Official Minnesota Dhs Form in PDF
The Minnesota Department of Human Services (DHS) plays a crucial role in establishing guidelines for providers who offer intensive supports and services. A key component of this regulatory framework is the Minnesota DHS form, which outlines the necessary policies and procedures that licensed providers must adhere to in order to comply with the 245D licensing requirements. This form includes a variety of mandatory policies, such as the Drug and Alcohol Prohibition Policy, Emergency Use of Manual Restraint Policy, and Grievance Policy, all of which must be in place by specific deadlines. Additionally, the form highlights policies related to the reporting of maltreatment of minors and vulnerable adults, ensuring that providers maintain a safe environment for all service recipients. Providers are encouraged to customize sample policies provided by the DHS, but they must ensure that these adaptations meet the statutory requirements. Understanding the nuances of these policies is essential for compliance, and providers should familiarize themselves with the relevant statutes and rules. With a focus on safety, accountability, and quality care, the Minnesota DHS form serves as a foundational tool for providers committed to delivering effective support services.
Form Example
Minnesota Department of Human Services
Licensing Division
Sample Policies and Forms for Intensive Supports and Services
245D licensed providers may link to the sample policies and forms below and modify them for use in their programs. Providers are responsible for ensuring any policy and forms they use meet the 245D licensing requirements, including the samples provided. Read the applicable statute sections or rule parts to ensure you understand the requirements.
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Required policies and procedures |
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Applicable MN statute or rule |
Date of last |
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revision |
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Required Policies and Procedures |
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These policies are required at time of application for providers who do not hold a 245B license. |
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Drug and Alcohol Prohibition Policy |
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245A.04, subd. 1(c) |
10/31/2013 |
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Emergency Use Of Manual Restraint (EUMR) Policy |
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245D.06, subd. 1(a); 245D.06, |
10/31/2013 |
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subd. 5; & 245D.061, subd. 9 |
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Grievance Policy |
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245D.10, subd. 2 |
10/31/2013 |
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Maltreatment Of Minors Reporting and Internal Review Policy |
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245A.66 and 626.556 |
10/31/2013 |
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Service Suspension And Termination Policy |
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245D.10, subd. 3 |
10/31/2013 |
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Vulnerable Adults Maltreatment Reporting and Internal Review Policy |
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245A.65, subd. 1(a) and (b) & |
10/31/2013 |
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626.557, subd. 4a |
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Required Policies and Procedures |
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All policies must be developed by January 1, 2014. |
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Admission Criteria Policy |
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245D.11, subd. 4 |
10/31/2013 |
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Data Privacy Policy |
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245D.11, subd. 3 |
10/31/2013 |
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Emergency Response, Reporting and Review Policy |
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245D.11, subd. 2; 245D.02, subd. |
10/31/2013 |
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8; 245D.22, subd |
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Health Service Coordination and Care (Residential Programs) Policy |
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245D.11, subd. 2(2) |
10/31/2013 |
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Incident Response, Reporting and Review Policy |
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245D.11, subd. 2(7); 245D.02, |
10/31/2013 |
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subd. 11; 245.91, subd. 6; |
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609.341, subd. 3 and 14 |
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Safe Medication Assistance and Administration Policy |
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245D.11, subd. 2(3) |
10/31/2013 |
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Safe Transportation Policy |
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245D.11, subd. 2(4) |
10/31/2013 |
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Universal Precautions and Sanitary Practices Policy |
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245D.11, subd. 2(1) |
10/31/2013 |
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Required Policies And Procedures for Community Residential Settings and Day Services Facilities |
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All policies must be developed by January 1, 2014. Samples will be available in July and August 2014. |
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Program Abuse Prevention Plan (PAPP) |
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245A.65, subd. 2 (a) & 245A.65, |
10/31/2013 |
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subd. 2 (a) |
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Documentation Requirements – Optional Program Forms |
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45 Day Meeting Summary |
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10/31/2013 |
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Admission and Discharge Register form |
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10/31/2013 |
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1
Revised 10/31/2013
Minnesota Department of Human Services
Licensing Division
Assessment Results for Intensive Support Services |
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10/31/2013 |
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Emergency Report and Internal Review Form |
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10/31/2013 |
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Fire Drill Log |
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10/31/2013 |
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Funds and Property Authorization |
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10/31/2013 |
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Health Needs Change Notice |
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10/31/2013 |
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Health Needs Record |
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10/31/2013 |
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Incident Report and Internal Review |
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10/31/2013 |
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Individual Abuse Prevention Plan (IAPP) Form |
245A.65, subd.2(b) & 626.6557, |
10/31/2013 |
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subd. 14 |
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HCBS Incident Reporting Requirements - Who to Notify Form |
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10/31/2013 |
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HCBS Service Recipient Rights Packet |
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10/31/2013 |
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HCBS Service Recipient Rights Restrictions |
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10/31/2013 |
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Intensive Support Services Assessment |
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10/31/2013 |
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Medication Administration and Emergency Medical Authorization |
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10/31/2013 |
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Medication Administration Review Record |
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10/31/2013 |
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Medication and Treatment Administration Packet |
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10/31/2013 |
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Medication Setup Record |
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10/31/2013 |
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10/31/2013 |
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Progress Review Report for Intensive Support Services |
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10/31/2013 |
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Psychotropic Medication Use and Monitoring Record |
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10/31/2013 |
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Quality Management Evaluation and Program Improvement Plan |
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10/31/2013 |
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Release of Information Authorization |
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10/31/2013 |
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Satisfaction Evaluation |
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10/31/2013 |
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Service Admission Checklist for Intensive Services |
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10/31/2013 |
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Service Recipient Information Cover Sheet |
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10/31/2013 |
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Service Recipient Record Checklist |
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10/31/2013 |
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Service Suspension or Termination for Intensive Support Services Checklist |
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10/31/2013 |
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Staff Orientation and Training Packet |
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10/31/2013 |
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Support Team Meeting Summary |
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10/31/2013 |
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Supports and Outcome Methods for Intensive Support Services |
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10/31/2013 |
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2
Revised 10/31/2013
Form Specifications
| Fact Name | Description |
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| Governing Law | The Minnesota Department of Human Services (DHS) form is governed by Minnesota Statutes, specifically sections 245A and 245D. |
| Required Policies | Providers must develop specific policies, such as the Drug and Alcohol Prohibition Policy and Grievance Policy, before applying for a 245D license. |
| Revision Date | Most policies listed on the form were last revised on October 31, 2013, and must be up to date. |
| Submission Deadline | All required policies must be developed and ready for submission by January 1, 2014. |
| Sample Policies | Providers can modify sample policies provided by DHS to meet their specific program needs. |
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