(Revised 5/1/06 ML #3015)
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Purpose: The form is completed to provide evidence that a freestanding Adult Day Care facility or home meets minimum standards.
When Prepared:
Upon the request of a potential free standing Adult Day Care facility or home. (A free standing Adult Day Care facility is an Adult Day Care that will not co-mingle residents, share staff and be located within a licensed nursing home or basic care facility. Adult Day Care facilities that are located with a licensed nursing home or basic care facility, share staff and co-mingle the residents should contact Health Facilities as they may be designated as an Adult Day Care based on their current license. These facilities do not need to complete a check list. )
By Whom Prepared:
The county social service board shall make a visit to the free standing Adult Day Facility or home to complete the checklist, maintain a record of the evaluation, the decision, and the reason for that decision.
SPECIFIC INSTRUCTIONS:
Check all standards in sections I-III either yes or no.
All responses must be yes prior to consideration of approval for an Adult Day Care freestanding facility or home.
If the Adult Day Care facility or home is approved complete the valid through section, not to exceed two years, check that they meet the standard, sign and date the form. The Adult Day Care Provider must also agree to maintain the standard by signing and dating the form.
If the facility or home does not meet the standards, check, does not meet the standard, and sign the form. Make the provider aware they have the opportunity to reapply to be an Adult Day Care QSP when they have made any needed corrections to meet the standards.
Approval of Adult Day Care Facility or Home
Upon determining the free standing Adult Day Care QSP facility or home meets the standards, a copy of the completed SFN 1703, Compliance Checklist/Adult Day Standards, should be given to the provider and another copy should be mailed to Medical Services/HCBS. The County should maintain the original.
This form is not available from the state office. It is electronically available through the state’s e-forms.