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Sample Policies and Forms for Basic Supports and …

Minnesota Department of Human services Licensing Division Sample Policies and Forms for Basic Supports and services 245D licensed providers may link to the Sample Policies and Forms below and modify them for use in their programs. Providers are responsible for ensuring any policy and Forms they use meet the 245D licensing requirements, including the samples provided. Read the applicable statute sections or rule parts to ensure you understand the requirements. Required Policies and procedures Applicable MN statute or rule Date of last revision Required Policies and Procedures These Policies are required at time of application.

Minnesota Department of Human Services Licensing Division Revised 07/01/17 1 . Sample Policies and Forms for Basic Supports and Services. 245D licensed providers may link to the sample policies and forms below and modify them for …

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1 Minnesota Department of Human services Licensing Division Sample Policies and Forms for Basic Supports and services 245D licensed providers may link to the Sample Policies and Forms below and modify them for use in their programs. Providers are responsible for ensuring any policy and Forms they use meet the 245D licensing requirements, including the samples provided. Read the applicable statute sections or rule parts to ensure you understand the requirements. Required Policies and procedures Applicable MN statute or rule Date of last revision Required Policies and Procedures These Policies are required at time of application.

2 Drug and Alcohol Prohibition Policy (DOC) , subd. 1(c) 07/01/2017. Emergency Use of Manual Restraint (EUMR) Not Allowed Policy (DOCX) , subd. 1(a); , 07/01/2017. subd. 5, ; and Emergency Use of Manual Restraint (EUMR) Allowed Policy (DOCX) , subd. 1(a); , 07/01/2017. subd. 5, ; and Grievance Policy (DOC) , subd. 2 10/31/2013. Maltreatment of Minors Reporting and Internal Review Policy DHS-7634A (PDF) and 01/01/2018. Service Termination Policy (DOCX) , subd. 3 08/01/2015. Temporary Service Suspension Policy (DOCX) , subd.

3 3 08/01/2015. Vulnerable Adults Maltreatment Reporting and Internal Review Policy DHS-7634B , subd. 1(a) and (b) & 01/01/2018. (PDF) , subd. 4a Optional Policies and Procedures for Basic support services Admission Criteria Policy (DOC) , subd. 4 07/01/2017. Data Privacy Policy (DOC) , subd. 3 10/31/2013. Emergency Response, Reporting and Review Policy (DOC) , subd. 2; , subd. 10/31/2013. 8; , subd 4-7. Health Service Coordination and Care (Residential Programs) Policy (DOC) , subd. 2(2) 07/01/2017. Incident Response, Reporting and Review Policy (DOC) , subd.

4 2(7); , 07/01/2017. subd. 11; , subd. 6;. , subd. 3 and 14. Safe Medication Assistance and Administration Policy (DOCX) , subd. 2(3) 07/01/2015. Safe Transportation Policy (DOC) , subd. 2(4) 10/31/2013. Universal Precautions and Sanitary Practices Policy (DOC) , subd. 2(1) 10/31/2013. Required Policies and Procedures for Community Residential Settings and Day services Facilities Program Abuse Prevention Plan (PAPP) (DOCX) , subd. 2 (a) & , 07/01/2015. subd. 2 (a). Documentation Requirements Optional Program Forms Admission and Discharge Register (DOC) 10/31/2013.

5 Revised 07/01/17. 1. Minnesota Department of Human services Licensing Division Emergency Report and Internal Review (DOC) 10/31/2013. Funds and Property Authorization (DOC) 10/31/2013. Health Needs Change Notice (DOCX) 07/01/2015. Health Needs Record (DOC) 10/31/2013. Incident Report and Internal Review (DOC) 10/31/2013. Individual Abuse Prevention Plan (IAPP) (DOC) Basic support SERVICE , (b) & , 10/31/2013. PROVIDERS ARE REQUIRED UNDER TO DEVELOP AN IAPP subd. 14. HCBS Incident Reporting Requirements - Who to Notify (DOC) 09/15/2014.

6 HCBS Service Recipient Rights Packet (DOC) 07/01/2017. HCBS Service Recipient Rights Restrictions (DOC) 07/01/2017. Medication Administration and Emergency Medical Authorization (DOCX) 07/01/2015. Medication Administration Review Record (DOC) 10/31/2013. Medication and Treatment Administration Packet (DOC) 10/31/2013. Medication Setup Record (DOC) 10/31/2013. Notice of Service Termination form (DOCX) 08/01/2015. Notice of Temporary Service Suspension form (DOCX) 08/01/2015. Person-Centered Planning and Service Delivery Requirements (DOC) 10/31/2013.

7 Policy Receipt and Signature Page (DOCX) 07/01/2017. Psychotropic Medication Use and Monitoring Record (DOC) 10/31/2013. Quality Management Evaluation and Program Improvement Plan (DOC) 10/31/2013. Release of Information Authorization (DOC) 10/31/2013. Satisfaction Evaluation (DOC) 10/31/2013. Service Admission Checklist for Basic services (DOCX) 02/02/2017. Service Recipient Information Cover Sheet (DOCX) 07/01/2017. Service Recipient Record Checklist (DOC) 10/31/2013. Staff Annual Training Record (DOCX) 07/01/2017.

8 Staff Orientation Record (DOCX) 07/01/2017. Status/Progress Report for Basic support services (DOC) 10/31/2013. support Team Meeting Summary (DOCX) 07/01/2017. Variance Request DHS-3141 (PDF) , subd. (9). Revised 07/01/17. 2.


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