Intercommunity

Homemaking Time and Activity

1First Week
2Second Week
  • Intercommunity Home Health Care
    27 E Franklin Ave – Minneapolis, MN 55404.
    Tel: 612-435-0283   Fax: 612-338-1493

    Homemaking Time and Activity

    • Dates of service

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    • Activities

    • Vacuuming

    • Dust

    • Wash Windows

    • Clean Toilet

    • Clean Fridge

    • Clean Stove

    • Change Bedding

    • Empty Garbage

    • Prepare Food/Serve

    • Thursday

    • Friday

    • Saturday

    • Sunday

    • Monday

    • Tuesday

    • Wednesday

    • Visit One

    • Ratio staff to recipient

    • Shared care location

    • Time In

    • Time Out

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    • Visit Two

    • Ratio staff to recipient

    • Shared care location

    • Time In

    • Time Out

    • Daily

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    • Total Hours for First Week

    • Acknowledgment and Required Signatures

    • After 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

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