Sample Policies and Forms for Intensive Supports …

1 Minnesota Department of Human Services Licensing Division Updated April 2018 1 Sample Policies and Forms for Intensive 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); , subd. 5, ; and 07/01/2017 Emergency Use of Manual Restraint (EUMR) Allowed Policy (DOCX) , subd. 1(a); , subd. 5, ; and 07/01/2017 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 08/01/2015 Vulnerable Adults Maltreatment Reporting and Internal Review Policy DHS-7634B (PDF) , subd.

3 1(a) and (b) & , subd. 4a 01/01/ 2018 Required Policies and Procedures 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. 8; , subd 4-7 10/31/2013 Health Service Coordination and Care (Residential Programs) Policy (DOC) , subd. 2(2) 07/01/2017 Incident Response, Reporting and Review Policy (DOC) , subd. 2(7); , subd. 11; , subd. 6; , subd. 3 and 14 07/01/2017 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.

4 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) & , subd. 2 (a) 07/01/2015 Documentation Requirements Optional Program Forms 45-Day Meeting Summary (DOC) 04/01/2017 Admission and Discharge Register form (DOC) 10/31/2013 Minnesota Department of Human Services Licensing Division Updated April 2018 2 Emergency Report and Internal Review form (DOC) 10/31/2013 Fire Drill Log (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) form (DOC) , (b) & , subd.

5 14 10/31/2013 HCBS Incident Reporting Requirements - Who to Notify form (DOC) 09/15/2014 HCBS Service Recipient Rights Packet (DOC) 07/01/2017 HCBS Service Recipient Rights Restrictions (DOC) 07/01/2017 Intensive Support Self-Management Assessment (DOCX) 07/01/2017 Medication Administration and Emergency Medical Authorization (DOCX) 07/01/2015 Medication Administration Review Record (DOCX) 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 Policy Receipt and Signature Page (DOCX) 07/01/2017 Progress Review Report for Intensive Support Services (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 Residency Agreement (DOCX) 03/01/2017 Satisfaction Evaluation (DOC) 10/31/2013 Service Admission Checklist for Intensive Services (DOCX) 01/10/2017 Service Recipient Information Cover Sheet (DOCX)

6 07/01/2017 Service Recipient Record Checklist (DOC) 10/31/2013 Staff Annual Training Record (DOCX) 07/01/2017 Staff Orientation Record (DOCX) 07/01/2017 Progress Review Meeting Summary (DOCX) 04/10/2017 Supports and Outcome Methods for Intensive Support Services (DOCX) 07/01/2017 Variance Request DHS-3141 (PDF) , subd. (9) 03/18