ATTENTIVE HOME CARE
Statement of Home Care Services
STATE EVALUATION: COMPREHENSIVE HOME CARE PROVIDERS (144A )
Home Care Provider Name:
Below is a list of all services that may be provided with a comprehensive home care license. Each service offered by this provider is indicated by a check in the box next to the service.
☑ Advanced practice nurse services
☑ Registered nurse services
☑ Licensed practical nurse services
☐ Physical therapy services
☐ Occupational therapy services
☐ Speech-language pathologist services
☐ Respiratory therapy services
☐ Social worker services
☐ Dietician or nutritionist services
☑ Medication management services
☑ Delegated tasks to unlicensed personnel
☑ Hands-on assistance with transfers and mobility
☑ Treatment and therapies
☑ Eating assistance for clients with complicating eating problems (i.e. difficulty swallowing, recurrent lung aspirations, or requiring the use of a tube, parenteral or intravenous instruments)
☑ Complex or specialty healthcare services Describe: Dementia, Alzheimer’s
☑ Assistance with dressing, self-feeding, oral hygiene, hair care, grooming, toileting, and bathing
☑ Standby assistance within arm’s reach for safety while performing daily activities
☑ Verbal or visual reminders to take regularly scheduled medication (includes bringing clients previously set-up medication, medication in original containers, or liquid or food to accompany the medication)
☑ Verbal or visual reminders to the client to perform regularly scheduled treatments and exercises
☑ Preparing modified diets ordered by a licensed health professional
☑ Laundry
☑ Housekeeping/other household chores
☑ Meal preparation
☑ Shopping
By signing below, I acknowledge that I have received a copy of this Statement of Home Care Services.
Minnesota Department of Health
Health Regulation Division
Home Care
PO Box 3879
St. Paul, MN 55101-3879
651-201-4200
health.homecare@state.mn.us
www.health.state.mn.us
12/30/2022
To obtain this information in a different format, call: 651-201-4200
