Assessment Domains Housing & Environment About this Domain (Housing & Environment) To gather information about the adequacy and safety of the person’s current living arrangement and to assess the need for assistance in making changes and/or modifications Housing & Environment Does the recipient live in a home or apartment that is owned or controlled by the PCA provider? No Yes Unsure If the person needed assistance to find a new place to live, are there any special considerations? No Yes Chose not to answer If ‘Yes’ was selected, the following question will be displayed: Check all that apply: Accessibility Distance from work/family/friends Location Pets Public Transportation Access Service Animal Other Other Last update: 08/06/2014 Page 1 of 4 Assessment Domains If the person has a physical disability, home has been adapted sufficiently to allow the person access to main areas of the home, bathroom, and bedroom? No Yes Chose not to answer Does the person have access to a private space within the home when desired? No Yes Chose not to answer Does the person have access to a telephone or other means of calling for help and assistance? No Yes Chose not to answer Has the person been evicted from his/her home, in the past? No Yes Explain: Chose not to answer (Displays when ‘Yes’ is checked) Are there any concerns with the safety, accessibility, or sanitary conditions? No Yes Chose not to answer If ‘Yes’ was selected, the following questions will be displayed: Last update: 08/06/2014 Page 2 of 4 Assessment Domains AREAS OF CONCERN: Areas that expose or may expose the person to accident, fire, burns, shock or other danger or risk to their health and safety. Check all that apply: Structural damage Barriers to access (including steps and stairs) Mold or water damage Lead-based paint Insects/Rodents or other pests Pet waste - indoor/outdoor Lighting - indoor/outdoor Smoke/Carbon monoxide detectors Electrical hazards/outlets/other fire hazards Plumbing/Sewage Hot/Cold water supply Heating/Cooling Appliances Unsanitary environment Cluttered living space Flooring/Rugs Other Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Specify: Notes/Comments: Assessment of Sleep has been reviewed and updated? (Displays for reassessment only) Yes Last update: 08/06/2014 Page 3 of 4 Assessment Domains Referrals (Housing & Environment) What is important to the individual? Referrals Needed: Advocacy Services Disability Linkage Line® (1-866-333-2466) Environmental Accessibility Consultation Follow-Up to Safety Concerns of lease Home Maker Assistance Housing Services Lead Agency Environmental Health Services Minnesota Department of Health Occupational Therapist Pest Control Protective Services Senior Linkage Line® (1-800-333-2433) Other Specify: Other Specify: (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) (Displays if checked) Assessed Needs and Support Planning Implications Referrals & Goals (Housing & Environment) has been reviewed and updated? (Displays for reassessment only) Yes Last update: 08/06/2014 Page 4 of 4