavioral or Psychological Symptoms for People with Dementia (BPSD) Flowsheet
  
• BPSD Series Delirium and Medical Issues
  
• BPSD Series Non-Drug Approaches (ongoing)
  
• WHEN YOUR RESIDENT IS RESTLESS (Great poster for caregivers!)
  
• Night Activity Form

Diabetes Care in the Adult Family Home

• Diabetes: Simple Explanation
  
• Diabetes Complications and Caregiver Interventions
  
• Diabetes: Food tips (Including Sick Day Management)
  
• Blood Glucose Level Monthly Flowsheet 
• High and Low Blood Sugar

Labor and Industry Compliance

• Bloodborne Pathogen Certificate Sample
• Bloodborne Pathogens 2019 Video
• Hepatitis B Vaccination Form
• L & I Safety Orientation Checklist
• Emergency and First Aid Checklist
• Sharps Injury Log
  
  

Medication Related Forms

(for insulin related forms see “Diabetes Care in the Adult Family Home” above)

• Controlled Substance Policy
  
• Drug Hazard Assessment Certification Form
  
• Format for Listing Medications on the MAR
  
• Hospice Comfort Kit Medication Tracking Sheet
  
• Hospice Comfort Kit Flow Sheet: Medication Instructions from Hospice Nurses
  

 

Mobility Device Forms

• Policy for Positioning/Transferring Devices
  
• Side Rails: Informed Consent and Release
  
• Transfer Pole: Informed Consent and Release
  
• Resident Evaluation for Use of Medical Devices
  
• Side Rails & Transfer Pole Safety Policy and Procedure
  

 

Policies

• POA Agreement for Privately Paid Companions in the AFH