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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.

 

 

 

 

 

 

Required policies and procedures

 

Applicable MN statute or rule

Date of last

 

 

 

 

revision

 

 

 

 

 

 

 

 

 

 

Required Policies and Procedures

 

 

 

 

 

 

These policies are required at time of application for providers who do not hold a 245B license.

 

 

 

 

 

 

 

Drug and Alcohol Prohibition Policy

 

245A.04, subd. 1(c)

10/31/2013

 

 

 

 

 

 

Emergency Use Of Manual Restraint (EUMR) Policy

 

245D.06, subd. 1(a); 245D.06,

10/31/2013

 

 

 

subd. 5; & 245D.061, subd. 9

 

 

 

 

 

 

 

Grievance Policy

 

245D.10, subd. 2

10/31/2013

 

 

 

 

 

 

Maltreatment Of Minors Reporting and Internal Review Policy

 

245A.66 and 626.556

10/31/2013

 

 

 

 

 

 

Service Suspension And Termination Policy

 

245D.10, subd. 3

10/31/2013

 

 

 

 

 

 

Vulnerable Adults Maltreatment Reporting and Internal Review Policy

 

245A.65, subd. 1(a) and (b) &

10/31/2013

 

 

 

626.557, subd. 4a

 

 

 

 

 

 

Required Policies and Procedures

 

 

 

 

 

 

 

 

All policies must be developed by January 1, 2014.

 

 

 

 

 

 

 

Admission Criteria Policy

 

245D.11, subd. 4

10/31/2013

 

 

 

 

 

 

Data Privacy Policy

 

245D.11, subd. 3

10/31/2013

 

 

 

 

 

 

Emergency Response, Reporting and Review Policy

 

245D.11, subd. 2; 245D.02, subd.

10/31/2013

 

 

 

8; 245D.22, subd 4-7

 

 

 

 

 

 

 

Health Service Coordination and Care (Residential Programs) Policy

 

245D.11, subd. 2(2)

10/31/2013

 

 

 

 

 

 

Incident Response, Reporting and Review Policy

 

245D.11, subd. 2(7); 245D.02,

10/31/2013

 

 

 

subd. 11; 245.91, subd. 6;

 

 

 

 

609.341, subd. 3 and 14

 

 

 

 

 

 

 

Safe Medication Assistance and Administration Policy

 

245D.11, subd. 2(3)

10/31/2013

 

 

 

 

 

 

Safe Transportation Policy

 

245D.11, subd. 2(4)

10/31/2013

 

 

 

 

 

 

Universal Precautions and Sanitary Practices Policy

 

245D.11, subd. 2(1)

10/31/2013

 

 

 

 

 

Required Policies And Procedures for Community Residential Settings and Day Services Facilities

 

 

 

 

 

 

 

 

All policies must be developed by January 1, 2014. Samples will be available in July and August 2014.

 

 

 

 

 

 

 

Program Abuse Prevention Plan (PAPP)

 

245A.65, subd. 2 (a) & 245A.65,

10/31/2013

 

 

 

subd. 2 (a)

 

 

 

 

 

 

Documentation Requirements – Optional Program Forms

 

 

 

 

 

 

 

 

 

45 Day Meeting Summary

 

 

10/31/2013

 

 

 

 

 

 

Admission and Discharge Register form

 

 

10/31/2013

 

 

 

 

 

1

Revised 10/31/2013

Minnesota Department of Human Services

Licensing Division

Assessment Results for Intensive Support Services

 

10/31/2013

 

 

 

Emergency Report and Internal Review Form

 

10/31/2013

 

 

 

Fire Drill Log

 

10/31/2013

 

 

 

Funds and Property Authorization

 

10/31/2013

 

 

 

Health Needs Change Notice

 

10/31/2013

 

 

 

Health Needs Record

 

10/31/2013

 

 

 

Incident Report and Internal Review

 

10/31/2013

 

 

 

Individual Abuse Prevention Plan (IAPP) Form

245A.65, subd.2(b) & 626.6557,

10/31/2013

 

subd. 14

 

 

 

 

HCBS Incident Reporting Requirements - Who to Notify Form

 

10/31/2013

 

 

 

HCBS Service Recipient Rights Packet

 

10/31/2013

 

 

 

HCBS Service Recipient Rights Restrictions

 

10/31/2013

 

 

 

Intensive Support Services Assessment

 

10/31/2013

 

 

 

Medication Administration and Emergency Medical Authorization

 

10/31/2013

 

 

 

Medication Administration Review Record

 

10/31/2013

 

 

 

Medication and Treatment Administration Packet

 

10/31/2013

 

 

 

Medication Setup Record

 

10/31/2013

 

 

 

Person-Centered Planning and Service Delivery Requirements

 

10/31/2013

 

 

 

Progress Review Report for Intensive Support Services

 

10/31/2013

 

 

 

Psychotropic Medication Use and Monitoring Record

 

10/31/2013

 

 

 

Quality Management Evaluation and Program Improvement Plan

 

10/31/2013

 

 

 

Release of Information Authorization

 

10/31/2013

 

 

 

Satisfaction Evaluation

 

10/31/2013

 

 

 

Service Admission Checklist for Intensive Services

 

10/31/2013

 

 

 

Service Recipient Information Cover Sheet

 

10/31/2013

 

 

 

Service Recipient Record Checklist

 

10/31/2013

 

 

 

Service Suspension or Termination for Intensive Support Services Checklist

 

10/31/2013

 

 

 

Staff Orientation and Training Packet

 

10/31/2013

 

 

 

Support Team Meeting Summary

 

10/31/2013

 

 

 

Supports and Outcome Methods for Intensive Support Services

 

10/31/2013

 

 

 

2

Revised 10/31/2013

Form Specifications

Fact Name Description
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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