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

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_________________________________________________________________________________________ _________________________________________________________________________________________ C. Name and address of facility manager/director if different from the ownership ______________________________________ Name ______________________________________________ Address ______________________________________ ______________________________________________ State Telephone # III. Certification and Verification State of_______________________________ County of _____________________________________ I hereby certify that I have read the aforementioned Application and that all statements are true to the best of my knowledge and belief. I am aware that any willful misrepresentation of any material fact contained on the Application will subject me to penalties as prescribed in the State Licensing Law including, but limited to revocation and/or suspension of this license. I further affirm that I understand that I am eligible for a license only if the facility is in compliance with the law and regulations thereunder, and that the Office of Long Term Care is empowered to deny, suspend, or revoke my license on any of the grounds listed in the State Licensing Law. ___________________________________________ ___________________________________________ Signature of person(s) authorized to sign in accordance with instruction II. C Subscribed and sworn to before me on this the _______________day of _________________________, _________ _____________________________________________ Notary Public (Notary Seal) My Commission expires on _________________________ DMS-803 (07/02) Page 3 of 4
INSTRUCTIONS A. Enclosed are two (2) copies of Application for Licensure. Complete one copy and return to the Office of Long Term Care and retain one copy for your files. B. Please read these instructions carefully and complete this application in full. This application must be completed in ink or typed. C. This application is not valid unless it is notarized. D. This license application must be signed by the following person(s) dependent upon the type of management and ownership. 1. If the institution is public (i.e., County, City, etc.) it must be signed by the person who is head of the governmental department having jurisdiction over it (i.e., Chairman of County Board or Chairman of Commission) or his duly authorized representative. This authorization must be in writing, notarized and submitted along with this application. 2. If the institution is private, it must be signed by the following dependent upon the type of business organization. Type Sole Proprietorship Partnership Corporation, Church, Non-Profit Association Signer Owner One of the partner If someone other than the above named is authorized to sign in his or her behalf, such authorization must be in writing, notarized and attached to this application. E. All license expire on midnight June 30 of the calendar year in which they are issued. F. Application for annual renewal must be postmarked no later than June 1 of the current year in order to avoid the payment of a penalty. This penalty shall be 10% of the facility’s licensure fee. G. This application should be returned by certified mail to the following address: DEPARTMENT OF HUMAN SERVICES OFFICE OF LONG TERM CARE P.O. BOX 8059 SLOT S408 LITTLE ROCK, AR 72203 Please make certain that you use the above listed address only. All other addresses used could cause delays and may result in penalties being applied to your annual licensure renewal fees. H. A check or money order for the required licensure fee made payable to Arkansas Department of Human Services must accompany this submission except for those facilities operated by the State. Licensure Fee: $10.00 per bed DMS-803 (07/02) Page 4 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
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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 and 138: Facility Investigation Report for R
Page 139: C. If privately owned list Ownershi
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