rules and regulations for assisted living facilities level ii - Arkansas ...

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ARKANSAS DEPARTMENT OF HUMAN SERVICES OFFICE OF LONG TERM CARE Assisted Living Facility APPLICATION FOR LICENSE TO CONDUCT AN ASSISTED LIVING FACILITY NOTE: Before beginning this application, please read carefully the instructions on page 4. For State Use Only [ ] Original [ ] Renewal License Issued for ______________ Year ______/_____/_____ Month Day Year License Number ______________ Vendor No. ____________________ No. Licensed For _____________________ Fee $ ___________________ License Granted Effective ___________________ License Denied ________________ Administrator, Residential and Adult Day Care _________________________________________________________ I. Name and Location The undersigned hereby make application for a license to operate [ ] Assisted Living Facility Level I [ ] Assisted Living Facility Level II Name of Facility _________________________________________________________________________________ Address of Facility _______________________________________________________________________________ Street City or Town _______________________________________________________________________________________________ County State Zip Code Telephone # Fax # Mailing Address if different from above ______________________________________________________________ II. Management and Ownership A. The Operation or management of the facility is vested in the following: (1) [ ] __________________________________________________ (2) Private [ ] (3) Non-Profit [ ] B. If public facility, list individual who heads the governmental department having jurisdiction over the facility and members of the Governing Board: Name Address 1. _____________________________________ ___________________________________________ 2. _____________________________________ ___________________________________________ 3. _____________________________________ ___________________________________________ 4. _____________________________________ ___________________________________________ 5. _____________________________________ ___________________________________________ DMS-803 (07/02) Page 1of 4
C. If privately owned list Ownership status (1) [ ]____Sole Proprietorship (2) [ ]______Partnership (3) [ ]_____Corporation Partnership: List names and addresses of partner Name ________________________________________ ________________________________________ ________________________________________ Address ______________________________________________ ______________________________________________ ______________________________________________ Corporation: List names and addresses of corporate officers and percentage of individuals owning 5% or more stock (List % of ownership by the individual’s names) Name _______________________________________ _______________________________________ _______________________________________ Address ________________________________________________ ________________________________________________ ________________________________________________ Non-Profit: List names and addresses of Board of Directors of the Governing Body Name _______________________________________ _______________________________________ _______________________________________ Address _______________________________________________ _______________________________________________ _______________________________________________ D. If ownership of building is different from the person(s) or group operating the facility, explain the relationship including names and addresses of the owner(s). Name _______________________________________ _______________________________________ _______________________________________ Address _____________________________________________ ______________________________________________ ______________________________________________ II. Licensure A. Number of beds _______ (Total) _________ (Level I) ________ (Level II) B. If above total is different from that which you are currently licensed, explain the difference DMS-803 (07/02) Page 2 of 4
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RULES AND REGULATIONS FOR ASSISTED
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1005 STATE MONITORING .............
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200 PURPOSE The purpose of these ru
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arrangement with an outside service
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esident will return. A discharge oc
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medication. Medication - Self Admin
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Separate Premises - Buildings housi
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400 LICENSURE 400.1 No Level II ass
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402 INITIAL LICENSURE 402.1 Initial
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. The complete name and address of
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. Lease of any portion of facility
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500 ADMINISTRATION 501 GOVERNING BO
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2. minimal qualifications, to inclu
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through the administrator. Sharing
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c. A second administrator shall be
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esidents from 8:00 p.m. to 7:00 a.m
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a. Permit unrestricted visiting hou
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c. The facility shall hold personal
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505.1.4 If a responsible party or p
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1. All reports involving accident o
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508 RESIDENT RECORDS 508.1 The assi
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times, unless removed pursuant to s
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esponsible party in place within th
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1. For a fourteen-day (14) period b
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facility ensures all of the followi
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D. The name, address, and telephone
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exercising these civil rights. 3. I
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P. Have the right and be allowed to
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700 SERVICES An assisted living fac
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h. Electric systems, including appl
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advance practice nurse and take app
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700.4 Ancillary Services All ancill
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1. Assessment of the health care se
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evaluation of the following: 1. Phy
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1. Physician’s orders; 2. Manufac
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or recommendations on the prescript
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2. Drug containers with illegible o
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. The dosage prescribed and the dos
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703.5 Influenza Immunization of Res
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action identified as a cause for co
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egarding Alzheimer's or related dem
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1. Visitors shall be permitted at a
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a. Psychosocial and Physical Assess
Page 87 and 88: needs of residents with dementia. T
Page 89 and 90: 804 EGRESS CONTROL a. Egress Polici
Page 91 and 92: (5) month period. 5. In addition to
Page 93 and 94: 3. Is designated by the Alzheimer
Page 95 and 96: cooperation; delay deterioration of
Page 97 and 98: plans and specifications shall be s
Page 99 and 100: location of the various members. Sc
Page 101 and 102: E. Sections describing material and
Page 103 and 104: f. All furnishings and equipment in
Page 105 and 106: community based residential facilit
Page 107 and 108: 905 APARTMENTS 2. The facility must
Page 109 and 110: functionally distinct area within t
Page 111 and 112: Health. 907.1 A contract to supply
Page 113 and 114: 1000 IMPOSITION OF REMEDIES - AUTHO
Page 115 and 116: 1. Regardless which remedy is appli
Page 117 and 118: 4. Not currently serve or, within t
Page 119 and 120: may specify the time frames in whic
Page 121 and 122: violation, in accordance with Ark.
Page 123 and 124: 1100 INFORMAL DISPUTE RESOLUTION (I
Page 125 and 126: APPENDIX FORMS 125
Page 127 and 128: COPIES FOR: ATY GEN______________ P
Page 129 and 130: STEPS TAKEN TO PREVENT CONTINUED AB
Page 131 and 132: Name of Facility: Facility Investig
Page 133 and 134: (Attach Additional Pages as Necessa
Page 135 and 136: Section IV- Notification/ Status Ad
Page 137: Facility Investigation Report for R
Page 141 and 142: INSTRUCTIONS A. Enclosed are two (2
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