D: DHHS Assisted Living Service Provider Checklist HCB Waiver for Aged Persons, Adults or Children with Disabilities (MILTC-1AD)

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SECTION 1 Provider Identification
Provider Name									FID Number
SECTION 2 General Provider Standards
I certify that I/my agency will: Meet all general provider standards in the Title 480 NAC, Chapter 5. .................. Bill according to procedures explained by the service area representative. ................ Assure that any suspected abuse or neglect will be reported to law enforcement and/or appropriate DHHS staff.................									Please Check Yes No
SECTION 3 Facility Standards
I certify that my facility will provide: A private room with bath consisting of a toilet and sink, for each waiver client. .......... The following standards also apply to Assisted Living facilities who also provide nursing facility care If my facility received funding through the Nebraska Health Infrastructure Fund Act, a tub or shower will also be provided in the waiver client's private room. ...................................... A separate location (e.g., wing or section of the building). .... A separate dining and common areas. ...........
SECTION 4 Service Components Standards
I certify that I/my staff will make available and provide each of the following services components as identified in the client specific plan of services and supports and as agreed upon in the Resident Service Agreement: Adult Day Care/Socialization Activities: Structured social, habilitative and health activities geared for the needs of the client. .. Escort Services: Accompanying or personally assisting a client who is unable to travel or wait alone. This may include assistance to and from a vehicle and/or place of local destination. This may also include providing or making arrangements for supervision and support to the client while away from the assisted living facility, as determined on an individual basis and specified in the Resident Service Agreement. ........ Essential Shopping: Obtaining clothing and personal care items for the client, when the client is unable to do so for him/herself. This does not include financing the purchase of clothing and personal care items. ..... Health Maintenance Activities: Non-complex interventions which can safely be performed according to exact directions, which do not required alterations of standard procedures and for which the results and client's responses are predictable. Need for health maintenance activities is determined on an individual basis. ............. Housekeeping Activities: Cleaning of public areas as well as the client's private residence, such as dusting, vacuuming, cleaning floors, cleaning of the bathroom and making and changing of the bed. Bed linens will be changed as soiled but at least weekly. Clean bath linens shall be made available daily. .... Laundry Services: Washing, drying, folding and returning client's clothing to his/her room. Dry cleaning is the responsibility of the client, but the facility will assist the client in arranging for this service if needed. ...............
MILTC-1-AD Rev. 4/98 (62001) (No previous version)

SECTION 4 (cont.) Service Components Standards
Meal Service: Three meals per day, seven days per week, as well as access to between meal snacks. Each meal must consist of a variety of properly prepared foods containing at least one-third of the Minimum Daily Nutritional Requirements for adults and take into account cultural, personal preference for food served. Meals will be delivered to a client's room for those experiencing temporary illness. ...... Medication Assistance: Assistance with administration of prescriptions and nonprescription medications. ..... Personal Care Services: Assistance with ADLs (e.g., transferring, dressing, eating, bathing, toileting, and bladder and bowel continence). The facility shall also provide assistance with eating. Assistance with eating includes opening packages, cutting food, adding condiments, and other activities which the client is unable to do for him/herself in preparing to eat food. If the client is unable to eat independently, the facility shall feed the client or shall assure other arrangements are made for this care. Personal care shall be provided in a manner in which the individual maintains as much independence and privacy as possible. The amount and degree of personal care services is determined on an individual basis. ........... Transportation Services: Transporting or making arrangements for transporting a client to and from local community resources identified during client assessment and included in the Plan of Services and Supports as directly contributing to the ability of the individual to remain in an assisted living facility. .....	Please Check Yes No
SECTION 5 Record Keeping
I certify that: Records will be maintained for four years as required in 480 NAC 5-011.. A file will be maintained on each client including: The Resident Services Agreement;.................... The Individualized Plan of Services and Supports; and.... Phone number of client's choice of physician and emergency contact person. ................... Client agreement to a multiple occupancy living arrangement. ......
SECTION 6 Comments

SECTION 7 Signatures and Dates
I have read and understand the above standards as explained by the service area representative. I certify that I and my employees will meet all the above standards while providing Waiver Assisted Living Service. I agree to allow Central Registry and law enforcement checks on myself and my employees. Sign Here _________________________________________________ Agency Representative Date I have explained the above standards to this provider, and this Assisted Living Facility meets all of the standards to provide waiver Assisted Living Service. Sign Here _________________________________________________ Health and Human Services Representative Date