Web607 rows · DSHS forms are available for electronic completion in different software; … WebCompleted Resident Characteristic Roster/Sample Selection (Attachment D). Completed list of staff with names, position, hire date, and month/day of birth (Attachment K). Request a copy of evidence of liability insurance coverage from the licensee/administrator. Request a copy of the disclosure form to identify the scope of care and services.

Assisted Living Facility Request For Documentation - Attachment B

WebComplete Assisted Living Facility Resident Characteristic Roster And Sample Selection - Attachment D - Dshs online with US Legal Forms. Easily fill out PDF blank, edit, and … WebA completed resident characteristic list (Attachment D, DSHS 15-574). Include all licensed rooms and all residents Complete list of staff, position title, birthdate, shift, and hire date Working schedule of care staff, nursing staff. MHPs and on-call RN and MHPs for prior two weeks Disclosure of Admission Agreement Location of the resident records short acting beta antagonist list

Title

WebAttachment D (Resident Characteristic Roster/Sample Selection) (DSHS 10-362) Attachment N (Contract Requirements) (DSHS 10-372) Attachment O (Environmental Observations for Contract Requirements) (DSHS 10-373) Attachment P (Food Service Observations) (DSHS 10-486) PROCEDURES. The Licensor will: WebRecord Reviews: Resident characteristic roster, staff list, infection line list, resident records, infection control policies and procedures, staff training, Page 1 of2 Thisdocument w / Residential Care Services Investigation Summary Report Allegation Summary: WebRecord Reviews: Characteristic Roster, Infection Control Policy, COVID-19 protocols, screening, testing, reporting suspected and actual cases of a communicable illness. Page 1 of2 This do cument ... (COVID19) to DSHS as required, and did not take the necessary preventative and protective actions to manage and limit the spread within the facility. sandwich library hours