Ohio Jfs 02390 Form Modify Form Here

Ohio Jfs 02390 Form

The Ohio JFS 02390 form is a critical document used to authorize skilled tasks for Home Care Attendants (HCAs) in Ohio. This form ensures that HCAs receive the necessary training and approval from authorized health care professionals before performing specific medical tasks for consumers. Understanding how to properly complete and utilize this form is essential for both consumers and caregivers in maintaining high standards of care.

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Table of Contents

The Ohio JFS 02390 form plays a crucial role in the home care system, ensuring that individuals receive the necessary assistance tailored to their specific health needs. This form is designed for use by consumers who require skilled care tasks to be performed by a Home Care Attendant (HCA). It outlines the essential steps for documenting the training and authorization of HCAs to perform these tasks safely and effectively. Consumers must provide their personal information, including their name, address, and recipient ID, along with a list of skilled tasks that the HCA has been trained to perform. Each task requires the approval of an Authorized Health Care Professional (AHP), who must initial the form to confirm the HCA’s competency. The form also emphasizes the responsibilities of all parties involved, including the consumer, the HCA, and the trainer, ensuring that everyone is aware of their roles and the importance of adhering to the outlined training protocols. By clearly documenting the training details and approval processes, the JFS 02390 form not only protects the consumer's health and safety but also provides a structured framework for accountability within the home care environment.

Form Sample

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

 

 

 

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 5101:3-46-04.1, as appropriate. I understand that this authorization may be revoked at any time by my authorizing health care professional. I am responsible for reporting any changes in my health or circumstances to the Case Management Agency (CMA) Case Manager, Trainer (if other than consumer, HCA, and Authorized Health Care Professional.

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 5101:3-46-94.1 or 5101:3-50-04.1, as appropriate, and as trained by the consumer, authorized representative and/or trainer. I understand that I am approved to perform on the listed task(s) for this consumer and that ODJFS may revoke that approval at any time if deemed necessary. I understand I am responsible for reporting any changes in my ability to perform the task(s) to the Consumer, CMA Case Manager, Trainer, and Authorized Health Care Professional.

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 non-support.

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)

 

 

 

 

 

 

Trainer Name (Please print)

Start Date

 

End Date

 

 

 

 

 

 

 

 

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

 

 

Task Training Detail

 

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

Form Information

Fact Name Description
Form Title Ohio JFS 02390 is titled "Home Care Attendant (HCA) Skilled Task Authorization."
Purpose This form authorizes Home Care Attendants to perform specific skilled tasks for consumers.
Consumer Information The form requires details such as the consumer's name, address, and recipient ID number.
Task Training Home Care Attendants must complete training for each skilled task listed on the form.
Health Care Professional Approval Authorized Health Care Professionals must initial each approved task to confirm training completion.
Governing Laws The form is governed by Ohio Administrative Code (OAC) Rule 5101:3-46-04.1 and 5101:3-50-04.1.
Revocation of Authorization Consumers can revoke authorization for the Home Care Attendant at any time.
Trainer's Role The trainer must verify that the Home Care Attendant has been successfully trained to perform the tasks.
Duration of Authorization The authorization period for tasks cannot exceed 12 months.
Emergency Contact The form requires an emergency phone number for the Authorized Health Care Professional.
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