Free Residential Care Apartment Complex (RCAC) Regulation Compliance Statement-F-62381 - Wisconsin

DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62381 (Rev. 07/08)

STATE OF WISCONSIN
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RESIDENTIAL CARE APARTMENT COMPLEX (RCAC) REGULATION COMPLIANCE STATEMENT
Completion of this form is required per HFS 89.53, Wisconsin Administrative Code, for certification or HFS 89.42, Wis. Admin. Code, for registration as a Residential Care Apartment Complex (RCAC). Check the boxes to confirm compliance with Wisconsin Administrative Code, HFS 89, Residential Care Apartment Complexes. For all initial applications, complete, sign, and submit this form to the Division of Quality Assurance (DQA) Regional Office that serves the county in which the RCAC is located. DQA regional office locations are found at http://dhs.wisconsin.gov/rl_dsl/Contacts/ALSreglmap.htm . Contact the appropriate regional office if you have questions about completion of this form.

Name ­ Facility Street Address City Name ­ Person Completing This Form County State Telephone Number Zip

COMPLIANCE WITH GENERAL CODES 1. The facility has developed written policies and procedures and has conducted staff orientation that reflects the requirements of all applicable statutes, rules and regulations. HFS 89.22(1) 2. The facility has evidence of plan approval by the Wisconsin Department of Commerce. HFS 89.22(1) 3. The facility has a copy of local building inspection approval and / or a copy of the occupancy permit. 4. The facility has developed policies and procedures to ensure tenant health and safety. A written emergency plan has been developed in cooperation with local fire and emergency services. Policies shall address staff orientation and availability of 24 hour service. HFS 89.23(2)(c) 5. Nursing services are provided consistent with the standards contained in "Wisconsin Statutes and Administrative Code Relating to the Practice of Nursing." HFS 89.23(4)(2) 6. The facility routinely conducts criminal records checks for all staff. HFS 89.23(4)(c) 7. The facility has written policies and procedures regarding the prohibition of coercion or retaliation preventing a tenant, employee, or service provider from filing a complaint or grievance. HFS 89.36, HFS 89.44(5) and HFS 89.58 8. The facility has written evidence of compliance with all fire, health, safety, and sanitation requirements. HFS 89.22(1) and HFS 89.55(2) 9. If the applicant is planning to convert a separate area of a nursing home or community based residential facility to a residential care apartment complex, the facility has submitted to the department the required information under HFS 89.61 10. The facility is in compliance with public and common use areas accessibility consistent with the requirements of the Wisconsin Department of Commerce. HFS 89.22(3) 11. A registered facility informs tenants that the Department does not routinely inspect or monitor registered residential care apartment complexes or enforce contractual obligations under the service or risk agreements. HFS 89.43(4)

F-62381 (Rev. 07/08)

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COMPLIANCE WITH OPERATIONAL CODES 1. The facility is in compliance with the requirements for independent apartments. HFS 89.22(2),(3) and (4) and HFS 89.13(3), (11), (16), (17), (18) and (19) 2. The facility provides or contracts with sufficient staff to meet the needs identified in the tenants' service agreements. HFS 89.23(2) 3. The facility has sufficient staff to meet the unscheduled needs of tenants and provide emergency assistance. HFS 89.23(2)(b) and (c) 4. The facility has qualified personnel to meet the care needs identified in the tenants' service agreements. Medication administration is a delegated task under the supervision of a nurse or pharmacist. HFS 89.23(3) and (4) 5. The facility has a written staffing plan which includes a designated person in charge when the service manager is not present. HFS 89.23(4) and (6) 6. The facility requires that all facility staff have training in safety procedures and in tenant rights. HFS 89.23(4)(d) 7. The facility has a procedure for computing tenants' services hours including procedures for allowing tenants to subcontract for additional hours. HFS 89.24 8. The facility's fee schedule includes separate identification of the monthly rent, meals, and services. The facility provides a copy of the fee schedule to the tenant and appropriate individuals. HFS 89.25 9. The facility conducts a comprehensive assessment prior to each admission and annually thereafter. HFS 89.26(1),(2),(3) and (4) 10. The facility has a mutually agreed-upon written service agreement with each tenant. HFS 89.27(1),(2),(3) and (4) 11. The facility has a jointly negotiated risk agreement with each tenant. HFS 89.28(1),(2),(3),(4),(5) and (6) 12. The facility has a policy for the admission and retention of residents. HFS 89.29(1),(2) and (3) 13. The facility is in compliance with tenants rights. HFS 89.32 and HFS 89.33

I attest that all statements made on this form are correct and accurate and that I will comply with all laws, rules, and regulations governing residential care apartment complexes.
SIGNATURE ­ Applicant Date Signed