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Bedingfield Assessment Report, blank

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Bedingfield Assessment Report, blank

  1. 1. Developmental Services Waiver: HCBS Medicaid Provider No. 68 41783 96 ABCVendorIDNo. F 593754678001 Family and Supported Living Waiver: HCBS Medicaid Provider No. 68 41783 98 ABCVendorIDNo. F 593754687001 HOME MODIFICATION ASSESSMENT REPORT DATE: December 26, 2005 Client Name D.O.B. Medicaid No. Soc. Sec. No. Phone No. Cell/Pager No. Address of Client Apt. No. City State Zip FL Address of Property Assessed Apt. No. City State Zip FL Parent/Guardian Name Phone No. Cell/Pager No. Address (If other than Client’s) Apt. No. City State Zip FL Corporate/Fictitious Provider Name Phone No. Fax No. Support Coordinator Cell No. Pager No. Physical Address Apt./Suite City State Zip FL Mailing Address # City State Zip FL Provider No. E-mail Address Billing Code Description Authorization Date S5165U6SC Environmental Accessibility Assessment 12-22-05 Adaptive Home Modifications Consulting 1951 72nd Avenue N.E. Saint Petersburg, Florida 33702
  2. 2. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 2 CLIENT INFORMATION Residence Single Family Home Condo Apartment Owned Rented x Conditions Influencing Modifications: The Bathroom is very small and the landlord does not want any removal or alteration, including holes, to the tile in the Bathroom. Primary Diagnosis of Client: Cerebral Palsy Secondary Conditions: Moderate impairments of fine motor skills and speech. Client Capabilities / Limitations: The Client uses a manual wheelchair. He does rely on the services of a caregiver for assistance with mobility, toileting, dressing, bathing, personal hygiene and grooming, meal preparation, transportation, laundry, cleaning, personal affairs, including grocery shopping and financial matters.
  3. 3. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 3 DISCLAIMER Walton D. Dutcher, Jr. d/b/a Adaptive Home Modification Consulting (Consultant) is not licensed as any type of contractor with the Construction Industry Licensing Board, or as an architect with the Board of Architecture and Interior Design, or as an engineer with the Florida Board of Professional Engineers, all of which are under the Department of Business and Professional Regulation of the State of Florida, or any other profession upon which reliance may be placed relative to expertise in the matters which may be involved in the design and specifications of renovation, remodeling or construction of the home addressed in this Report. Any design(s) or specification that may accompany this Report are offered solely for the purposes of planning. Any such work that may be required for construction, and fields related thereto, which must comply with the Florida Building Code (Code) and specialty Volumes thereunder, must be reviewed by a licensed architect, engineer, or other professional familiar with the Code and with the authority to provide construction drawings that are compliant with the Code. This Disclaimer extends to the installation of any items recommended, specified or included in this Report that are a part of the renovation, remodeling or construction of housing. Consultant does not knowingly have any direct or indirect interest in any company that manufactures any of the products which may be suggested in this Report. FINDINGS 1. There is a step up at the front entrance (4") and the rear entrance (2"). 2. None of the doors have lever handles. 3. The fan/lights in the Living area and Front Bedroom, where the Client plans on sleeping, are operated by pull switches. 4. The Kitchen cabinet drawers and doors do not have handles and there are no pullout shelves in the lower cabinet. 5. There is one drawer to the left of the range which is not properly functioning 6. The side of the Kitchen sink base cabinet is missing and there was some attempt to provide one to support a half-shelf in the base cabinet to the right of the sink base cabinet. 7. The side of the Kitchen sink base cabinet is missing and there was some attempt to provide one to support a half-shelf in the base cabinet to the right of the sink base cabinet.
  4. 4. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 4 8. The refrigerator door gasket is damaged and does not function properly which could result in improper temperatures for food stored. 9. The Bathroom door is only 2'-4" wide and swings inward. 10. The Hallway is only 3'-0" wide. 11. The Bathroom sink is mounted in a base cabinet making inaccessible. 12. The toilet is not ADAAG compliant by reason of its lower height. 13. The valve control for the tub/shower is on the same wall as the toilet and sink. Any typical slide transfer from the commode would result in placing the Client’s back facing the control and any hand-held shower head mounting that would be added for bathing. 14. There is no gate at the east end of the front porch to provide access to the parking area. Client’s Specific Request(s): 1. Install kickplates on both sides of the exterior doors. 2. Install slip resistant ceramic tile in Client’s Bedroom. 3. Provide a NuProdux multiCHAIR Model 4000 4. Install a Bidematic Hot and Cold Model 5. An ADA compliant toilet is not needed. Scope of Work: Based on the findings presented and the Client’s request, we have approached the design concept to provide the following goals: 1. Provide temporary landings and ramps at both exits. 2. Develop transfer devices for use in the Bathroom. These must be constructed in such a fashion so as to be easily removable and without costly damage to the walls or fixtures. The landlord emphatically instructed that there shall be no damage to the wall or floor tile. 3. Install other items to achieve a higher level of accessibility and functionality. 4. Minimize any damage to the walls, floors, or fixtures and there mitigate any expense that may be incurred when the premises are vacated.
  5. 5. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 5 Funding Limitations $ 20,000 RECOMMENDATIONS 1. Construct and install temporary ramps and landings at each entrance as illustrated in the included designs. These items shall be constructed of PT lumber and marine grade plywood. The landings and ramps shall be coated with Duraback nonslip coating for outdoor applications or equivalent. The coverage rate is 65 sq. ft. per gallon. Total area for both installations is 100 sq. ft. JUSTIFICATION: The premises is a rental apartment with limitations as to any permanent installation. 2. Construct and install the transfer devices for the Bathroom as illustrated in the included designs. JUSTIFICATION: The premises is a rental apartment with limitations as to any permanent installation. The unique design solution for these transfer devices was achieved through a collaboration of the company and the Client’s father. It was imperative that the units must be easily removable and that no damage was to be caused to the wall or floor tile. 3. Change the swing of the Bathroom door to open into the Hallway as shown in the included design. Install clear swing hinges to allow as much doorway clearance as possible. JUSTIFICATION: The Bathroom door is only 2'-4" wide which offers a clearance of only 2'-2" (26 in.). Changing the swing allows the door to be closed when the Client is using the Bathroom. The additional clearance mitigates possible injury to the Client’s hands as well as provides better maneuvering. 4. Install handles on the kitchen cabinets.
  6. 6. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 6 RECOMMENDATIONS JUSTIFICATION: Handles are required since the Client has impairment of his fine motor skills. 5. Install lever handles in all doors. JUSTIFICATION: Lever Handles are required since the Client has impairment of his fine motor skills. 6. Install clear acrylic kickplates affixed with brass screws on both sides of the exterior doors. JUSTIFICATION: The Client pushes the doors with his feet to open or close the doors. The kickplates mitigate any damage to the doors. 7. The fan/lights in the Living area and Front Bedroom, where the Client plans on sleeping, are operated by pull switches. Request the landlord to wire the existing wall switches that were originally used for a light to be rewired and switches installed to operate the fans and the lights. If the landlord denies this request, they will be required for the Client to operate them. JUSTIFICATION: As stated, the fan/lights are operated by pull switches that hang from the fixture which renders them inoperable by the Client. The wall switches are required by the Client so as to make the operation accessible for the Client. 8. Provide and install slip resistant ceramic tile that is deemed to comply with ADAAG requirements by the manufacturer in the Client’s Bedroom. JUSTIFICATION: The Client prefers tile over glue down 28 oz. or better BCF Nylon commercial carpet. The Client does use a manual wheelchair and tile offers a surface that is easier to maneuver than carpet. Additionally, the Client has concern over spillage of urine and the ability to easily clean it up.
  7. 7. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 7 RECOMMENDATIONS 9. Provide and install a hand-held shower head and tub spout with diverter valve and outlet for hand-held shower head. Alsons provides a combination model as shown in the Sampling of Available Products section. If the Client prefers a different hand-held shower other than the Alsons, the tub spout with diverter valve and hand-held outlet and hand-held shower head can be purchased separately. JUSTIFICATION: A hand-held spray is required by the Client to bathe. The diverter valve must be within Client’s reach. 10. Provide and install Bidematic Cold Water Model. JUSTIFICATION: The Client does not have the ability to wipe himself. The Bidematic removes the urine and fecal matter from the perineal area. 11. Provide a NuProdx multiCHAIR Model 4000 as specified in the Sampling of Available Products section and requested by the Client including the optional commode pan for travel use. JUSTIFICATION: The Client requires the ability to move toward and away from the water control and hand-held spray. This product fulfills that requirement. The Client also travels from time to time and this product with it’s standard features plus the commode pan offers the ability to have a means to accomplish toileting in unaccessible places. 12. Provide and install Sequoia model overhead lift structure manufactured by Waverley Glen or an equivalent that is acceptable to Client. The motor is not required since the Client will use a trapeze device. JUSTIFICATION: The apartment is being rented by the Client and the installation of a permanently mounted overhead track is not an option.
  8. 8. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 8 RECOMMENDATIONS 13. Install shower track as specified in the Sampling of Available Products section in the manner specified in the included designs. JUSTIFICATION: The specified shower track allows the rotating arm to function thus providing a means for the use of the bathtub. The existing shower rod would not allow the rotating arm to function. CONSIDERATIONS DURING MODIFICATION PROCESS Interruption of services Electricity N/A Water N/A Sanitary X Heating / AC N/A Interruption of functions Ability to access each room X Ability to use appliances N/A Ability to maneuver in any room X Ability to use AT equipment N/A Environmental considerations Removal of hazards; asbestos, lead based paint, etc. N/A Dust control; a particular consideration when Client has breathing problems. N/A Use of chemicals or installation of new fabrics; a particular consideration if Client has chemical sensitivities. N/A Need for continuous use of heating and air conditioning N/A Other
  9. 9. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 9 PICTURES OF APARTMENT
  10. 10. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 10
  11. 11. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 11 SAMPLING OF APPLICABLE AVAILABLE PRODUCTS The following is a sampling of products that were discovered through internet research and are offered as being possible solutions for a specific application referenced in any of the recommendation(s) made herein above. Resources provided are for information purposes only. Walton D. Dutcher, Jr. d/b/a Adaptive Home Modification Consulting does not endorse or knowingly have any vested interest in any product presented. Selection of any and all products are left to the sole discretion of the Client or Client’s parent(s) or legal guardian. Sequoia by Waverley Glenn Lutron Skylark® Three Speed Fan Control, Pushbutton Light Switch Aubuchon Item # 683333 http://www.hardwarestore.com/ Box Track Hanger 450 Lb. (x 2) Aubuchon Item # 658638
  12. 12. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 12 Box Trolley Track 450 Lb. 6' long Aubuchon Item # 658898 PEMKO Ramp Profile No. 259A A = Mill Finish Aluminum Amerock Dulcet Pull 5-1/32 in. (Polished Chrome) DURABACK™ Outdoor Textured Brown DURABAK™ is a tough, single-pack, totally flexible, slip-resistant, water-resistant protective polyurethane coating with self-contained recycled rubber granules for an attractive tough-textured finish. When exposed to atmospheric moisture, DURABAK™ undergoes a chemical curing process which changes it from a liquid to a tough polyurethane membrane. It has excellent abrasion and chemical resistance. Northern Tool, Twisted Clevis Pin Size 3/4in. x 1/2in. Item No. 318016 Black powder-coated finish. Pins are yellow zinc dichromate plated. www.northerntool.com
  13. 13. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 13 Alsons Add-A-Shower Deluxe all Brass 5'' Diverter Tub Spout Model 1000L Alsons Push Button “Pause Control” Hand-held Shower and Tub Spout w/ Diverter Model 410SPB Brookstone Handheld Shower SKU 234716 Bidematic® http://www.1800wheelchair.com/
  14. 14. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 14 NuProdx MultiChair 4000 Standard features: • Push handle back • Fold-back locking arms • Adjustable swing-away footrests • Total-lock brakes on 5" casters • Adjustable seat height • Seamless padded Ensolite™ back and 1½” square seat cushion Optional feature requested: • Commode Pan Schlage Elan Door Leverset Full Mortise Swing Clear Hinge Model 633 (US4) for 1d” door SKU #219343 www.hardwaresource.com 877-944-6437
  15. 15. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 15 Keyless Interconnected Deadbolt Lock Item 1794 $298 • Custom set codes from 4 to 6 digits • Stores up to 8 codes • Easy to program • Incorrect Code Warning Alarm - if incorrect code is entered three times • Alarm is activated and flashing red light indicates entry has been attempted with an incorrect code • Long lasting battery life; 30,000 entries orone to two years of stand-by life • Easy to operate; just lift the lever handle to lock and press down to unlock http://www.nokey.com/853111/keyelindeadl.html
  16. 16. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 16 EXISTING APARTMENT
  17. 17. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 17 PROPOSED BATHROOM MODIFICATIONS
  18. 18. Adaptive Home Modifications Consulting Client: Assessment Report Date: December 26, 2005 Page 18 TRANSFER DEVICE STRUCTURE
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