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Forms, Policies and Templates

The forms, documents, policies and procedures attached here are provided to Aging Services of Washington members as a resource. Their origins may be from other states and retirement communities as well as outside agencies. They are intended to be of assistance when drafting your own documents or policies to meet your communities' corporate compliance, regulatory and legal responsibilities.

Members Only documents. For login Please email Cassi at cmeritt@agingwa.org

Updated: January 29, 2010 3:08 PM

A)

Abuse_Neglect Compliance	Abuse_Neglect Compliance (amended May 2006)
Abuse and Neglect	Activities/Parkinson's Exercises for Aging Populations
Admission_Residents
Administrative Manual Table of Contents for P & P	Advanced Directive
Advance Directive/Durable Power of Attorney Forms	Aggressive or Assaulting Behaviors_Managing
Anti-Discrimination
Armed Intruder Policy	Assessments - Mini-Mental
Assistive Devices - Bed Rail Safety Procedures	Authorization_Release Health Information

B)

Beauty Shop Price Comparison	Bed Alarm, Assistive Devices Assessment Policy
Bed Rail Safety Procedures - Assistive Devices	Behaviors_Managing Aggressive or Assaulting
Behavior Aggressive and Assaultive

Boarding Home Regulations
Collateral Interview	Full Inspection Process
Environmental and Food Services Observations	Exit Preparation

Interior Finish Construction Checklist	IDR Process
Pre-Inspection Prep	Residential Care Services Notes
Request for Documentation	Resident Group Meeting
Resident Characteristic Roster	Resident Interview
Resident List	Resident Record Review
Resident Sample	Staff Record Review

Building_Resident Safety

C)

Catheter Care in Assisted Living Survey Results	Care Coordination Log
CDC Influenza Website	Cell Phone Policy Cell Phone Policies 2
Changes in Condition
Computer Stations Member Feedback	Community Education Assistance
Complaint & Incident Investigation Procedure	Complaint/Incident Investigation Guidance Q * SURE
Credit and Background Check on Residents Member Feedback

D)

Death with Dignity Final Policy_Member Sample	Death with Dignity Opt-Out Physician Assisted Suicide Procedures
Death with Dignity Opt-In Physician Assisted Suicide Procedures	Death with Dignity Opt-In Policy Sample Willing Provider
Death with Dignity Opt-Out Sample Policies, Experiences from Oregon	Death with Dignity Opt-Out Sample Policies, Experiences from WA
Death with Dignity Opt-Out Sample Policy and Principle Statement	Death with Dignity Opt-Out Unwilling Health Care Provider Notification
Death with Dignity Willing Provider Policy
Decisional Capacity	Decision Capacity_Guardianship
Decision Tree - Scope of Practice	Dementia Screening Tool
Diabetes in Assisted Living	Diet Aide Performance Evaluation
Diet (Prescribed) Release Form
Disaster and Fire Drill Record	Disaster Planning
Discharge_Resident
Driver_ Application for Qualified Status	Drug Policies and Procedures


DSHS Boarding Home Re-Inspection Process
Collateral Interview	Full Inspection Process
Environmental and Food Services Observations	Exit Preparation
Interior Finish Construction Checklist	IDR Process
Pre-Inspection Prep	Residential Care Services Notes
Request for Documentation	Resident Group Meeting
Resident Characteristic Roster	Resident Interview
Resident List	Resident Record Review
Resident Sample	Staff Record Review


Durable Power of Attorney Forms/Advance Directives

E)

EIV Security Checklist	EIV Documentation of Verification
EIV Documenting Screening in the Resident Selection Plan	EIV Security Policy
EIV File Checklist Appendix B	EIV Instructions form HUD (dated Dec 7, 2009)
Elevator Inspections Update HUD/REAC
Ethics Committee Charter
Employee TB Testing	Employment Eligibility Forms (I-9)
Education Assistance	Evaluation Guidelines - Performance
Excercises for Parkinson's and the Aging Population

F)

Post Fall Assessment	Fall Response
Fax Policy	Fire and Life Safety Inspection form WA State Patrol
Fire Incident Report	Fire Marshal Life Safety Code - Door Locking K Citation
Fire Safety Handbook for Apartment Managers	Fire Drill - Monthly Report WA State Patrol
Fire Drill and Disaster Record
Food and Beverage Worker Manual (English)	Food Services
Food Services (amended May 2006)
Full Nursing Assessment	Surveyor Guidance, Quality of Life F-Tags

G)

Guardianship
Green River Flooding Notice from DSHS

H)

Health Information_ Authorization to Release	HIPAA_Policy
Hot Weather Resources	HUD Housing: Affirmative Fair Housing Regulatory Update
HUD Form and Policies, Samples from RBD	HUD Form and Policies, Instructions from RBD
HUD EIV Instructions (dated Dec. 7, 2009)	HUD/REAC Elevator Inspections Update
HUD/REAC Stoves and Ranges FINAL Inspection Changes
HUD Social Security Rule	HUD Section 8, VAWA Guidance
HUD/Violence Against Women Act, Tenant Notice

I)

IDR Process in Boarding Homes	Infection Control
Influenza Policy, Seasonal	Informed Consent
Incident Reporting	Incident/Complaint Investigation Guidance (Q*SURE) ADSA/DSHS
Inspections
Insulin in Assisted Living	Interior Finish Construction Checklist

J)

Job Descriptions: Director of Finance Human Resources Director of Nursing Assistant Activity Director Activity Coordinator Fund Development Dining Staff Driver VP of Development Receptionist Treasurer CFO Controller

Job Analysis Handbook

K)

L)

Living Will Registry	Loss and Theft

M)

Mandated Reporter
Medication_Release or Destruction	Medication Services (amended May 2006)
Medication Services (revised May 2006)	Medical Emergencies_CPR
Med Orders for Assisted Living
Medicaid Policy: Sample #1 Resident Application, Private Pay Non Medicaid Contract Participation Notification Revised July 2009	Medicaid Policy: Sample #2 Resident, Private Pay Non-Medicaid Contract Participation Notification Revised July 2009
Medicaid Policy: Sample #3 Resident Applicant, Active Medicaid Contract Participation Notification Revised July 2009	Medicaid Policy: Sample #4 Resident Active Medicaid Contract Participation Notification July 2009
Mental Health and Well Being Checklist
Mini-Mental Exams	Mold Notification, Landlord Tenant Law Change

N)

Negotiated Service Agreement
New Employee Mentoring Policy	New Employee Initiation & Mentoring Program
NO Health Care Provider
Nursing Assessment	Nursing Assistant
Nursing Credential Search
Nursing Delegation
Nursing Delegation - Assumption of Delegation	Nursing Delegation - Community Based Care Settings
Nursing Delegation - Change in Medication Errors	Nursing Delegation - Consent for Delegation of Tasks
Nursing Delegation - Instruction for Nursing Task	Nursing Delegation - Nursing Assistant Credentials and Training
Nursing Delegation - PRN Medication	Nursing Delegation - Supervision or Rescinding Delegation
Nursing Home Guidelines 'aka' Purple Book	Nursing Home Surveys or F-Tags

O)

Oil and Gas Vehicle Record
Ombudsman	Ombudsman Policy
Ombudsman Best Practices for Visiting	Ombudsman Role
Ombudsman LTCOP Training Outline	Oxygen

P)

Parkinson's Exercises for the Aging Population
Performance Evaluation Guidelines	Personal Belongings Policy
Pet Agreement	Pet Policy
Pet Registration	Pet Temperament Certification
POLST Form	POLST Fact Sheet
Purple Book 'aka' Nursing Home Guidelines

Q)

Quality of Life and Care of Resident	Q * SURE Quality and Safety through Use of Required Elements (DSHS/ADSA)

R)

REAC- Stoves and Ranges FINAL Inspection Changes	REAC Elevator Inspections Update (effective Jan. 4, 2010)
	Release Form Prescribed Diet
Record Retention Schedule #1	Record Retention Schedule #2
Red Flag Policy and Procedures #1	Red Flag Policy and Procedures #2
Red Flag Policy and Procedures #3	Red Flag Rules_Aging Services_AAHSA Analysis
Red Flag Rules Decision Tree	Red Flag Rules Synopsis
Red Flags	Renovating and Upgrading Resident Units - Best Practices
Resident Admission
Resident Care Assessment Plan	Resident Discharge
Resident Grievances
Resident Health Plan Recovery	Resident Records
Resident Rights
Resident Quality of Life and Care	Resident Selection Plan Update Letter
Resident Selection Plan SSN and Citizen/NonCitizen Update Letter	Resident Selection Plan SSN, Citizenship, VAWA Update Letter

Resident Aggressive or Assaulting Behaviors	Resident Supervision and Monitoring
Resident Supervision and Monitoring (amended May 2006)	Resident Unresponsive or Dead
RETRO Job Analysis Handbook

S)

Safety Building_Resident	Safety Building_Resident (amended May 2006)
Scope of Practice_Decision Tree	Scope of Care and Services
Seasonal Influenza Policy	Shift, 3 week Rotation Schedule
Smoking Policy	Social Security Number Policy
Staff Support_Urgent Additions
Stoves and Ranges FINAL Inspection Changes	Surveyor Guidance, Quality of Life F-Tags

T)

TB Testing of Volunteers	TB Testing of Employees
	Tenant Notice
Theft and Loss

U)

V)

VAWA Guidance, HUD Section 8	VAWA Notice to Tenants
VAWA Violence Against Women Act

Vehicle Operation Agreement	Vehicle Safety Policy
Vehicle Self Inspection Report	Vehicle Training Checklist
Vehicle Oil and Gas Record	Visitors
Volunteers

W)

WA State Living Will Presentation	Weapons Policies in Senior Housing and LTC Settings
Well Being and Mental Health Checklist
Workplace Drug Policies and Procedures
Workplace Privacy Policy

XYZ)

Members Only documents. For login Please email Cassi at cmeritt@agingwa.org

Updated: January 29, 2010 3:08 PM