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Forms and Policy

MEET OUR SAPPHIRE BUSINESS PARTNERS! VALUE ~ GROWTH ~ SUCCESS

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 Annie at arunnels@agingwa.org

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
Aggressive and Assualtive Resident Policy Aggression – Effectively Responding to Hostile Residents
  Alzheimers Resource & Fact Sheet
Anti-Discrimination  
Armed Intruder Policy Assessments – Mini-Mental
Assistive Devices – Bed Rail Safety Procedures Authorization_Release Health Information
Assistive Policies – Motorized Cart, Scooter, Wheelchair Policy & Agreement  

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 Bipolar Fact Sheet

Boarding Home Regulations
  Disclosure of Services Form (10-351) pdf
Disclosure of Services Form (10-351) word  
Collateral Interview Full Inspection Process
Environmental and Food Services Observations Exit Preparation
Guidelines (New) Purple Book  
Interior Finish Construction Checklist IDR Process
Medicaid Rates July 2010  
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  
Business Associate Agreement Contract Business Associate Agreement Contract #4
   

C

Caregiver Training Requirements DOH Presentation #1 Caregiver Training Requirements DSHS Presentation #2
Caregiver Training Requirements HoCA Presentation #3  
Catheter Care in Assisted Living Survey Results Care Coordination Log
CCRC Disclosure & Transparency  
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 
Continuing Competency Rules  

Coordination of Services

 Resident Arranged Health Care Services #1
Resident Arranged Health Care Services #2 Resident Arranged Health Care Services #3
Resident Arranged Health Care Services #4 Resident Arranged Health Care Services #5
Resident Arranged Health Care Services #6 Resident Arranged Health Care Services #7
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
Dementia Fact Sheet Dental – Institutional Residence Verfication for Dental Services
Dental – NEW Coverage Policies issued by DSHS Rates Mgmt Depression Fact Sheet
Dealing with Depression in Later Life  
Diabetes in Assisted Living Diet Aide Performance Evaluation
Diet (Prescribed) Release Form  
Disaster and Fire Drill Record Disaster Planning
Discharge_Resident Disclosure & Transparency
Driver_ Application for Qualified Status Drug  Policies and Procedures
Drug and Alcohol Testing Referral Sheet Drug and Alcohol Free Workplace Policy
   

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

Education Assistance  
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)
EIV Checklist – Bremerton EIV Q & A from Webinar 8/26
Elevator Inspections Update HUD/REAC  
Ethics Committee Charter  
Employee TB Testing Employment Eligibility Forms (I-9)
Entertainment – Motion Picture Licensing Corp – Fee Agreement for Leading Age Members  
Evaluation Guidelines – Performance  
Excercises for Parkinson’s and the Aging Population  

F

Post Fall Assessment Fall Response
Fall Prevention Information & Resource Links Falls – Comprehensive Assessment
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 Marshal Inspection Guidance: Fire Doors  Fire Marshall_Winterizing Your Community
Fire Drill and Disaster Record Fire Sprinkler Systems (Automatic) NFPA 25 Modified
Food and Beverage Worker Manual (English) Food Services
Food Services (amended May 2006) Foundation Resources AAHSA
Foundation Resources #2 Governance Philanthropy  
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
HIRE Act – Clark Nuber Hoarding Fact Sheet
Compulsive Hoarding – What is it? Hoarding Animals
  Hot Packs in AL
Hot Weather Resources HR Update! Dependent Children Coverage to Age 26
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
Installation – New Fire Regulations  

J

Job Descriptions:
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
Director of Finance  

K

   

L

Living Will Registry Loss and Theft

M

Mandated Reporter Medicaid Rates 2010 –  Boarding Homes
Med D Collaterals Medicare Enrollment Periods – Understanding
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 Mental Health Resources
Mini-Mental Exams Mold Notification, Landlord Tenant Law Change
Motion Picture Licensing Corp – Fee Agreement for Leading Age Members  

N

Negotiated Service Agreement  
New Employee Mentoring Policy New Employee Initiation & Mentoring Program
NO Health Care Provider  
Nursing Assessment Nursing Assistant
Nursing Conduct and Practice (Standards)  
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 Nursing Home Regulations Best Practices
Nurse Practice Act / Functions of an RN and LPN  

O

Obsessive – Compulsive Disorder  
Oil and Gas Vehicle Record Olfactory Hallucinations
Ombudsman Ombudsman Policy
Ombudsman Best Practices for Visiting Ombudsman Role
Ombudsman LTCOP Training Outline Oxygen
Operational Costs – Best Practices  

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’ Boarding Home Guidelines (New) 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 Aggressive or Assaulting Behaviors

Resident Care Assessment Plan

 Resident Arranged Health Care Services #1
Resident Arranged Health Care Services #2 Resident Arranged Health Care Services #3
Resident Arranged Health Care Services #4 Resident Arranged Health Care Services #5
Resident Arranged Health Care Services #6 Resident Arranged Health Care Services #7
Resident Grievances Resident Discharge
Resident Health Plan Recovery Resident Records
Resident Policy – Aggressive and Assaultive  
Resident Rights Resident Rosters
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 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)
Schizophrenia Schizophrenia – Useful Information
Scooter Policy  
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 Standards of Nursing Conduct and Practice
Stoves and Ranges FINAL Inspection Changes Suicide – No Harm Contract
Suicide – No Harm Contract Doument Suicide Rates in King County 2001 
  Surveyor Guidance, Quality of Life F-Tags

T

TB Testing of Volunteers TB Testing of Employees
Tenant Selection Plan – Bremerton – Feb 2010 Tenant Notice
Theft and Loss Theft and Policy Policy 2

U

Urinary Tract Infections Urinary Tract Infections for Seniors
UTI – Sudden Cause for Confusion in Seniors  

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 Wheelchair Policy
Workplace Drug Policies and Procedures  
Workplace Privacy Policy  

XYZ

   

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