Describe the service activities provided by the CDAC provider. Enter the amount of time per day and the number of days per week or month required to provide the activity. Enter “Not applicable” (NA) for components of the CDAC service that will not be provided. *Reminders, cueing, and supervision are not billable CDAC services. Non-Skilled Service Components. To be completed by the member or member’s legal representative. Describe CDAC Provider Activity as allowable by the Iowa Administrative Code. List the amount of time required each day for each activity. Number of days service will be provided per month. Total minutes for the line. N1 Dressing 0 N2 Bathing, grooming, personal hygiene – includes shaving, hair care, make-up, and oral hygiene. 0 N3 Meal preparation and feeding – includes cooking, eating, and feeding assistance (but not the cost of meals themselves). 0 N4 Toileting – includes bowel, bladder, and catheter assistance (emptying the catheter bag, collecting a specimen, and cleaning the external area around the catheter). 0 N5 Transferring, ambulation, mobility – includes access to and from bed or a wheelchair, repositioning, and mobility in general. 0 N6 Essential housekeeping – activities which are necessary for the health and welfare of the member such as grocery shopping, laundry, general cleaning. 0 N7 Minor wound care – includes foot care, skin care, nail trimming, and skin/nail observation and inspection. 0 Member Name:
Non-Skilled Service Components. To be completed by the member or member’s legal representative. Describe CDAC Provider Activity as allowable by the Iowa Administrative Code. List the amount of time required each day for each activity. Number of days service will be provided per month. Total minutes for the line. N8 Financial and scheduling assistance – includes money management, cognitive tasks, and scheduling personal business matters. 0 N9 Assistance in the workplace – assistance with self-care tasks, environmental tasks, and medical supports necessary for the member to perform a job. Assistance with understanding and completing essential job functions is not included. 0 N10 Communication – includes interpreting, reading services, assistance with communication devices, and supports that address the member’s unique communication needs. This does not include reading mail, newspapers or helping the member 'talk' to friends. 0 N11 Essential transportation – assisting or accompanying the member in using transportation essential to the health and welfare of the member. 0 N12 Medication assistance – includes assisting the member in sorting, storing, organizing, and taking medications ordinarily It also includes medication equipment maintenance and medication administration. 0 Member Name:
Skilled Service Components. To be completed by the member, member’s legal guardian, nurse/ therapist, and CDAC provider. Describe CDAC Provider Activity as allowable by the Iowa Administrative Code. List the amount of time required each day for each activity. Number of days service will be provided per month. Total minutes for the line. S8 Colostomy care. 0 S9 Care of medical conditions out of control (includes brittle diabetes and comfort care of terminal conditions) when hospice is not utilized. 0 S10 Post-surgical nurse delegated activities under the supervision of the licensed nurse. 0 S11 Monitoring medication requiring close supervision because of a fluctuating physical or psychological condition. 0 S12 Preparing and monitoring responses to therapeutic diets. 0 S13 Recording and reporting of changes in vital signs to the nurse or therapist. 0 Total Minutes 0 Enter the number in the “Total Units” box into the Total Units Per Month box below: 0 Member Name: