Client Care Observation

On 9/15/2016, CM met with the client for Bi-Weekly ILP Review. Client was dressed appropriately for the weather. She was well groomed. As usual client in the meeting was loquacious, and loud. Client continues to be hostile towards this worker. Client continues to repeat to this worker as quote: "I am not mad with you, and this has nothing to do with you. It's all about DHS and your supervisor." Client was hostile due to an Authorization of Release Form client signed for staff to contact her therapist Dr. Iris Yankelevich for a copy of the client psychosocial and psychiatrist evaluations. Client continues to report that she didn’t signed the Authorization of Release Form because the form stated that the form is for HRA 2010e and she doesn’t know how many time she need to repeat herself that she doesn’t meet the ‘CRITERAI FOR SRO”. CM tries to explain to the client that staff is requesting a copy of her psychosocial and psychiatrist evaluation, but then client continue to talk over CM and threat to contact the Coalition and DHS. Client continues to set in her way and refuses to work with staff to meet her unmet needs. CM observed that the client walk with a book bags and a small shopping cart. Client reported she walk with all her documents and letters from Adult Protective Services & Social Security Administration stating that she is capable of living independently.

CM Ayfer met the client at his home in Somerville, Client showed CM his apartment and his room it was clean and tidy. Client is a student at Banker Hill Community College and he has 4 classes during the week, Client reported that he has a difficulty with the Math classes, CM suggested maybe it will be helpful if we find a tutor so he can get an extra support. CM and client talked about ETV form CM explain to the client what the form is about. Client is looking for a new health provider in Somerville CM explained to him the process of transferring his medical report from Fitchburg to Somerville. CM will send him the care center which is accepting Mass Health as an insurance and taught him how he can register as anew patients. Client is working

CM was out on vacation from 5/3/2017 to 6/14/2017. On 6/20/2017, CM met with the client to complete Bi-Weekly ILP Review. Client was dressed in proper attire for the weather. Her affect and mood was appropriate. Client maintains eyes contact appropriately and she was oriented to person, place, time and situation. Client continue to deny suicidal or homicidal ideation

EMPLOYMENT UPDATE: Client is WECARE/FEDCAP exempt from work. Client submitted doctor note stating she cannot work due to medical problem.

CM was out for the period of 5/22/2015 to 6/9/2015. On 6/11/2015, CM met with the client and completed Bi-Weekly ILP Review. Client arrived early for the meeting. She was dressed appropriately for the weather. She appears to be friendly and cooperative. In the meeting the client was very talkative. She mentioned to CM her niece gave birth to a baby girl and she can wait to see the baby. She also mentioned to spoke with her sons last night and everything is well with her family. CM inquires if client participate in the onsite Recreation Activities. Client reported she doesn’t participate in the some of the activities. She prefers to go to Bread of Life for food and socialization.

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.

I- CM inquired if client returned LA Family Housing’s call to set up his CES assessment appointment. CM made client call LA Family Housing during the session, because client has not been able to make an appointment. CM informed client that he requested a dental consult with the VA liaison. CM inquired if client visited the Bob Hope Patriotic Hall to start his application for getting the “Veteran” label on his CA driver license. CM continued to inquire if client was interested in creating a savings plan. CM continued to assess client’s mental health and medication compliance

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 8/4/2015, CM met with the client and completed Bi-Weekly ILP Review. Client arrived early for the meeting. In the meeting client appeared her stated. She was alert, satisfactorily groomed, and casually dressed. She was cooperative and appropriate in the meeting. She sometimes made eye contact. She appears to have intellectual functioning disorder. She doesn’t grasp information like everyone else. Her conversation is always one side geared towards her son. She blamed everyone including her lawyer, LHMC and Case Planner of doing anything to help her get her son back. She continues to ambulate with a cane as she continues to quote “her leg is broken” but she is refusing medical attention. She appeared depressed but again she is refusing referral.

On July 2, 2015, the CP left a message at 11:41 a.m. regarding the missed intake appointment. She stated that she did not know the appointment time, the date of her last appointment, and her address changed. On July 6, 2015, the intake supervisor returned a telephone call to the CP; a left voicemail for the CP at 8:00 a.m. regarding an appointment rescheduled for August 3, 2015. On July 16, 2015, a letter was mailed to the CP for an intake appointment on August 3, 2015. On July 30, 2015, the intake supervisor received a telephone call from the CP regarding verification that she was at work on May 5, 2015. The CP was advised that the only information received from her was the Report/Request Form on May 28, 2015. The CP stated that she turned in a letter from her employer in June. The intake supervisor discussed with the CP that she had missed two intake appointments. The CP stated she would turn in documentation from her employer regarding the two missed appointments. The CP stated she did not know of the July 1, 2015 appointment. The intake supervisor asked the CP about her mailing address. The CP stated that she was staying at the Avon Street address and

Sw called pt to discuss the status of the home health request. Pt informed sw that he has an appt with Dr. Gabler on Monday, and will discuss the request. Pt says that he has been paying a friend to transport him to medical appointments. He will continue doing so until he is able to utilize the friends services as his provider with Medicaid. Pt did not list additional needs but states that he will contact sw if needs

Slid out of his wheelchair to the floor witness by staff. Back lounge monitoring staff observed patient sliding out of wheelchair to lie on the floor. Patient stated, "I wanted to lie on the floor because it helps my back. I put myself on the floor because of my back hurting. I don't need to go to the ER. I just need to lie down." Patient denies hitting his head while sliding out of his wheelchair, no visible bruising, no signs of bleeding noted. VS obtained. Patient advised that he can lie down while in his room. Patient noted getting up from the floor stating, "I'll go to my room and lie on the floor in my room." POD, NOD, CN notified of patient sliding out of his wheelchair so that he could lie on the floor because of his posterior back.

CM was out on vacation from the period of 5/31/2017 to 6/14/2017. On 6/20/2017, CM met with the client to complete Bi-Weekly ILP Review. Today, client was calm and quiet in the meeting. She was dressed appropriately for the weather. Client affects and mood was in appropriate. Client continues to appear to have cognitive impairment and she doesn’t grasp information. e.g. when try to explain herself she will have flight of ideas. She doesn’t provide a complete story of the event before she jumped into another subject.

Ms. Fawziyyah Ijelu, Case Manager (CM) met Ms. Williams, Client. Client arrived on time for her scheduled appointment with her youngest daughter Zoe Zigler. Ms. Williams informed CM her partner secured a job in Manhattan, NY a restaurant called Eataly for the overnight shift, Mr. Zigler working hours are 11pm to 7am. Ms. Williams also informed her CM she took the day off from work, since she had no one to watch her daughter. Ms. Williams daughters’ daycare is located in Far Rockaway Queens. At this present time client doesn’t want to change her daughters’ daycare, even though Ms. Williams is unable to make the trip to drop her daughter off at daycare. Ms. Williams mother will assist her too watch her granddaughter September 28, 2017 but,

At my time in the facility, only good observations were made, all the teachers and assistant acted professionally and seemed to know what they were doing. There is not much to say in regards to how to improve, but maybe devoting more time to the infants individually could help to further the relationships with each infant. As far as the three R’s go, the one that was most observed, reciprocal care was dealt with respect followed by respectful care and ending with responsive care, however the responsive care provided was very good in terms of showing an example of the care. In my own practice I now know that I should tell infants what I am doing as I am doing it in hopes of experiencing responsive care, I should give them options to choose from