Lic 602A Template

The LIC 602A form is a Physician's Report required for Residential Care Facilities for the Elderly (RCFE) in California. This form gathers essential health information about a resident or prospective resident to ensure appropriate care is provided in a non-medical facility. Completing this form accurately is crucial for compliance with state regulations and the well-being of residents.

To fill out the LIC 602A form, click the button below.

Table of Contents

The LIC 602A form plays a crucial role in the admission process for residents in California's Residential Care Facilities for the Elderly (RCFE). This form, officially titled the Physician's Report for Residential Care Facilities for the Elderly, is designed to ensure that prospective residents receive appropriate care tailored to their medical needs. It begins with essential facility and resident information, including the facility's name, address, and license number, as well as the resident's name, birth date, and age. One of the key components of the LIC 602A is the authorization for the release of medical information, which must be completed by the resident or their legal representative. This ensures that the facility can access necessary medical history to provide the best possible care. The physician's section is particularly important, as it requires detailed information about the resident's health status, including diagnoses, treatment plans, and any potential need for supervision. The form also addresses various health conditions, such as cognitive impairments, allergies, and physical health status, allowing caregivers to understand the unique needs of each resident. By compiling this information, the LIC 602A helps facilities determine if they can adequately support the resident’s health and well-being in a non-medical care environment.

Lic 602A Sample

California Health & Human Services Agency

California Department of Social Services

MEDICAL ASSESSMENT FOR RESIDENTIAL CARE FACILITIES FOR THE ELDERLY

NOTE TO LICENSED MEDICAL PROFESSIONAL: The person/patient named below is either a prospective resident or resident of a Residential Care Facility for the Elderly (RCFE) licensed by the Department of Social Services. The licensee is required to provide primarily non-medical care and supervision to meet the needs of that person/patient. The information that you provide about this person/patient is required by law to assist in determining whether the person/patient is appropriate for care in this non-medical facility [California Code of Regulations (CCR), Title 22, Section 87458, Medical Assessment]. THESE FACILITIES CANNOT PROVIDE SKILLED NURSING CARE.

This form is provided as a courtesy to prospective residents/residents and licensees.

(Please attach separate pages if needed.)

I.FACILITY INFORMATION (To be completed by the licensee/designee)

NAME OF FACILITY/FACILITY CONTACT PERSON

PHONE NUMBER

E-MAIL ADDRESS

ADDRESS

CITY

ZIP CODE

II.PROSPECTIVE RESIDENT/RESIDENT INFORMATION (To be completed by the prospective resident/resident or prospective resident’s/resident’s legal representative)

NAME	DATE OF BIRTH	AGE

ADDRESS	CITY	ZIP CODE

III. AUTHORIZATION FOR RELEASE OF MEDICAL INFORMATION

(To be completed by prospective resident/resident or prospective resident’s/resident’s legal representative)

I hereby authorize release of medical information in this report to the facility named above.

I acknowledge that by providing my electronic signature for this form, I agree my electronic signature is the legal binding equivalent to my handwritten signature. I hereby confirm that my electronic signature represents my execution of authentication of this form, and my intent to be bound by it.

SIGNATURE OF PROSPECTIVE RESIDENT/RESIDENT OR	DATE
PROSPECTIVE RESIDENT’S/RESIDENT’S LEGAL REPRESENTATIVE

IV. PROSPECTIVE RESIDENT/RESIDENT INFORMATION
(To be completed by the licensed medical professional)

DATE OF EXAM

GENDER

HEIGHT

WEIGHT

BLOOD PRESSURE

LIC 602A (4/25) (CONFIDENTIAL)

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California Health & Human Services Agency	California Department of Social Services

DIAGNOSIS/DIAGNOSES

a.Please indicate the prospective resident’s/resident’s diagnosis/diagnoses:

b.Treatment/medication (type and dosage)/equipment:

c. Can prospective resident/resident manage own treatment/medication/equipment?	Yes	No
If no, describe what assistance is needed:

DEFINITIONS

Mild Cognitive Impairment (MCI): Refers to cognitive abilities that are in a “conditional state” between normal aging and dementia.

Major Neurocognitive Disorder (major NCD): Refers to substantially decreased cognitive or mental function due to a medical disease other than a psychiatric illness. Major NCD includes Alzheimer’s disease and related disorders diagnosed by a licensed medical professional acting within their scope of practice. Related disorders considered to be major NCDs include, but are not limited to, vascular dementia, Lewy body dementia, Parkinson’s disease, and frontotemporal dementia. Major NCDs cause impairment that is sufficient enough to interfere with independence in daily activities and may result in changes that include, but are not limited to, increased tendency to wander and decreased hazard awareness and ability to communicate.

COGNITIVE CONDITIONS
a. Does prospective resident/resident have any cognitive conditions?	Yes	No

If yes, please indicate cognitive condition(s): _______________________________________________

b. Treatment/medication (type and dosage)/equipment:

c. Can prospective resident/resident manage own treatment/medication/equipment?	Yes	No
If no, describe what assistance is needed:

RESULTS OF EXAM FOR COMMUNICABLE TUBERCULOSIS (TB)

DATE TB TEST GIVEN	DATE TB TEST READ	TYPE OF TB TEST	RESULTS OF TB TEST

Action taken (if positive):

LIC 602A (4/25) (CONFIDENTIAL)

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California Health & Human Services AgencyCalifornia Department of Social Services

RESULTS OF EXAM FOR INFECTIOUS DISEASES

a. Does prospective resident/resident have any infectious diseases? Yes No

If yes, please indicate infectious disease(s): ________________________________________________

b. Treatment/medication (type and dosage)/equipment:

c. Can prospective resident/resident manage own treatment/medication/equipment?	Yes	No
If no, describe what assistance is needed:

RESULTS OF EXAM FOR CONTAGIOUS DISEASES

a. Does prospective resident/resident have any contagious diseases? Yes No

If yes, please indicate contagious disease(s): _______________________________________________

b. Treatment/medication (type and dosage)/equipment:

c. Can prospective resident/resident manage own treatment/medication/equipment?	Yes	No
If no, describe what assistance is needed:

RESULTS OF EXAM FOR OTHER MEDICAL CONDITIONS

a. Does prospective resident/resident have any other medical conditions? Yes No

If yes, please indicate other medical condition(s): ____________________________________________

b. Treatment/medication (type and dosage)/equipment:

c. Can prospective resident/resident manage own treatment/medication/equipment?	Yes	No
If no, describe what assistance is needed:

LIC 602A (4/25) (CONFIDENTIAL)

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California Health & Human Services AgencyCalifornia Department of Social Services

ALLERGIES
a.	Does prospective resident/resident have any allergies (e.g., seasonal, food, medication, dander)?
	Yes	No
	If yes, please indicate allergy(ies): ________________________________________________________
b.	Treatment/medication (type and dosage)/equipment:

c. Can prospective resident/resident manage own treatment/medication/equipment? Yes	No
If no, describe what assistance is needed:

1.	OVERALL PHYSICAL HEALTH		GOOD	FAIR	POOR

PHYSICAL HEALTH STATUS		YES	NO	ASSISTIVE DEVICE	EXPLAIN
				(If applicable)
a.	Hearing Loss

b.	Vision Loss

c.	Wears Dentures

d.	Wears Prosthesis

e.	Special Diet

f.	Substance Abuse

g. Use of Alcohol

h. Use of Nicotine or Related
	Products
i.	Bowel Incontinence

j.	Bladder Incontinence

k.	Motor Impairment/Paralysis

l.	Requires Assistance with
	Repositioning and Transferring
m. History of Skin Condition or
	Breakdown
COMMENTS:

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California Health & Human Services Agency				California Department of Social Services



2.	CAPACITY FOR SELF-CARE	YES	NO	EXPLAIN

a.	Able to Bathe Self

b.	Able to Dress/Groom Self

c. Able to Feed Self

d.	Able to Care for Own Toileting
	Needs
e. Able to Manage Own Cash
	Resources
f.	Able to Communicate

g.	Able to Follow Directions/
	Instructions
h.	Able to Leave Facility
	Unsupervised (considering
	physical or cognitive abilities);
	if no, please explain.

COMMENTS:

3.	OVERALL MENTAL HEALTH	GOOD		FAIR	POOR

MENTAL HEALTH STATUS		YES	NO		EXPLAIN

a.	Depressed

b.	Suicidal Ideation

c.	Self-Abuse

d. Other

COMMENTS:

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California Health & Human Services Agency				California Department of Social Services



4.	BEHAVIORAL EXPRESSIONS*	YES	NO	EXPLAIN

a.	Disorientation

b.	Lack of Hazard Awareness

c. Lack of Impulse Control

d.	Unsafe Wandering**

e.	Elopement***

f.	Expressions of Frustration

g.	Hallucinations

h.	Other

*“Behavioral expression” means behavior or behaviors displayed by a resident that may result in harm to self or others including, but not limited to, unsafe wandering, or elopement, expressions of frustration, disorientation, hallucinations, or lacking in hazard awareness or impulse control. Behavioral expression may be due to boredom, fear, overstimulation, perceived threat, fatigue, physical discomfort, pain, “Major Neurocognitive Disorder (major NCD)”, or other causes including, but not limited to, medication interactions and/or illnesses such as urinary tract infections.

**“Unsafe wandering” occurs when a resident at risk enters an area that is physically hazardous or contains items that are potential safety hazards. For example, unsafe wandering may occur when a resident enters another resident’s room when doing so may lead to an altercation or contact with hazardous items.

***“Elopement” occurs when a resident who is at risk of harm due to their cognitive condition leaves the facility unsupervised, or while in the licensee’s care, leaves another safe location unsupervised.

COMMENTS:

LIC 602A (4/25) (CONFIDENTIAL)

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California Health & Human Services Agency		California Department of Social Services



5. ACCESS TO ITEMS	YES NO	EXPLAIN

Would the prospective resident’s/ resident’s or other resident’s safety be at risk if the resident had access to the following items:

a.Personal care and hygiene items

b.Disinfectants, cleaning solutions, poisonous substances, knives, matches, tools, sharp objects, and other similar items which could pose a danger to residents.

c.Nutritional supplements, vitamins, alcohol, cigarettes and other potentially toxic substances, such as certain plants, gardening supplies, and auto supplies.

Does the prospective resident/resident require supervision by the licensee when in proximity to or when there is use of:

a.Ranges, ovens, heaters, fireplaces, wood stoves, inserts, and other heating devices.

b.Fishponds, wading pools, hot tubs, swimming pools, or similar large bodies of water.

c.Birdbaths, fountains, or similar smaller decorative water features.

COMMENTS:

LIC 602A (4/25) (CONFIDENTIAL)

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California Health & Human Services Agency				California Department of Social Services



6. MEDICATION MANAGEMENT	YES	NO	N/A	EXPLAIN

a. Able to Administer Own
Prescription Medications
b. Able to Administer Own
Injections
c. Able to Perform Own Glucose
Testing
d. Able to Administer Own PRN
Medications
e. Able to Administer Own
Oxygen
f. Able to Store Own
Medications
COMMENTS:

AMBULATORY STATUS:

a. 1. The prospective resident/resident is able to independently transfer to and from bed:

Yes

2.For purposes of a fire clearance, this prospective resident/resident is considered:

Ambulatory Nonambulatory Bedridden

Nonambulatory: The prospective resident/resident is unable to leave a building unassisted under emergency conditions. This includes, but is not limited to, a prospective resident/resident who depends upon mechanical aids such as crutches, walkers, and wheelchairs. It also includes a prospective resident/resident who is unable, or likely to be unable, to respond physically or mentally to a sensory signal approved by the State Fire Marshal, or an oral instruction relating to fire or other dangers, and if unassisted, to take appropriate action relating to such danger.

Note: A prospective resident/resident who is unable to independently transfer to and from bed, but who does not need assistance to turn or reposition in bed, shall be considered non-ambulatory for the

purposes of a fire clearance.

Bedridden: For the purpose of a fire clearance, this means a prospective resident/resident who requires assistance with turning or repositioning in bed.

b. If prospective resident/resident is nonambulatory, this status is based upon:

Physical Condition	Mental Condition	Both Physical and Mental Condition


LIC 602A (4/25) (CONFIDENTIAL)		Page 8 of 9

California Health & Human Services Agency	California Department of Social Services

c.If a prospective resident/resident is bedridden, check one or more of the following and describe the nature of the illness, surgery or other cause:

Illness: _______________________________________________________________________

Recovery from Surgery: __________________________________________________________

Other: ________________________________________________________________________

NOTE: An illness or recovery is considered temporary if it will last 14 days or less.

d.If a prospective resident/resident is bedridden, how long is bedridden status expected to persist?

1.________ (number of days)

2.______________________ (estimated date illness or recovery is expected to end or when prospective resident/resident will no longer be confined to bed)

3.If illness or recovery is permanent, please explain:

e.Is prospective resident/resident receiving hospice care?

No	Yes If yes, specify the terminal illness: ___________________________________

COMMENTS:

V. LICENSED MEDICAL PROFESSIONAL INFORMATION

LICENSED MEDICAL PROFESSIONAL NAME AND ADDRESS (PRINT)

PHONE NUMBER

E-MAIL ADDRESS

LENGTH OF TIME YOU HAVE PROVIDED CARE TO PROSPECTIVE RESIDENT/RESIDENT

LICENSED MEDICAL PROFESSIONAL SIGNATURE

DATE

LIC 602A (4/25) (CONFIDENTIAL)

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▼ Lic 602A PDF Form

Document Attributes

Fact Name	Description
Purpose	The LIC 602A form is a Physician's Report required for residents of Residential Care Facilities for the Elderly (RCFE) in California.
Governing Law	This form is governed by California Health and Safety Code, Section 1569.69.
Facility Information	Section I of the form requires details about the facility, including its name, address, and license number.
Resident Information	Section II collects personal information about the resident, such as their name, birth date, and age.
Authorization	Residents or their legal representatives must authorize the release of medical information in Section III.
Physician's Role	Physicians must complete Section IV, providing a diagnosis and health status relevant to the resident's care needs.
Non-Medical Care	The form emphasizes that RCFE facilities provide primarily non-medical care, not skilled nursing care.
Tuberculosis Testing	Section IV includes specific requirements for tuberculosis testing, including dates and results.
Health Assessments	Sections on physical and mental health status assess the resident's ability to perform daily activities and manage medications.
Confidentiality	The LIC 602A form is marked as confidential, ensuring that the information is protected and only shared with authorized parties.

Lic 602A: Usage Instruction

Completing the Lic 602A form is an important step in ensuring that the necessary medical information is accurately reported for residents in a residential care facility for the elderly. This form requires input from various parties, including the facility licensee, the resident or their representative, and a physician. Each section must be filled out carefully to ensure compliance with the requirements set forth by the California Department of Social Services.

Facility Information: Fill in the name of the facility, telephone number, address, city, zip code, licensee’s name, and their telephone number. Also, include the facility license number.
Resident/Patient Information: Provide the resident's name, birth date, and age.
Authorization for Release of Medical Information: The resident or their legal representative must sign to authorize the release of medical information. Include their address and the date of signing.
Patient's Diagnosis: The physician will complete this section. They should include the date of examination, sex, height, weight, blood pressure, and details of the tuberculosis test, including dates, type, and results.
Primary Diagnosis: The physician must provide the primary diagnosis, any treatments or medications, and whether the patient can manage their own treatment.
Secondary Diagnosis(es): Similar to the primary diagnosis, detail any secondary conditions, treatments, and the patient's ability to manage them.
Contagious/Infectious Disease: Indicate if the patient has any contagious diseases and provide necessary details.
Allergies: List any known allergies, treatments, and the patient’s ability to manage their own care.
Other Conditions: Document any other medical conditions, treatments, and management capabilities.
Physical Health Status: Answer questions regarding the patient’s physical health and any assistive devices they may require.
Mental Condition: Assess the resident's mental health status and any relevant behaviors.
Capacity for Self-Care: Evaluate the patient’s ability to perform daily activities independently.
Medication Management: Determine the resident's ability to manage their own medications.
Ambulatory Status: Assess the resident’s ability to transfer independently and their status regarding ambulatory needs.

Frequently Asked Questions

What is the purpose of the LIC 602A form?
The LIC 602A form serves as a Physician's Report for Residential Care Facilities for the Elderly (RCFE) in California. It is designed to collect essential health information about a resident or prospective resident. This information helps the facility determine if the individual is suitable for non-medical care and supervision, as required by state regulations.
Who is responsible for completing the LIC 602A form?
The form is divided into sections that must be completed by different parties:
- The licensee or their designee fills out the facility information.
- The resident or their responsible person provides personal details.
- A physician is responsible for completing the medical information section, including diagnoses and treatment plans.
What type of information is required from the physician?
The physician must provide a comprehensive overview of the resident's health status. This includes:
- Basic information such as height, weight, and blood pressure.
- Results from tuberculosis tests and any necessary follow-up actions.
- Primary and secondary diagnoses, including treatment plans and the resident's ability to manage their own care.
- Details about any allergies, cognitive impairments, and physical or mental health conditions.
All information must be accurate and complete to ensure appropriate care can be provided.
Is the information on the LIC 602A form confidential?
Yes, the LIC 602A form is marked as confidential. The information contained within it is protected and should only be shared with authorized personnel involved in the care of the resident. This confidentiality is crucial to maintain the privacy and trust of the individual receiving care.

Common mistakes

Filling out the Lic 602A form can be straightforward, but many people make common mistakes that can lead to delays or complications. One frequent error is leaving out important information. For instance, all sections must be completed, including the facility and resident information. Omitting details like the facility's address or the resident's birth date can cause issues. Always double-check to ensure no fields are left blank.

Another mistake occurs when signatures are missing. The section for the authorization of medical information requires the resident or their legal representative to sign. Without this signature, the form may be considered incomplete. It’s essential to ensure that all necessary signatures are included before submission.

People often misinterpret the medical questions as well. The physician's section asks for specific details about the resident's health status, including their diagnosis and any medications. Misunderstanding these questions can lead to inaccurate or vague responses. Providing clear and accurate information helps ensure that the resident receives appropriate care.

Additionally, some individuals fail to check the boxes related to the resident’s health conditions. For example, if the resident has allergies or cognitive impairments, these must be indicated. Not marking these boxes can result in a lack of necessary accommodations or care adjustments.

Finally, another common mistake is not providing sufficient explanations in the sections that ask for details about the resident’s health conditions. Simply stating “no” or “yes” without elaboration can leave healthcare providers without crucial context. Clear explanations help caregivers understand the resident’s needs better and ensure they receive the right support.

Documents used along the form

The Lic 602A form is essential for documenting the health status of residents in residential care facilities for the elderly in California. Along with this form, several other documents play a crucial role in ensuring comprehensive care and compliance with regulations. Below is a list of these documents, each with a brief description.

LIC 500 - Application for a License: This form initiates the licensing process for a residential care facility. It collects information about the facility, its owners, and its proposed operations.
LIC 610 - Emergency Disaster Plan: This document outlines procedures for responding to emergencies, ensuring the safety of residents and staff during disasters.
LIC 701 - Personnel Report: This report provides details about the staff members, including qualifications and background checks, to ensure they meet state requirements.
LIC 9050 - Facility Sketch: A visual representation of the facility layout, this sketch helps in understanding the physical environment and safety measures in place.
LIC 308 - Designation of Facility Responsibility: This form designates a responsible party for the facility, ensuring accountability in operations and resident care.
LIC 9221 - Plan of Operation: This document outlines the facility's operational policies and procedures, including care services provided to residents.
LIC 602 - Physician's Report: Similar to the LIC 602A, this form provides a detailed medical evaluation of the resident, focusing on their medical history and current health status.
LIC 702 - Staff Training Record: This record tracks the training and certifications of staff members, ensuring they are equipped to provide quality care.
LIC 811 - Incident Report: This form is used to document any incidents or accidents involving residents, which is crucial for maintaining safety and compliance.
LIC 9102 - Personal Rights: This document outlines the rights of residents, ensuring they are informed about their rights and protections within the facility.

Each of these documents serves a specific purpose, contributing to the overall framework of care and compliance in residential care facilities. Properly managing and maintaining these forms not only ensures adherence to regulations but also promotes a safe and supportive environment for residents.

Similar forms

LIC 602 Form: Like the Lic 602A, this form is also used in California for documenting the medical history and needs of residents in care facilities. It serves a similar purpose in assessing the suitability of individuals for care.
LIC 500 Form: This document is required for licensing residential care facilities. It includes information about the facility's operation and is essential for compliance, just as the Lic 602A ensures proper medical assessment.
LIC 610 Form: This form details the admission agreement between the resident and the facility. It parallels the Lic 602A by ensuring that all necessary information is shared for proper care and understanding of the resident's needs.
LIC 700 Form: This is a record of the facility’s staff qualifications and training. Similar to the Lic 602A, it ensures that the facility is equipped to meet the medical and personal needs of residents.
LIC 808 Form: This form is used to report incidents within the facility. Like the Lic 602A, it is crucial for maintaining the health and safety of residents by documenting any significant events that could impact their care.
LIC 9182 Form: This form is for the application for a license to operate a care facility. It shares similarities with the Lic 602A in that both are foundational documents needed for the proper functioning of care facilities.
PH-27 Form: This is a health assessment form used for various health care settings. It is similar to the Lic 602A in that it collects essential health information about individuals to ensure appropriate care.
SB 893 Form: This form is used for reporting elder abuse. It parallels the Lic 602A by addressing the health and safety of elderly individuals in care facilities, ensuring they receive the protection they need.
Patient Health Questionnaire (PHQ-9): This screening tool assesses mental health, much like the mental condition section of the Lic 602A. Both aim to identify issues that may affect a resident's care and quality of life.
Medication Administration Record (MAR): This document tracks medications given to residents. Similar to the Lic 602A, it ensures that residents receive the correct medications and helps manage their health needs effectively.

Dos and Don'ts

When filling out the Lic 602A form, it’s essential to approach the task with care and attention to detail. Here are six important guidelines to follow, as well as some common pitfalls to avoid.

Do double-check all information. Ensure that names, dates, and other personal details are accurate.
Do provide complete medical history. Include all relevant diagnoses, treatments, and medications.
Do sign and date the authorization section. This step is crucial for the release of medical information.
Do clarify any medical conditions. Use additional pages if necessary to explain complex health issues.
Don't leave any sections blank. Incomplete forms can delay processing and care.
Don't omit the physician's signature. Ensure that the physician completes and signs the required sections.

By adhering to these guidelines, you can help ensure that the Lic 602A form is filled out correctly and efficiently. Proper completion of this form is vital for the well-being of the resident and the smooth operation of the facility.

Misconceptions

The following are common misconceptions about the Lic 602A form, along with clarifications to help understand its purpose and requirements.

Misconception 1: The Lic 602A form is only for current residents.

This form is also required for prospective residents, ensuring that their health needs are assessed before admission to a residential care facility.

Misconception 2: The form is only concerned with physical health.

In addition to physical health, the Lic 602A form addresses mental health conditions, medication management, and capacity for self-care.

Misconception 3: Completing the form is optional.

The completion of this form is mandated by law to determine the suitability of a resident for non-medical care in a facility.

Misconception 4: All facilities provide skilled nursing care.

Residential care facilities primarily offer non-medical care. The form helps ensure that residents do not require skilled nursing services.

Misconception 5: The physician's report is not confidential.

The Lic 602A form is marked as confidential, and the information contained within it is protected to respect the privacy of the resident.

Misconception 6: Only doctors can complete the form.

While a physician must provide medical information, the form can be initiated by the resident or their legal representative.

Misconception 7: The form does not require a signature.

A signature from the resident or their legal representative is necessary to authorize the release of medical information.

Misconception 8: The form is only for elderly residents.

Although it is designed for residential care facilities for the elderly, it can also apply to younger individuals who meet the criteria for care.

Misconception 9: The Lic 602A form is not important for care planning.

The information gathered from this form is crucial for developing a tailored care plan that meets the specific needs of each resident.

Key takeaways

Filling out the Lic 602A form is an important step in ensuring that residents receive appropriate care in a residential care facility for the elderly. Here are key takeaways to keep in mind:

The form is divided into four main sections: facility information, resident information, authorization for medical information release, and the physician's diagnosis.
Accurate completion of the facility information section is crucial. This includes the facility's name, address, and license number.
The resident or their responsible person must fill out the resident information section, which includes the resident's name, birth date, and age.
Authorization for the release of medical information must be signed by the resident or their legal representative. This step is essential for compliance with privacy regulations.
Physicians must provide a comprehensive diagnosis in the physician's section. This includes details about the resident's health status, including any treatments or medications.
It is important to check the status of tuberculosis (TB) testing. The form requires specific dates and results related to TB tests.
All questions should be answered thoroughly. Incomplete forms can delay the admission process or lead to inappropriate care placements.
The physician must assess the resident's ability to manage their own treatment. This includes evaluating their capacity for self-care and medication management.
Be aware of any contagious or infectious diseases. The physician must note these conditions and specify the necessary supervision or treatment.
Finally, the form must be kept confidential. It is designed to protect the privacy of residents while ensuring they receive the appropriate level of care.