Provider Resources

Personal Care Home-Required Forms

• Personal Care Homes — Application for Licensure
  
• Personal Care Homes — Reportable Incident Form
• Personal Care Homes — Request For Waiver Of Regulation
  
• Personal Care Homes — Preadmission Screening
  
• Personal Care Homes — Documentation of Medical Evaluation (DME)
  
• Personal Care Homes — Resident Assessment-Support Plan (RASP)
  A Personal Care Home may opt to use its own Resident Assessment and Support Plan (RASP) form, provided it includes all of the elements included on the Department’s form.
• Personal Care Home Resident Rights Poster
  
  • PCH Resident Rights — English
  • PCH Resident Rights — Spanish

Assisted Living Residence-Required Forms

• Assisted Living Residence — Application for Licensure
  
• Assisted Living Residence — Documentation of Medical Evaluation
• Assisted Living Residence — Preadmission Screening Form
  
• Assisted Living Residence — Assessment-Support Plan Form
  An Assisted Living Residence may opt to use its own Assessment and Support Plan form, provided that it includes all of the elements included on the Department’s form.
• Assisted Living Residence — Request to Admit a Resident with an Excludable Condition Form
  
• Assisted Living Residence — Reportable Incident Form — 10/1/2016
• Assisted Living Residence — Request for Waiver of Regulation Form
• Assisted Living Residence Resident Rights Poster
  • ALR Resident Rights — English
  • ALR Resident Rights — Spanish

Model Forms

The following forms are not mandatory, but they have been designed with provider convenience and regulatory compliance in mind.

• Record of Financial Transactions
  
• Cash Distribution Record
  
• Quarterly Financial Summary
  
• Record of Training
  
• Staff Training Plan
  
• Fire Drill Record
  
• Resident-Home Contract
  
• Addendum C To Resident-Home Contract — Rent Rebates
  
• Medication Administration Record
  
• Supervised Fire Drill and Fire-Safety Inspection
  
• Evacuation Time Designation Document
  
• Personal Care Homes — Entrance Conference Guide
  
• Assisted Living Residences — Entrance Conference Guide
  

 

Additional Resources 

• Mandatory Abuse Reporting Form
  
• Influenza Awareness Act
• Influenza Awareness Act — Poster
  
• Respiratory Virus Outbreak Toolkit
• Frequently Asked Questions About Unlicensed Personal Care Homes
  
• Self-Inspection for Capacity Increase Tool
• Procedures for Self-Inspection to Increase Maximum Capacity