Advanced Search

Free Community Based Residential Facility (CBRF) Initial Licensure Checklist-F-62416 - Wisconsin



Download Download File ( 19.2 kB)
Excerpt: DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62416 (Rev. 04/09) STATE OF WISCONSIN Page 1 of 2 COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) INITIAL LICENSURE CHECKLIST Name - CBRF Name Reviewer Address - Facility (Street Address) City County Date Form Completed Zip Code A. A completed application includes the following items. 1. 2. 3. 4. 5. 6. 7. 8. 9. Completed CBRF Initial License Application (F-60287) Background check completed by Office of Caregiver Quality on the licensee and all non-residents age 10 and older. Floor plan. DHS 83.05(2)(b) A licensing fee of $306, plus $39.60 per resident based on capacity of facility. NOTE: For a PROBATIONARY LICENSE, the fee for 12 months is 1/2 this amount. Evidence of financial ability to operate for 60 days. DHS 83.05(2)(f) Balance sheet. DHS 83.05(2)(e) Program statement. DHS 83
DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62416 (Rev. 04/09)

STATE OF WISCONSIN Page 1 of 2

COMMUNITY BASED RESIDENTIAL FACILITY (CBRF) INITIAL LICENSURE CHECKLIST
Name - CBRF Name Reviewer Address - Facility (Street Address) City County Date Form Completed Zip Code

A.

A completed application includes the following items.
1. 2. 3. 4. 5. 6. 7. 8. 9. Completed CBRF Initial License Application (F-60287) Background check completed by Office of Caregiver Quality on the licensee and all non-residents age 10 and older. Floor plan. DHS 83.05(2)(b) A licensing fee of $306, plus $39.60 per resident based on capacity of facility. NOTE: For a PROBATIONARY LICENSE, the fee for 12 months is 1/2 this amount. Evidence of financial ability to operate for 60 days. DHS 83.05(2)(f) Balance sheet. DHS 83.05(2)(e) Program statement. DHS 83.05(2)(a) Fire inspection. DHS 83.05(2)(c) The Department (DHS) has received a response to the hazard request from the municipality or thirty (30) days have elapsed since DHS sent the hazard request to the municipality.

B. The following items will be requested or may be reviewed on-site.
1. 2. 3. 4. 5. 6. 7. 8. 9. Emergency plan. DHS 83.47(2) Admission agreement. DHS 83.29 Community Advisory Committee documentation. DHS 83.05(3) and Chapter 50.03(4)(g), Wis. Stats. Resident rights, house rules policy. DHS 83.32 Grievance procedure. DHS 83.33 Evidence of site approval if the land is zoned for commercial, industrial, or manufacturing use. Approval by the Department of Natural Resources where a public water supply is not available. Documentation of approval of building plans by DHS and/or Dept. of Commerce. Documentation of final inspection of the building by DHS and/or Dept. of Commerce.

10. Documentation of sprinkler plan approval for new construction or documentation of sprinkler system inspection for existing buildings. 11. Documentation of smoke and heat detection system compliance.

C. The following items will be reviewed during the on-site visit or tour of the facility.
1. 2. 3. 4. 5. 6. Background Information Disclosure (HFS form F-82064) and completed background check for employees. Well water test results. DHS 83.46(3) Resident room size (60/80/100). DHS 83.54(4) Administrator qualifications. DHS 83.15(1) Furnace and chimney inspection results. DHS 83.46(1)(c) Carpet flame spread rating. DHS 83.61(2)

F-62416 (Rev. 04/09)

Page 2 of 2

7. 8. 9.

Clothes dryer vented with rigid metal ducting. DHS 83.44(1)(c) Windows operate easily, are screened, and have window coverings. DHS 83.60 Water temperature at 115 degrees F or less. DHS 83.55(6)(b)

10. Fire extinguishers with current tags mounted at the proper height and in the proper locations. DHS 83.47(4)(a-b) 11. Posting of house rules, resident rights, grievance procedure, activity schedule, and exit diagram. DHS 83.13(3) 12. Emergency plan readily available to all employees. DHS 83.47(2)(a) 13. Menus available to residents. DHS 83.41(2)(c)2 14. Medication storage area (locked). DHS 83.37(3)(c) 15. Accessibility requirement in bathrooms, bedrooms, and common areas. DHS 83.54(1)(a), 83.55(2), and 83.52(2) 16. The facility has proper exits. If exits are ramped, the ramps comply with requirements. DHS 83.59(1) and (6) 17. Properly located smoke detectors, heat detectors, and sprinkler heads. DHS 83.48(4), (6), and (8) 18. All doors have one-hand-one-motion door hardware. DHS 83.59(2)(a) 19. Food storage areas meet requirements. DHS 83.41(3)(b) 20. Pet vaccinations. DHS 83.39(5)

D. Miscellaneous Review and Discussion Items
1. 2. 3. 4. 5. 6. 7. 8. 9. Background Information Disclosure (HFS form F-82064) and criminal background check on staff. Must be 18 years of age. Employees screened for illness detrimental to residents, including TB, within 90 days. DHS 83.17(2) Staff Orientation. DHS 83.19 Department Approved Training. DHS 83.20 Employee Training. DHS 83.21 Task Specific Training. DHS 83.22 Training Exemptions. DHS 83.24 Continuing Education. DHS 83.25 Training Documentation. DHS 83.26

10. Resident Record: Statement of financial condition/resource center referral, pre-admission assessment, individual service plan, documentation of physician's orders and visits, health screening, medication administration records, resident evacuation assessment, admission agreement, annual satisfaction evaluation. 11. DHS 12 and DHS 13 requirements; Chapter 50, Wis. Stats.; and DHS 94 (if applicable). 12. Fire and other evacuation drill requirements, including simulated night time. DHS 83.47(2)(d) and (e) 13. Medication administration system and requirements. 14. Smoke and heat detection system testing requirements. DHS 83.48(1)(b) and (3). 15. Sprinkler system testing requirements. DHS 83.48(8)(b)1 16. Investigation, notification, and reporting requirements. DHS 83.12 17. Management of resident funds. DHS 83.34 18. DHS 83 available for review. 19. Hospice and respite care requirements. 20. Restraints (Department approval required). DHS 83.32(3)(g) 21. Annual fire inspection requirement. DHS 83.47(3)

File Size: 19.2 kB
Pages: 2
File Format: PDF
State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
Word Count: 768 Words, 5,073 Characters
Page Size: Letter (8 1/2" x 11")
Embed
URL

http://dhs.wisconsin.gov/forms1/F6/F62416.pdf