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PCA Time and Activity Document |  |  |  |  |  |  |  |  |  |  | FAX TO: (612) 249-6469 |  |  |  |  |  |  |\n| --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- | --- |\n| 1. Activities* |  |  |  |  |  |  |  | Activities* |  |  |  |  |  |  |  |  |  |\n| Dressing |  |  |  |  |  |  |  | Dressing |  |  |  |  |  |  |  |  |  |\n| Grooming |  |  |  |  |  |  |  | Grooming |  |  |  |  |  |  |  |  |  |\n| Bathing |  |  |  |  |  |  |  | Bathing |  |  |  |  |  |  |  |  |  |\n| Eating |  |  |  |  |  |  |  | Eating |  |  |  |  |  |  |  |  |  |\n| Transfers |  |  |  |  |  |  |  | Transfers |  |  |  |  |  |  |  |  |  |\n| Mobility |  |  |  |  |  |  |  | Mobility |  |  |  |  |  |  |  |  |  |\n| Positioning |  |  |  |  |  |  |  | Positioning |  |  |  |  |  |  |  |  |  |\n| Toileting |  |  |  |  |  |  |  | Toileting |  |  |  |  |  |  |  |  |  |\n| Behavior |  |  |  |  |  |  |  | Behavior |  |  |  |  |  |  |  |  |  |\n| Health-Related |  |  |  |  |  |  |  | Health-Related |  |  |  |  |  |  |  |  |  |\n| IADL's |  |  |  |  |  |  |  | IADL's |  |  |  |  |  |  |  |  |  |\n| WEEK 1 | THUR | FRI | SAT | SUN | MON | TUE | WED | WEEK 2 | THUR | FRI | SAT |  | SUN | MON |  | TUE | WED |\n| mm/dd/yyyy | 3/10/19 | 3/11/19 | 3/12/19 | 3/13/19 | 3/14/19 | 3/15/19 | 3/16/19 | mm/dd/yyyy | 3/17/19 | 3/18/19 | 3/19/19 |  | 3/20/19 | 3/21/19 |  | 3/22/19 | 3/23/19 |\n| Time IN* | \\#NAME?\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | Time IN* | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM |  | AM\u003Cbr>PM | AM\u003Cbr>PM |  | AM\u003Cbr>PM | AM\u003Cbr>PM |\n| Time OUT* | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | Time OUT* | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM |  | AM\u003Cbr>PM | AM\u003Cbr>PM |  | AM\u003Cbr>PM | AM\u003Cbr>PM |\n| Time IN | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | Time IN | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM |  | AM\u003Cbr>PM | AM\u003Cbr>PM |  | AM\u003Cbr>PM | AM\u003Cbr>PM |\n| Time OUT |  |  |  |  |  |  |  | Time OUT |  |  |  |  |  |  |  |  |  |\n|  | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM |  | AM\u003Cbr>PM | AM\u003Cbr>PM | AM\u003Cbr>PM |  | AM\u003Cbr>PM | AM\u003Cbr>PM |  | AM\u003Cbr>PM | AM\u003Cbr>PM |\n| Daily Hrs: | * | * | * | * | * | * | * | Daily Hrs: | * | * | * |  | * | * |  | * | * |\n| WEEK 1 |  |  |  | 1:1 Total hours: |  | * |  | WEEK 2 |  |  |  | 1:1 Total hours: |  |  | * |  |  |\n| Acknowledgements & Signatures:\u003Cbr>After the PCA has documented his/her time and activity, the recipient must draw a line through any dates and times he/she did not receive services from the PCA. Review the completed time sheet for accuracy before signing. It is a federal crime to provide false information on PCA billings for Medical Assistance payment. Your signature verifies the time and services entered above are accurate and that the services were performed as specified in the PCA Care Plan . |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |  |\n| Print Recipient Name |  |  |  |  | MA \\# or DOB |  |  | Please use standard 12 hr time, in 15 min increments, with minutes noted. |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  | Timesheet must indicate A(AM) or P(PM) for every Time IN and every Time OUT. |  |  |  |  |  |  |  |  |  |\n| Recipient/Responable Party Signature: |  |  |  |  | Date: |  |  | Every date box must have month/day/year entered for entire timesheet. |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  | Timesheet must be filled out each shift. |  |  |  |  |  |  |  |  |  |\n|  |  |  |  |  |  |  |  | Timesheet must be an ORIGINAL timesheet-not photocopied. |  |  |  |  |  |  |  |  |  |\n| I certify and swear under penalty of law that I have accurately reported on this time sheet the hours I actually worked, the services I provided, and the dates and times worked. I understand that misreporting my hours is fraud for which I could face criminal prosecution and civil proceedings. |  |  |  |  |  |  |  | Incomplete, incorrect, or illegible timesheets canno","cbCaimxYcyu9CWLp","https://ap.wps.com/l/cbCaimxYcyu9CWLp","pdf",132002,"English","# Activities\n## Time IN/Time OUT entries\n## Daily totals and weekly summary\n# Acknowledgements & Signatures","[{\"question\":\"What activities categories are included on the PCA time sheet?\",\"answer\":\"The form includes Dressing, Grooming, Bathing, Eating, Transfers, Mobility, Positioning, Toileting, Behavior, and Health-Related activities including IADL’s.\"},{\"question\":\"How should Time IN and Time OUT be recorded?\",\"answer\":\"Use standard 12-hour time in 15-minute increments and indicate A(AM) or P(PM) for every Time IN and every Time OUT.\"},{\"question\":\"What are the signature and legal requirements for the timesheet?\",\"answer\":\"The recipient/responsible party and the PCA must print names and sign and date as required for validity. The acknowledgements state that false information on PCA billings is a federal crime and that misreporting hours is fraud.\"}]","VALLEY VIEW HOME CARE LLC. PCA Time and Activity Document - Timesheet Template | PDF",1790076377]