Free Adult Family Home Initial Licensure Checklist-F-62671 - Wisconsin


File Size: 15.2 kB
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Date: February 24, 2009
File Format: PDF
State: Wisconsin
Category: Health Care
Author: Division of Quality Assurance
Word Count: 504 Words, 3,286 Characters
Page Size: Letter (8 1/2" x 11")
URL

http://dhs.wisconsin.gov/forms1/F6/F62671.pdf

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DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62671 (Rev. 02/09)

STATE OF WISCONSIN

ADULT FAMILY HOME INITIAL LICENSURE CHECKLIST
Name ­ Facility Street Address Reviewer City County Date Form Completed

A. A completed application contains the following:
1. 2. 3. 4. 5. 6. 7. 8. 9. Completed F-60945, AFH Initial License Application. Verify that the licensee is 21 years old. Background check completed by Office of Caregiver Quality on the licensee and all non-residents age 10 and older Floor plan with room measurements and showing the use of the rooms License fee of $135.00 Evidence of financial ability to operate for 60 days [DHS 88.04(3)] Balance sheet Copy of car and house insurance Copy of an acceptable program statement [DHS 88.03(2)(b)2] Certificate showing completion of viewing the "Starting an Adult Family Home" webcast (if you are a new provider)

B. The following items will be requested for review prior to the licensing visit or reviewed on-site:
1. 2. 3. 4. 5. Fire evacuation plan with meeting place [DHS 88.05(4)(d)1] Resident rights policy [DHS 88.10(2)] Admission/service agreement [DHS 88.06(2)(c)1 ­ 8] House rules and responsibilities Resident grievance procedure [DHS 88.10(2)]

C. The following items will be reviewed during the on-site visit or tour of the facility:
1. 2. 3. 4. Review accessibility requirements. Note if facility has ramps to grade, grab bars, levered door handles, door widths according to requirements, and the proper turning radius in bathrooms. [DHS 88.05(2)] Resident rooms ­ 60 square feet per resident for double, 80 square feet for single, 100 square feet for wheelchairs 88.05(3)(h)5] Fire extinguishers with current tags are mounted at the proper height and in the proper locations [DHS 88.05(4)(a)] Smoke detectors in each habitable room except the kitchen and bathroom, at the head of each open stairway, at the door leading to every enclosed stairway, on the ceiling of each sleeping room, living room, and family room, and in the basement [DHS 88.05(4)(b)] Two (2) exits from first floor ­ other exits, as needed [DHS 88.05(4)(c) and DHS 88.05(3)(m)] Clothes dryer vented with rigid metal ducting Water temperature at 120 degrees F. or less at all fixtures accessible to the residents Medication storage area (locked) [DHS 88.07(3)(e)] Well water test results [DHS 88.05(3)(d)] [DHS

5. 6. 7. 8. 9.

10. Furnace and chimney inspection results [DHS 88.05(3)(e)] 11. Pet vaccinations [DHS 88.05(6)]

D. Miscellaneous Review and Discussion Items
1. 2. 3. 4. 5. 6. 7. 8. 9. Criminal background check on service providers; must be 18 years of age. Licensee and employees screened for illness detrimental to residents, including TB, within 90 days [DHS 88.04(2)(g)1] Training ­ 15 hours (including fire safety and first aid), within 6 months [DHS 88.04(5)(a)] Eight (8) hours of training annually [DHS 88.04(5)(b)] Resident Record: pre-admission assessment, individual service plan, documentation of physician's orders and visits, health screening, medication administration records, resident evacuation assessment DHS 12 and DHS 13 requirements Fire drill requirements [DHS 88.05(4)(d)2] Medication administration system and requirements [DHS 88.07(3)] Smoke detectors tested monthly [DHS 88.05(4)(b)2]