Renewal of an Adult Foster Care License 660-05-20-20

(Revised 10/1/20 ML 3596)

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An application to renew an AFC license is not complete until all required information and verifications are submitted to the HCBS Case Manager and the Aging Services Division. This includes:

Must be present in file from initial license:

1. SFN 1013, “Application to Provide Adult Foster Care”.
2. Floor plan indicating escape routes
3. Examples of service logs to account for service time and tasks performed
4. Examples of daily menu plans
5. Three reference letters
6. SFN 823, "Evacuation Disaster Plan - Adult Foster Care".

Required for license renewal:

1. A completed SFN 1031, “Relicensing Study – Adult Foster Care”.
2. Evidence that all caregivers have requested renewal of qualified service provider status and the completed forms listed below have been approved by the Medical Services Division.

1. SFN 1605, “Individual Request to be a Qualified Service Provider/AFC Provider”.
2. SFN 750, “Documentation of Competency,” or applicable license, certification, or accreditation.
3. SFN 615, “Medicaid Program Provider Agreement”.
4. SFN 1168, “Ownership Controlling Interest and Conviction Information”.
5. SFN 433, “Child Abuse and Neglect Background Inquiry”.
6. W 9 “Request for Taxpayer Identification Number & Certification”.
7. A copy of a form of ID, ex: driver’s license or social security card.
   

• If a background check was not completed previously or a break in licensure has occurred, or if the provider has not been continuously licensed since August 1, 1999, provide evidence that all AFC applicants and individuals age 18 or over living in the AFC home have completed:

1. SFN 467, “Personal Authorization for Criminal Record Inquiry”.
2. SFN 466, “Background Check Address Disclosure”.
3. Two fingerprinting cards, if required.
4. A new SFN 800, “Fire Safety Self Declaration,” form.
5. Documentation of applicant’s current completion of the Department approved Fire Prevention and Safety Course.
6. Current proof of auto insurance.
7. Review the copy of the provider’s Service and Rental Agreement including landlord tenant and eviction and appeals process and all items listed in (Section 660-05-30-45). The Service and Rental Agreement must be signed by the provider and the resident or resident’s legal representative on admission.
8. Copies of the Home and Community Based Services Adult Foster Care Setting Experience Interviews (SFN 636) completed annually with all residents both public and private paying living in the facility.

1. For individuals on the Traditional IID/DD HCBS Waiver (DD Waiver), the SFN 636 will be completed initially and annually by the Developmental Disabilities Program Manager (DDPM). The completed forms will be sent to the DD Services Administrator who will review and forward to HCBS Aging Program Manager.

1. For biannual licensing review by the HCBS Case Manager, the DDPM will accompany the HCBS Case Manager to complete the client experience interview or SFN 636.

9. A report of a professional inspection of all heating units, to include furnace, water heater, and alternate heating devices, is required upon license renewal. (Section 660-05-30-30 (2)).
10. If applicable, proof of up to date pet vaccinations.
11. Additional information and verifications as requested by the Department (Section 05-20-15-05).