APPLICATIONS 2021/2022 (April March)
Transcript of APPLICATIONS 2021/2022 (April March)
APPLICATIONS 2021/2022 (April – March)
PLEASE READ THE FOLLOWING CAREFULLY
The forms are available from the offices of Badisa Knysna for a non-refundable, once off. administrative fee of R80.00. Electronic forms are free of charge via e-mail or the Loeriehof website.
All the application documents – application form, financial declarations and evidence thereof, medical
practitioner’s report and social worker report - must be completed in full otherwise it will not be processed.
The financial declaration must be certified by a Commissioner of Oaths. Please note that there is no such service available at Loeriehof.
Tariffs are valid from 1 April 2021 – 31 March 2022. Financial declarations must be submitted annually. Tariffs are adjusted annually with approximately 10% per annum.
The medical practitioner’s report may only be completed by a qualified, certified medical practitioner or clinic nursing sister.
Internal medical reports will be completed per appointment by the applicant and the Head of Department Caring.
The social work report may only be completed by either the Department of Social Development’s Social Worker or a Social Worker from Loeriehof’s sister programme Family Care Services. Family Care Service do however charge a R300 fee per form.
The Department of Social Development can be contacted at 044 382 0056 and Family Care Services at 044 382 2721.
All applications are subject to a selection process that may include a home visit from a Nurse and/or
Social Worker.
Please Note: Loeriehof has limited subsidized space available for lower income applicants.
Please note that selections are done as space becomes available in the Home, but enquiries are welcome at any time.
Flat rental is R5 713.00 per month for a single flat and R7 113.00 for a double flat and includes lunch, weekly cleaning, and weekly laundry service.
Skoolhuis rooms are R2 385.00 per month per room and includes daily lunch, weekly cleaning of rooms, access to a washing machine and monthly clinic at Loeriehof.
Assisted Living costs R8 480.00 per month which includes all meals, tea/coffee, weekly cleaning of rooms, laundry, monthly clinic, and access to care staff.
Frail Care costs R8 978.00 per month and includes all meals, coffee/tea, cleaning, and laundry service with preferred access to care staff.
Blister packs are compulsory for all Frail – and Assisted Living Residents with more than one
prescription and is an additional cost of R140.00 per month.
Please feel free to contact us with any further queries on 382 2721 or via or website www.loeriehof.co.za
FACILITY: LOERIEHOF HOME FOR THE ELDERLY Frail Care Assisted Living Flat Skoolhuis First choice: ________________________________ Second choice: __________________________________ 1. SURNAME: _____________________________________________________________________________________ 2. FULL NAMES: __________________________________________________________________________________ 3. ID.NO: 4. DATE OF BIRTH: (dd/mm/yyyy) 5. CURRENT ADDRESS: _________________________________________________________________________
_________________________________________________________________________________________________ WHERE DO YOU LIVE AT THE MOMENT?
Own Residence
Flat
Children
Hospital
Care Home
AAPPPPLLIICCAATTIIOONN FFOORR SSEERRVVIICCEESS IINN AA BBAADDIISSAA FFAACCIILLIITTYY FFOORR EELLDDEERRLLYY PPEERRSSOONNSS
Room / Boarding House
Shelter
REASON FOR APPLICATION:
________________________________________________________________________________________________________
________________________________________________________________________________________________________
________________________________________________________________________________________________________ 6. TELEPHONE NO: ______ (Code:_____________________) [Self]
CELL: __________________________
ALTERNATIVE CONTACT NAME AND RELATIONSHIP TO APPLICANT:
______________________________________________________________________________________________________
TELEPHONE NO: ______ (Code :_____________________)
CELL: __________________________
7. GENDER: Male Female 8. RACE: Coloured Indian Black White 9. MARITAL STATUS: _________________________________________________________________________________ 10. NAME OF SPOUSE / PARTNER: _____________________________________________________________________ OR DATE DECEASED / DIVORCED / SEPERATED: __________________________________________________ 11. HOME LANGUAGE: ________________________________________________________________________________
12. RELIGIOUS DENOMINATION: ______________________________________________________________________ 13. PREVIOUS OCCUPATION: __________________________________________________________________________ 14. PERSON / INSTITUTION RESPONSIBLE FOR YOUR FUNERAL COSTS Name: _________________________________________________________________________________________________ Address: _______________________________________________________________________________________________
________________________________________________________________________________________________________
Tel no: _________________________________________________________________________________________________
15. DO YOU HAVE A WILL? YES NO
IF YES, WHERE IS IT KEPT? ________________________________________________________________________________________________________ WHO IS YOUR EXECUTOR? ___________________________________________________________________________
Address: _________________________________________________________________________________________
_____________________________________________________________________________________________________
Tel. no: _____________________________________________________________________________________________
16. NAME OF HOSPITAL AND FILE NUMBER (Government Patients):
_____________________________________________________________________________________________________ 17. NAME OF MEDICAL AID (Private Patients):
____________________________________________________________________________________________________
PLAN NAME: _________________________________________________________________________________ Medical Aid Number: _________________________________________________________________________
18. PLEASE DESCRIBE YOUR HEALTH IN YOUR OWN WORDS:
_________________________________________________________________________________________________
Please list any official medical diagnoses (i.e. diabetes; blood pressure etc.): _________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
_________________________________________________________________________________________________
Allergies: _______________________________________________________________________________________
_________________________________________________________________________________________________
________________________________________________________________________________________________
Do you require any assistance with any of the following? (Specify)
Mobility (walking etc.)
Bathing/dressing/eating
19. FINANCIAL MANAGEMENT
I manage my own finances
I require assistance
It is managed on my behalf
If your finances are being managed on your behalf, please supply full contact details – name of person responsible, their contact number and relationship.
________________________________________________________________________________________________
________________________________________________________________________________________________
20. PERSON RESPONSIBLE FOR THE ACCOUNT [Please attach a separate list if the space is not enough]
FULL NAMES AND SURNAMES: ____________________________________________________________________
TEL NR & CEL NR: __________________________________________________________________________________
E-MAIL ADDRESS: _________________________________________________________________________________
EMPLOYER: ________________________________________________________________________________________
ADDRESS OF EMPLOYER: __________________________________________________________________________
TEL NR OF EMPLOYER: _____________________________________________________________________________
21. CONTACT DETAILS OF ALL CHILDREN (OR RELATIVES / FRIENDS IF NO CHILDREN) [Please attach a separate list if the space is not enough] Name Address and Tel no Relationship Occupation [1] Address:
Tel no: Fax no: Cell: E-mail:
[2] Address:
Tel no: Fax no: Cell:
E-mail:
[3] Address:
Tel no: Fax no: Cell: E-mail:
[4] Address:
Tel no: Fax no: Cell: E-mail
22. WHEN WOULD YOU LIKE TO BE ADMITTED?
As soon as possible
Later
Approximate Date: ___________________________
23. THE UNDERSIGNED HEREBY DECLARES THAT:
- All details in this application form are true and correct.
- Should admission to the Home take place, the undersigned undertakes to abide by the rules and regulations of Loeriehof Home for the Elderly, even if they are changed from time to time.
______________________ _______________________
SIGNATURE OF APPLICANT DATE
(OR PERSON RESPONSIBLE)
24. Herewith the below mentioned person responsible / authorised representative accepts responsibility with regards to the applicant. Person 1 Person 2 Relationship: Initials and Surname: ID no: Address: Telephone no:
Cell: E-mail: Signature:
Date:
This application is valid for 12 months from date of completion. Thereafter re-application might be required.
1
STATEMENT OF INCOME AND EXPENDITURE (Documentary proof of income/expenditure must be attached)
Name of applicant: _________________________________________________ A. INCOME
1. Pension received (Type of pension) Pay point, e.g. bank/post office
Ref. no Monthly income
Self Spouse
1.1
1.2
1.3
2. Annuity (Name of fund)
2.1
2.2
3. Income from trust and maintenance allowances (Name of fund/person)
3.1
3.2
3.3
4. Shares (Name of fund)
4.1
4.2
4.3
5. Director’s fees (Name of company)
5.1
5.2
5.3
6. Cash investments (Specify financial institution) Amount invested
Monthly income
Self Spouse
6.1
6.2
6.3
6.4
7. Fixed property, e.g. farms, dwellings (Full description and where situated)
Municipal assessment
Bond in arrears
Monthly income
Self Spouse
7.1
7.2
8. Other sources if income, e.g. income from business usufruct/Fidei Commissum (Please specify)
Self Spouse
8.1
8.2
8.3
TOTAL R
2
B. TOTAL VALUE OF ASSETS SOLD AND DONATIONS MADE OVER THE LAST 10 YEARS (Please specify) 1. Did you sell or donate any assets (fixed property) during the past ten (10) years? If so, please
give the following details:
[a] Assets sold (description)
[i] Date sold
[ii] Bruto amount received R
[iii] Minus selling costs (please specify on separate page) R
Nett income R
[b] Assets donated (description)
[i] Date donated
[ii] Amount donated R
[c] Cash donated (description)
[i] Date donated
[ii] Amount donated R
2. EXPENDITURE OF A CONTINUOUS NATURE (Documentary proof of expenditure must be
furnished) Specify e.g. medical fund, subscription fees, municipal tax, installments, etc in the case of property:
2.1 R
2.2 R
2.3 R
TOTAL R
I hereby declare that the information furnished by me, is to the best of my knowledge, true and correct and
that the declared income the total income of the applicant is for the _______________tax year.
SIGNATURE OF APPLICANT/AUTHORISED PERSON
DATE
NB: All interest revenue must be certified per certificate of balance by financial institutions.
A false declaration is a punishable offence.
3
DECLARATION I certify that, before administering the oath/affirmation, I asked the deponent the following questions and wrote down his/her answers in his/her presence: [a] Do you know and understand the contents of the declaration? Answer: _______________ [b] Do you have any objection in taking the prescribed oath? Answer: _______________ [c] Do you consider the prescribed oath to be binding on your conscience? Answer: _______________ I certify that the deponent has acknowledged that he/she knows and understands the contents of this declaration which has sworn to/affirmed before me and the deponent’s signature/thumb print/mark was placed thereon in my presence.
COMMISSIONER OF OATHS PLACE
DATE
FOR OFFICIAL USE
Nett income R
Boarding per month R
Officer employed by the Department of Social Development
Date
FOR OFFICIAL USE BY A SCREENING OFFICER OF THE DEPARTMENT OF SOCIAL DEVELOPMENT
Gross income R
Minus approved expenditure (specify)
[a] R
[b] R
[c] R
[d] R
Nett income R
Income group code
1. FULL NAME AND SURNAME: __________________________________________________________ 2. AGE: ____________________ 3. OVERVIEW OF APPLICANT’S MEDICAL HISTORY EN PREVIOUS TREATMENT:
_________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 4. OVERVIEW OF APPLICANT’S SURGICAL HISTORY: _________________________________________________________________________________________ _________________________________________________________________________________________ _________________________________________________________________________________________ 5. GENERAL EXAM:
5.1. General physical condition ________________________________________________________________________________________ ________________________________________________________________________________________
5.2. Respiratory System ________________________________________________________________________________________ ________________________________________________________________________________________
5.3. Cardiovascular System Blood Pressure:_____/____ _________________________________________________________________________________________ _________________________________________________________________________________________
MEDICAL PRACTIONER REPORT FOR ADMISSION TO HOME FOR THE ELDERLY
5.4. Urinary System and Genitals (Urine test please) ____________________________________________________________________________________________ ____________________________________________________________________________________________
5.5. Digestive and other Abdominal Systems _____________________________________________________________________________________________ _____________________________________________________________________________________________
5.6. Endocrine System _____________________________________________________________________________________________ _____________________________________________________________________________________________
5.7. Musculoskeletal System (Name any anomalies) _____________________________________________________________________________________________ _____________________________________________________________________________________________
5.8. Central Nervous System _____________________________________________________________________________________________ _____________________________________________________________________________________________
5.9. Skin Conditions (i.e. bed sores, scabies etc.): _____________________________________________________________________________________________
_____________________________________________________________________________________________
5.10. Other Conditions (Does the patient suffer from any of the following?) Asthma Previous Hemiplegia Chronic Osteoarthritis Cerebral Atrophy KOLS CCF Tabes dorsalis CVA Rheumatism Carcinoma
Myopathies Parkinson’s Hypertension Contagious diseases
5.11. Does the applicant have control over excretory functions? _____________________________________________________________________________________________ _____________________________________________________________________________________________
5.12. Does the applicant have problems with:
Deafness Poor Speech Balance
5.13. Has there been any cancer diagnoses? (Please describe) _________________________________________________________________________________________ _________________________________________________________________________________________
5.14. Allergies
_________________________________________________________________________________________ _________________________________________________________________________________________
6. MENTAL HEALTH (Please mark where applicable)
Remarks: __________________________________________________________________________________________ __________________________________________________________________________________________
6.1 SCHIZOPHRENIA Schizophrenia, including hallucinations
Schizophrenia, including delusions / paranoide thoughts
Remarks: _________________________________________________________________________________________ _________________________________________________________________________________________
Remarks: _________________________________________________________________________________________ _________________________________________________________________________________________
Remarks: ___________________________________________________________________________________________ ___________________________________________________________________________________________
6.2 ALZHEIMERS Early Stage
Intermediate Stage
Advanced Stage
6.3 DIMENTIA Early Stage
Intermediate Stage
Advanced Stage
6.4 ANXIETY DISORDERS Psychosomatic Obssessive-compulsive Hysteria
Phobias
Remarks: _________________________________________________________________________________________ _________________________________________________________________________________________
Remarks: ___________________________________________________________________________________________ ___________________________________________________________________________________________
Remarks: ___________________________________________________________________________________________ ___________________________________________________________________________________________
6.5 DEPRESSION Reactive / moderate Endogenous / severe Manic-depressive psychosis
6.6 DISORDERS
Delirium / Confusion conditions Chronic Dimentia Severity
6.7 PERSONALITY DISORDERS Passive dependent Passive aggressive Bipolar
Remarks: ______________________________________________________________________________________________ ______________________________________________________________________________________________
Remarks: _______________________________________________________________________________________________ _______________________________________________________________________________________________ 7. CURRENT PSYCHICAL / PHYSICAL FUNCTIONING
7.1. Orientation with relation to name, time, place etc.: ______________________________________________________________________________________
7.2. Ability to communicate: ______________________________________________________________
6.8
SUBSTANCE DEPENDENCY (Specify – alcohol, medication etc.)) ................................................................................................................................................................................................................................................................................
Social Chronic Brain Damage
6.9 EPILEPSY YES NO
6.10 MENTALLY DISABLED YES NO
7.3 Assistance where required (mark where applicable):
7.3.1 MOBILITY Moves independently Moves with aides – walking stick etc. Wheelchair bound Immobile – bed bound
7.3.2 CLOTHING Does not require assistance with dressing Requires supervision with dressing Requires assistance with buttons etc. Completely dependent
7.3.3 FEEDING Does not require any assistance Requires supervision Requires some assistance with spreading bread, cutting meat etc. Completely dependent Dependent on tube feeding
7.3.4 MEDICATION
Takes madication independently without assistance Uses medication independently, but requires assistance with ordering medication and monthly check on medication
8. CURRENT MEDICATION (Specify with relation to physical and mental health:) _______________________________________________________________________________________________ _______________________________________________________________________________________________ _______________________________________________________________________________________________ 9. HOW LONG HAVE YOU BEEN TREATING THE PATIENT/APPLICANT? ________________________________________________________________________________________________ 10. GENERAL REMARKS: _________________________________________________________________________________________________ _________________________________________________________________________________________________ ______________________________ _______________________ _____________________ PRACTITIONER PRACTITIONER DATE [PRINT] [SIGNATURE] Address: _______________________________________________________________________________________ Tel nr: _________________________
Medication has to be administered – specialised assistance required.
7.3.5 PERSONAL HYGIENE Does not require assistance Requires encouragement and supervision Requires some assistance Completely dependent
Contact Department Social Development, on 044 382 0056 or visit Demar Building, Main Road, Knysna, 6571 1. SURNAME (Applicant): _________________________________________________________________ 2. FULL NAME (Applicant): _______________________________________________________________ 3. ID NO: 4. DATE OF BIRTH : 5. ADDRESS: ____________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
6. TELEPHONE NO: (Code:_________) _____________________________
7. CELL: ____________________________
8. FAMILY COMPOSITION AND BACKGROUND:
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________
SSOOCCIIAALL WWOORRKKEERR RREEPPOORRTT
9. BEHAVIOURAL CHARACTERISTICS (Personality, interests, adapting in a group etc.):
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
10. SOCIAL CIRCUMSTANCES:
10.1. Care:
Cares for self
Cared for by children/family/friends/other
10.2. Quality of Care:
Good
Average
Poor
10.3 Social interaction:
Sufficient interaction with family / friends
Interaction is limited
Lonely
10.4 Social adaptability:
Well adapted
Difficulty adapting
Depressed
Behavioural issues
Motivate: ____________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
____________________________________________________________________________________
11. ENVIRONMENT AND HOUSING CIRCUMSTANCES (Living arrangements / motivation for
admission / housing problems):
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
___________________________________________________________________________________
11.1. CURRENT HOUSING:
Own house
Rental house
Boarding house
Home for the Elderly
Retirement Village
Hospital
Resides with others
Resides with children
Flat
Shelter
11.2. Surety of current accommodation:
Unable to determine
Uncertain
Has to move
Can remain, but the circumstances does not suit
the Elderly Person
Motivate: _____________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
_____________________________________________________________________________________
12. PHYSICAL AND MENTAL FACTORS Is the applicant able to:
12.1. PHYSICAL Yes No To a degree Prepare and cook own meals
Keep living areas tidy
Wash self Dress self Eat without assistance
Move freely and without assistance
Health: (Mark with a √) Good Uncertain Poor
12.2. MENTAL (Poor memory, comprehension, depression, psychosis, aggressive behaviour):
_______________________________________________________________________________________
_______________________________________________________________________________________
_______________________________________________________________________________________ Please mark (√)
Coherent thoughts
Forgetful
Displays a lack of interest
Clear signs of Dementia
Psychiatric report attached? Yes No
12.3. Is there a history of substance abuse and/or dependancy? If so explain: ______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
13. ECONOMIC CIRCUMSTANCES (Brief overview of income and expenditure): ______________________________________________________________________________________
______________________________________________________________________________________
14. REASONS FOR ADMISSION (Age, social circumstances, housing problems, physical and mental frailty, economic circumstances, loneliness):
______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________ 15. SERVICES ALREADY DELIVERED (Including applications to other homes):
______________________________________________________________________________________
______________________________________________________________________________________
16. RECOMMENDATION (Specify placement i.e. room, frail care, flat): ______________________________________________________________________________________
______________________________________________________________________________________
______________________________________________________________________________________
17. How long have you known the applicant? ____________________________
_______________________ __________________________ __________________
SOCIAL WORKER NAME OF ORGANISATION DATE
________________________________
Registration no: Social Worker
BLISTERPAKKE Loeriehof het van 1 Junie 2019 verpligte blisterpakke in gebruik geneem vir Inwoners wat op meer as een
medikasie is. Die redes hiervoor is: OM MEDIKASIE REG TOE TE DIEN VOLGENS DIE WET OP “MEDICINES AND RELATED
SUBSTANCES ACT (NO.101 OF 1965) “, PHARMACY ACT (NO.53 OF 1974) EN NURSING ACT (NO.33 OF 2005), National Drug Policy, Health Standards/Norms for Residential Care Facilities for Older Persons (2015)
Om ‘n hoë standaard van sorg aan die inwoners te verseker Om die inwoners en personeel te verseker van veilige medikasie toedienings metodes Om die Loeriehof, publiek, en professionele personeel se risiko’s te verminder vir aanspreeklikheid Om ‘n standaard te skep sodat alle verpleeg personeel binne haar eie Bestek van Praktyk sal werk Koste vir 2021/2022 per blisterpak is R140 en is verpligtend vir alle Inwoners met meer as een
voorgeskrewe tablet.
BLISTER PACKS
Loeriehof has been using compulsory blister packs since 1 June 2019 for Residents who have more than one medication.
The reasons are as follows: TO ADMINISTER MEDICINE CORRECTLY IN ACCORDANCE WITH THE “MEDICINES AND RELATED
SUBSTANCES ACT (NO.101 OF 1965’, “PHARMACY ACT (NO.53 OF 1974) AND THE NURSING ACT (NO.33 OF 2005), National Drug Policy, Health Standards/Norms for Residential Care Facilities for Older Persons (2015)
To ensure high quality care is provided to Residents To ensure residents and staff of safe dispensing procedures To minimise the accountability risk of Loeriehof, public and professional staff To create a standard that allows all care staff to only operate within their own Scope of Practise Cost of the blister pack for 2021/2022 is R140 per month and compulsory for all Residents on more
than one prescribed tablet.