Statement of Home Care Services

STATE EVALUATION: COMPREHENSIVE HOME CARE PROVIDERS (144A )

☑ 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.
Clear Signature
MM slash DD slash YYYY
Minnesota Department of Health
Health Regulation Division
HomeCare
POBox3879
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.
This field is for validation purposes and should be left unchanged.

For Display Only

Schedule Appointment

This field is for validation purposes and should be left unchanged.