Clemens Health | Unfilled support coverage and action record
Updated 2026-10-05 | (651) 354-1196

Track actual gaps and confirmed offers. Keep authorization questions, provider staffing and temporary help on separate lines.

Uncovered visits
Which days, times and tasks remain unfilled?
Illustrative entry: Tuesday and Thursday evening routines.
Your notes: ________________________________________

Current authorization question
Is any document or service detail unresolved?
Illustrative entry: Case manager to confirm the current arrangement if unclear.
Your notes: ________________________________________

Provider response
What did the provider actually confirm?
Illustrative entry: Afternoons possible to discuss; evenings not confirmed.
Your notes: ________________________________________

Partial-offer fit
Would the offered arrangement address the person's need?
Illustrative entry: Person says the activity requiring support occurs in the evening.
Your notes: ________________________________________

Interim agreement
Who explicitly agreed to what, and with what limits?
Illustrative entry: No temporary evening helper has agreed.
Your notes: ________________________________________

Decision request
What should the planning team review?
Illustrative entry: Options for the two uncovered visits.
Your notes: ________________________________________

Action owner and review
Who follows up and at what agreed point?
Illustrative entry: Named coordinator records responses and updates the person.
Your notes: ________________________________________

Confirmed resolution
Which specific entry is now resolved?
Illustrative entry: Close only after the actual visit arrangement is confirmed.
Your notes: ________________________________________

Illustrative example
A person has requested support on four evenings. A provider confirms two and offers afternoons for the others. The tracker records two staffed evenings and two open evenings. The person explains that afternoons would not help with the chosen activity. The case manager reviews the remaining need while the confirmed visits proceed under the agreed arrangement. No one treats the family's involvement in phone calls as agreement to cover the other nights. The record stays accurate as the search continues.

Next step
Send the responsible planning contacts a concise description of the actual gap and ask them to review the unresolved arrangement with the person.

This is an optional discussion worksheet, not an official assessment, authorization, service plan, or emergency plan. Keep completed copies private and share through an agreed channel.