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Preview - Ohio Jfs 02390 Form
Ohio Department of Job and Family Services
HOME CARE ATTENDANT (HCA) SKILLED TASK AUTHORIZATION
Consumer Name (Please print)
Consumer Street Address
Recipient I.D. #
City |
State |
Zip Code |
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SKILLED TASKS TRAINING LIST
INSTRUCTIONS FOR TRAINER
Enter the medically necessary skilled task(s) the Home Care Attendant has successfully completed training to perform. Draw a single line through any unused boxes.
INSTRUCTIONS FOR AUTHORIZED HEALTH CARE PROFESSIONAL (AHP)
Place initials in the box for each approved task(s).
TASK
AHP
INITIALS
TASK
AHP
INITIALS
JFS 02390 (7/2010) |
Page 1 of 3 |
SKILLED TASKS APPROVAL
DIRECTIONS
Each team member shown below must complete the section that applies to her/his role. The HCA is not approved to perform the listed task(s) until though AHP has initialed the “Training Detail” page.
CONSUMER/AUTHORIZED REPRESENTATIVE
I, the undersigned have received the necessary training and am electing to select, instruct and direct the Home Care Attendant (HCA) to perform the task(s) set forth on this form. I will ensure that the HCA performs the task(s) consistent with her/his training and in accordance with OAC Rule
Name (Please print)
Signature
Initials
Date Signed
HOME CARE ATTENDANT
I, the undersigned have received training in task(s) set forth on this form, and will perform the task(s) in accordance with OAC Rule
Name (Please print)
Signature
Initials
Date Signed
TRAINER (Please read before signing and dating)
I, the undersigned, verify that I have successfully trained the Home Care Attendant to perform the task(s) set forth on this form.
Trainer Name (Please print)
Trainer Signature
Initials
Date Signed
AUTHORIZING HEALTH CARE PROFESSIONAL AND TRAINER (Please read before signing and dating)
I, the undersigned, approve the consumer’s decision to select, instruct and direct the Home Care Attendant in the performance of the task(s) set forth on this form. I understand that I may revoke approval at any time, if deemed necessary, by notifying the Consumer/Authorized Representative, CMA Case Manager, and Trainer.
Name (Please print)
Signature
Initials
Date Signed
Emergency Phone Number (Including Area Code)
Fax Number (Including Area Code)
In the event that no physician is aware of or supports the consumer’s decision to use the Home Care Attendant option, the Registered Nurse who is serving as the Authorized Healthcare Professional must be made aware of the physician’s exclusion or
Customer/Authorized Representative (Initials)
Authorized Healthcare Professional (Initials)
JFS 02390 (7/2010) |
Page 2 of 3 |
SKILLED TASK TRAINING DETAIL
Consumer Name (Please print) |
Effective Period (not to exceed 12 months) |
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Trainer Name (Please print) |
Start Date |
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End Date |
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DIRECTIONS
Trainer – Enter the name of the medically necessary skilled task required by the consumer. Enter the date the Home Care Attendant (HCA) completed training to successfully perform the skilled task. Write a detailed description of how HCA will perform the task, including times or intervals.
(If the consumer/authorized representative is the trainer, the consumer/authorized representative will complete this section.)
Name of Task |
Date Training Completed |
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Task Training Detail |
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Check here if CONTINUED on next page
AUTHORIZED HEALTHCARE PROFESSIONAL
My initials indicate approval of this task to be performed by the Home Care Attendant and that the Home Care Attendant has demonstrated the ability to perform the task.
(INITIAL HERE)
JFS 02390 (7/2010) |
Page 3 of 3 |
Document Properties
| Fact Name | Description |
|---|---|
| Form Purpose | The Ohio JFS 02390 form is used to authorize Home Care Attendants (HCAs) to perform medically necessary skilled tasks for consumers. |
| Governing Law | This form is governed by Ohio Administrative Code (OAC) Rule 5101:3-46-04.1 and 5101:3-50-04.1, which outline the responsibilities and training requirements for HCAs. |
| Training Requirement | HCAs must complete training for each task they are authorized to perform. The trainer must verify the completion of this training on the form. |
| Consumer Responsibility | The consumer or authorized representative is responsible for ensuring that the HCA performs tasks according to their training and must report any changes in health or circumstances to the Case Management Agency. |
| Revocation of Authorization | Authorization for an HCA to perform tasks can be revoked at any time by the authorized health care professional or consumer. |
Documents used along the form
The Ohio JFS 02390 form is essential for authorizing skilled tasks for Home Care Attendants (HCAs). However, several other documents often accompany it to ensure proper care and compliance with regulations. Below is a list of related forms that may be needed.
- Ohio JFS 02391: This form is used for the assessment of the consumer's needs. It helps determine the level of care required and identifies any specific tasks the HCA may need to perform.
- Ohio JFS 02392: This document is the training verification form for HCAs. It confirms that the HCA has received the necessary training to perform specific tasks safely and effectively.
- Consumer Service Plan: This plan outlines the services the consumer requires, including the frequency and type of care. It acts as a roadmap for the HCA's duties.
- Authorization for Release of Information: This form allows healthcare professionals to share the consumer's medical information with the HCA, ensuring that the care provided is informed and appropriate.
- Georgia Trailer Bill of Sale: This form officially records the sale of a trailer in Georgia, providing essential details about the buyer, seller, and the trailer. For more information, visit smarttemplates.net.
- Incident Report: In the event of any accidents or issues during care, this form is used to document the incident. It helps in evaluating and improving care practices.
- Caregiver Agreement: This agreement details the expectations and responsibilities of the HCA and the consumer. It serves as a contract to ensure clarity in the caregiving relationship.
- Health Assessment Form: This form provides a comprehensive overview of the consumer's health status. It is crucial for determining what tasks the HCA is qualified to perform.
- Emergency Contact Form: This document lists individuals to contact in case of an emergency. It ensures that the HCA knows whom to reach out to if urgent situations arise.
- Daily Care Log: This log is maintained by the HCA to record daily activities and any changes in the consumer’s condition. It aids in ongoing assessments of care effectiveness.
Having these documents organized and readily available can facilitate smoother communication and care delivery. They ensure that both the consumer and the HCA are clear on expectations, responsibilities, and protocols.
Guidelines on Filling in Ohio Jfs 02390
Filling out the Ohio JFS 02390 form is a straightforward process. This form is essential for authorizing a Home Care Attendant (HCA) to perform specific skilled tasks. Ensure you have all necessary information at hand before you begin.
- Consumer Information: In the top section, print the consumer's name, street address, city, state, and zip code. Also, include the recipient ID number.
- Skilled Tasks Training List: Enter the medically necessary skilled tasks the HCA has completed training for. If there are unused boxes, draw a single line through them.
- Authorized Health Care Professional (AHP) Section: The AHP must initial each approved task. Ensure that initials are placed in the correct boxes.
- Consumer/Authorized Representative Section: The consumer or authorized representative must print their name, sign the form, initial, and date it. This confirms their understanding of the HCA's training and responsibilities.
- Home Care Attendant Section: The HCA should print their name, sign, initial, and date the form. This indicates they are trained and understand their responsibilities.
- Trainer Section: The trainer must print their name, sign, initial, and date the form, verifying the HCA's training completion.
- Authorizing Health Care Professional Section: The AHP must print their name, sign, initial, and date the form, confirming approval of the consumer's choice regarding the HCA's tasks.
- Emergency Contact Information: Include the AHP's emergency phone number and fax number.
- Skilled Task Training Detail: Enter the name of each task, the date training was completed, and a detailed description of how the HCA will perform the task.
After completing the form, review it for accuracy. Ensure all necessary signatures and initials are present. Once confirmed, submit the form to the appropriate agency or individual as instructed.
Common mistakes
Filling out the Ohio JFS 02390 form is an important task that requires careful attention. However, many individuals make mistakes that can lead to delays or complications in the approval process. One common error is failing to provide complete information about the consumer. It is crucial to fill in all required fields, including the consumer's name, address, and recipient ID number. Omitting any of this information can result in the form being returned for correction, causing unnecessary delays.
Another frequent mistake is neglecting to have the authorized health care professional initial the approved tasks. Each task listed on the form must be accompanied by the initials of the authorized health care professional, indicating their approval. Without these initials, the Home Care Attendant cannot legally perform the designated tasks. This oversight can lead to confusion and may prevent the Home Care Attendant from providing necessary care.
In addition, individuals often forget to sign and date the form. Signatures are not just formalities; they signify agreement and understanding of the responsibilities involved. The consumer, Home Care Attendant, trainer, and authorized health care professional all need to sign and date the form. Missing signatures can halt the process and require resubmission of the entire document.
Finally, some people fail to update the form when changes occur. If there are any changes in the consumer’s health or circumstances, these must be reported to the Case Management Agency. Keeping the form current is essential for ensuring that the Home Care Attendant is authorized to perform the necessary tasks safely and effectively. Regular communication with the Case Manager can help prevent any lapses in care.
FAQ
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What is the Ohio JFS 02390 form?
The Ohio JFS 02390 form is a document used by the Ohio Department of Job and Family Services to authorize Home Care Attendants (HCAs) to perform medically necessary skilled tasks for consumers. This form ensures that HCAs have received the appropriate training and approval from an Authorized Health Care Professional (AHP) to carry out specific tasks as directed by the consumer or their authorized representative.
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Who needs to complete the Ohio JFS 02390 form?
Several parties are involved in completing this form. The consumer or authorized representative, the Home Care Attendant, the trainer, and the Authorized Health Care Professional must all provide their information and signatures. Each individual plays a crucial role in ensuring that the HCA is qualified to perform the designated tasks safely and effectively.
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What information is required on the form?
The form requires the consumer's name, address, and recipient ID number. It also includes sections for listing the skilled tasks the HCA has been trained to perform, along with the initials of the Authorized Health Care Professional for each task. Additionally, the form captures the signatures and dates for all parties involved, ensuring accountability and clarity.
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How long is the authorization valid?
The authorization on the Ohio JFS 02390 form is valid for a period not exceeding 12 months. After this period, the form must be updated, and the training details for the HCA must be re-evaluated to ensure continued compliance with the necessary standards.
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Can the authorization be revoked?
Yes, the authorization can be revoked at any time by the Authorized Health Care Professional. It is essential for the consumer or authorized representative to stay in communication with the AHP and report any changes in health or circumstances that may affect the HCA's ability to perform the tasks safely.
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What happens if the HCA cannot perform a task?
If the Home Care Attendant is unable to perform a task, they must report this to the consumer, the Case Management Agency (CMA) Case Manager, and the Authorized Health Care Professional. It is crucial to address any issues promptly to ensure the consumer receives the necessary care and support.
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Is there a specific training requirement for HCAs?
Yes, the form stipulates that HCAs must receive training for each skilled task they are authorized to perform. The trainer must verify that the HCA has successfully completed this training before the AHP initials the form, indicating approval for the HCA to proceed with the tasks.
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Where can I obtain the Ohio JFS 02390 form?
The Ohio JFS 02390 form can typically be obtained from the Ohio Department of Job and Family Services website or through local county Job and Family Services offices. It is important to ensure that you have the most current version of the form, as updates may occur.