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.