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
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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
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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:
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Notes/Comments:
Assessment of Sleep has been reviewed and updated? (Displays for reassessment only)
Yes
Last update: 08/06/2014
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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
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