Home Modification Assessment Report Summary

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

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.

Client:
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.

Client:
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.

Client:
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.

Client:
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.

Client:
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.

Client:
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

Client:
Page 9
PICTURES OF APARTMENT

Client:
Page 10

Client:
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)

Client:
Page 12
Box Trolley Track 450 Lb. 6' long
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

Client:
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/

Client:
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

Client:
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

Client:
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EXISTING APARTMENT

Client:
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PROPOSED BATHROOM MODIFICATIONS

Client:
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TRANSFER DEVICE STRUCTURE

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