Free None - Wisconsin

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Date: November 21, 2006
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State: Wisconsin
Category: Health Care
Author: SlateRA
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DEPARTMENT OF HEALTH AND FAMILY SERVICES Office of Quality Assurance OQA-2528 (Rev. 10-06)


Name Facility Reviewer Date Form Completed

Street Address



CERTIFIED RCACS: All items are applicable. REGISTERED RCACS: ONLY items A.1., A.2., A.3., A.4. and B.1. are applicable.

A. A COMPLETED APPLICATION INCLUDES THE FOLLOWING ITEMS. 1. Completed OQA-2380, RCAC Initial Certification or Registration Application. HFS 89.42 2. Completed OQA-2381, RCAC Regulation Compliance Statement. HFS 89.42 3. Background check completed by Office of Caregiver Quality. 4. Floor plan with room sizes. HFS 89.22(2)(c)1 5. Certification fees required by the Department. B. THE FOLLOWING ITEMS WILL BE AVAILABLE ON-SITE OR UPON REQUEST 1. Inspection reports HFS 89.55(2) a. Fire and safety inspection. b. Occupancy permit and / or local building inspection. c. Final inspection by the Department of Commerce or a DHFS final inspection if attached to a CBRF, nursing home or hospital. 2. Service Agreement. Services, fees, policies and procedures related to admission, retention and termination. HFS 89.27 3. Risk Agreement. HFS 89.28 4. Comprehensive assessment form and procedure. HFS 89.26(1) 5. Written grievance procedure. HFS 89.35 6. Written policy regarding rights of tenants. Rights and policy must be visibly posted for tenants, visitors and staff. HFS 89.32 7. Background check from the Department of Justice, caregiver background results and completed form HFS-64, Background Information Disclosure, for required persons. HFS 89.23(4)(c) 8. Written schedule of fees. HFS 89.25(1) 9. Written staffing plan. HFS 89.23(6) 10. Staff training. Fire safety, first aid, standard precautions, emergency plan and tenant rights. HFS 89.23(4)(d)1 11. Written emergency plans for fire, sudden serious illness, accident, severe weather or other emergency. HFS 89.23(2)(c) 12. If the facility is converting a portion of a CBRF or a nursing home, review for compliance. HFS 89.61 and HFS 89.62