CM Vacation Report

This is 51 year old AAF. Patient is here for general physical exam for Medicaid application. Patient states that she has a pancrititis. For that reason, she can only perform vare minimal activities. Patient sates she cannot work for that same reason. Patient denies chest pain, reports SOB with minimal activy, denies N/V/ D, or fever. Patient denies depressive moods.

Pt is seen in the ER room and states that he is tired and had tremors so he came to the ER to be on the safe side. Daughter also states that he had tremors in the morning and. Patient's CC is that was tired and had tremors in the morning. States that he stays alone, was worried, and has no past history. Assessment of the head shows no sign of deformities or trauma. Neck shows no sign of deformities or trauma. Chest shows no sign of

Employment: Case Manager inquired to client regarding her employment background. Client stated that she was working for 3 weeks as childcare provider. Client stated that she was getting paid $100.00 per day.

On 8/25/2015 S/O EMT Perez was dispatched to PV-509 regarding severe leg pain. S/O EMT Perez knocked and announced his presence at the door and was verbally invited in by the resident a Mrs. Margaret Folkins. Mrs. Folkins stated that she had been in severe leg pain the entire day and she was having difficulty resting. Mrs. Folkins also stated that she was at the hospital for it the day prior because of it but the cause of the pain couldn’t be diagnosed. S/O EMT Perez asked Mrs. Folkins if she had fallen recently and if that was the reason for her visit to the hospital prior. Mrs. Folkins stated that she fall’s all the time but that wasn’t the reason for her visit to the hospital yesterday. The reason for Mrs. Folkins visit to the hospital yesterday

Client also reported she is participating in FEDCAP sporadically located at 92-31 Union Hall Street 4th floor Jamaica NY 11433 tel# 718-301-7297. Next appointment is 5/24/206

On 12/22/2015, CM normally meets with the client every Wednesday but client walking in the social services office stating tomorrow she will not be available to meet for face to face meeting because she will be going apartment hunting. CM completed Bi-Weekly ILP Review and provided client with a list of broker name and telephone numbers. In the meeting client was dressed appropriately for weather. She appears cooperative and friendly.

On 8/12/2016, CM met with the client to complete Bi-Weekly ILP Review. In the meeting CM observed that the client was wearing the same clothes from last session. She was hostile in the meeting. Client was wearing a yellow skirt and black blouse. Client was wearing summer hat, reading glasses and a mask covering her nose and mouth. CM also observed client had foul body odors. During the interview session client continues to be loquacious complaining that “People are out to get client and how residents are using Marijuana on her foot. Client continues to reports some of the residents here at the shelter are part of the “Russian Mafia” and when they used Marijuana on both leg it triggered the open wound ulcer and it cause it to discharge foul odor.

On 1/28/2016, CM met with the client to complete Bi-Weekly ILP Review and to follow up and client uncontrolled seizures disorder. In the meeting client continues to appear space out and disoriented. Her affect was flat.

On 4/6/2016, CM met with the client to complete Bi-Weekly ILP Review. In the meeting client was dressed in a brown jacket and beige pants and black sneaker. She was wearing reading glasses. During the session client reported she wasn’t feeling well she have a strep throat for the past 8 days. She reports coughing, fever and sore throat.CM inquires if the client met with the on-site medical staff client replies “No”. CM advises the client to see on-site medical staff. Client in the meeting was repeating the same things over and over.

SC met with Pa, for scheduled RA HV in Pa's home on 03/1/2016. The completed both the LCD and CMI assessment. Pa appeared clean, appropriately dressed in PJ's and sitting on the couch SC in the home. Present in the home were the Pa visiting nurse Scott from Millennium home care. He was on the phone trying to order the Pa medicines. Also Pa’s aide was present from the agency aide. Pa appeared weak and in discomfort. The SC asked Pa if she okay and she reported that she is in a lot of pain. The SC asked if she is taking her medications and she reported that she ran out that’s why the nurse is helping now. The SC asked the Pa how did that happen and she stated that when she saw her PCP in January for her post hospital and rehab discharged he

On 6/22/2016, CM met with the client and completed Bi-Weekly ILP Review. In the meeting client appears cooperative and friendly. She continues to appear to have some cognitive impairment/short term memories.

Client arrived early for the meeting. She was dressed appropriately for the weather. She appears her stage age. In the meeting client displays signs of narcissism. She often dictates to staff what she will do as opposed to working with staff. She has a huge problem opening up to people. She often speak about children, Churches and some neighborhood in Brooklyn in a condescending tone of voice. CM also bring to the client attention an Infraction Report for non-complain. CM also went over the Code of Conduct had the client signed it, and provided client with a copy. Client wasn’t to happy as she quote “whatever”.

CM was out on vacation for the period of 8/15/2015 to 8/24/2015. On 8/27/2015, CM met with the client to complete Bi-Weekly ILP Review. Client arrived early for the meeting. She was alert, satisfactorily groomed, and casually dressed. She barely made eye contact and when she did it was rapid. The client’s mood was balanced and her affect was flat. CM inquires how the client has been doing Since the last Bi-Weekly ILP Review. The client reports “not to good” she reports she applied for SSI because of what she is going through. CM requested for the client to describe what she is going through but the client refuses to disclose.

On 8/8/2016, CM met with the client to complete Bi-Weekly ILP Review. Client appears to be alert, cooperative and friendly. She was dressed appropriately for the weather. CM inquires how the client has being doing since the last Bi-Weekly ILP Review. Client replies “ok”. CM inquires if the client is more active in participating in onsite recreation activities. Client replies; she is able to participate in some and not all due her psoriatic arthritis.

Confirmed name and DOB. Patient states that she has had swelling and stiffness to the left knee x1 week. The patient denies pain to left knee or calf muscle. Also the patient denies limited RO or accident/fall that would cause swelling and stiffness. Instructed the patient if she starts to have severe pain to knee or calf, limited ROM, unable to be pressure of the left knee go to the ER. Schedule the patient an appt. Informed the patient to arrive 15mins early prior to appt. The patient agreed and verbalized understanding.