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The Minnesota DHS form is a crucial document used by providers licensed under the 245D statute, specifically for intensive supports and services. This form includes various sample policies and procedures that providers can adapt for their programs, ensuring compliance with state licensing requirements. Understanding and properly completing this form is essential for maintaining quality care and legal compliance in service delivery.

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Document Data

Fact Name Description
Governing Law The Minnesota Department of Human Services form is governed by Minnesota Statutes, particularly sections 245A and 245D.
Required Policies Providers must have specific policies in place at the time of application, especially if they do not hold a 245B license.
Revision Dates Most policies listed on the form were last revised on October 31, 2013.
Policy Development Deadline All required policies must be developed by January 1, 2014, to comply with licensing requirements.
Sample Policies Availability Sample policies and forms for community residential settings and day services will be available in July and August of 2014.

Additional PDF Forms

Documents used along the form

The Minnesota Department of Human Services (DHS) requires various forms and documents to ensure compliance with licensing requirements for providers of intensive support services. Below is a list of other forms and documents commonly used alongside the Minnesota DHS form. Each document serves a specific purpose in the overall framework of service delivery and compliance.

  • Drug and Alcohol Prohibition Policy: This policy outlines the restrictions and guidelines regarding substance use within the service environment, ensuring a safe and supportive atmosphere for all clients.
  • Emergency Use of Manual Restraint (EUMR) Policy: This document details the circumstances under which manual restraint may be employed, along with the necessary reporting and review procedures.
  • Grievance Policy: This policy establishes a process for clients and their families to voice concerns or complaints about services, ensuring that issues are addressed promptly and fairly.
  • Maltreatment of Minors Reporting and Internal Review Policy: This document sets forth the procedures for reporting suspected maltreatment of minors and outlines the internal review process for such incidents.
  • Motor Vehicle Bill of Sale: A crucial document for vehicle transactions, providing protection for both parties involved in the sale. Complete the form by visiting Missouri PDF Forms.
  • Service Suspension and Termination Policy: This policy describes the conditions under which services may be suspended or terminated, providing clarity to both providers and clients.
  • Incident Report and Internal Review: This form is used to document any incidents that occur during service delivery, ensuring that they are reviewed and addressed appropriately.
  • Health Needs Record: This document tracks the health-related needs of clients, facilitating better care coordination and response to changing health conditions.
  • Medication Administration Review Record: This record provides a comprehensive overview of medication administration practices, ensuring compliance with health regulations and client safety.

These documents collectively help maintain high standards of care and compliance with Minnesota's licensing requirements. Providers must ensure that they are familiar with and utilize these forms appropriately to support their clients effectively.

Essential Questions on Minnesota Dhs

What is the Minnesota DHS form and who needs it?

The Minnesota DHS form is a collection of policies and procedures that licensed providers must develop and adhere to under the 245D licensing requirements. It is specifically designed for providers offering intensive supports and services. Providers who do not already hold a 245B license must complete these forms as part of their application process. Compliance with these forms ensures that providers meet state regulations regarding the care and treatment of individuals receiving services.

What are the key policies required by the Minnesota DHS form?

Several key policies are mandated for compliance with the Minnesota DHS form. These include the Drug and Alcohol Prohibition Policy, Emergency Use of Manual Restraint Policy, Grievance Policy, and Maltreatment of Minors Reporting and Internal Review Policy, among others. Each policy has a specific statute or rule associated with it, and it is crucial for providers to understand these requirements. Additionally, all policies must be developed by January 1, 2014, ensuring that all providers are operating under the same regulatory framework.

How can providers access the sample policies and forms?

Providers can access sample policies and forms through the Minnesota Department of Human Services Licensing Division. These samples are intended to guide providers in creating their own policies that comply with the 245D licensing requirements. It is important for providers to modify these samples as necessary to fit their specific programs while ensuring they meet all regulatory obligations.

What are the consequences of not adhering to the Minnesota DHS form requirements?

Failure to comply with the Minnesota DHS form requirements can lead to serious consequences for providers. Non-compliance may result in the denial of a license application or the revocation of an existing license. Additionally, it can expose providers to legal liabilities, including potential fines or sanctions. Ensuring that all policies and procedures are in place and up to date is essential for maintaining compliance and providing quality care.

When were the last revisions made to the Minnesota DHS form policies?

The last revisions to the Minnesota DHS form policies were made on October 31, 2013. It is essential for providers to regularly review and update their policies to reflect any changes in state statutes or regulations. Staying informed about any updates is crucial for maintaining compliance and ensuring the safety and well-being of service recipients.

Common mistakes

Completing the Minnesota Department of Human Services (DHS) form is a critical step for providers seeking to comply with licensing requirements. However, many individuals encounter pitfalls during this process. One common mistake is failing to read the instructions thoroughly. The form contains specific guidelines that detail what is required, and overlooking these can lead to incomplete submissions.

Another frequent error involves neglecting to update policies and procedures. The Minnesota DHS mandates that all policies be revised by specific dates. If a provider submits outdated policies, it can result in delays or denials of the application. It is essential to ensure that all documents reflect the most current standards and practices.

Inaccurate information is a significant concern as well. Providers often mistakenly enter incorrect data, whether it be contact information, policy dates, or other essential details. This oversight can complicate communication with the DHS and may lead to further complications in the licensing process.

Additionally, some individuals overlook the necessity of including all required policies. The Minnesota DHS lists specific policies that must be submitted with the application. Omitting any of these can lead to immediate rejection of the application, emphasizing the importance of checking off each required item before submission.

Another common mistake is failing to maintain proper documentation. Providers may not keep adequate records of their policies or procedures, which can hinder their ability to demonstrate compliance during audits or reviews. Maintaining organized documentation is crucial for both the application process and ongoing operations.

Some applicants also underestimate the importance of training and orientation for staff. The Minnesota DHS requires that staff be adequately trained in the policies and procedures that govern their work. If this training is not documented or is insufficient, it could lead to compliance issues down the line.

Misunderstanding the definitions of certain terms can also create confusion. For instance, terms like "emergency use of manual restraint" or "maltreatment of minors" are defined within the context of the DHS regulations. Providers must ensure they understand these definitions to apply them correctly in their policies.

Another mistake arises from not utilizing the sample policies provided by the DHS. These samples serve as a valuable resource for providers, offering templates that can be modified to fit specific needs. Ignoring these resources can lead to unnecessary challenges in policy development.

Lastly, a lack of attention to detail can result in typographical errors or formatting issues. Such mistakes, while seemingly minor, can detract from the professionalism of the submission and may raise questions about the provider’s commitment to compliance.

By being aware of these common mistakes, providers can take proactive steps to ensure their Minnesota DHS form is completed accurately and comprehensively, facilitating a smoother licensing process.

Similar forms

The Minnesota DHS form is similar to the Drug and Alcohol Prohibition Policy. This document outlines the expectations for providers regarding the use of drugs and alcohol within their facilities. Just like the DHS form, it emphasizes the importance of maintaining a safe environment for individuals receiving services. Providers must ensure that their policies align with the state regulations, which helps in promoting accountability and transparency in service delivery.

Another document that shares similarities is the Emergency Use of Manual Restraint (EUMR) Policy. This policy details the circumstances under which manual restraint may be employed, stressing that such measures should only be used as a last resort. Like the DHS form, it requires clear documentation and adherence to specific procedures to ensure the safety and dignity of individuals. Both documents aim to protect vulnerable populations while providing guidance on appropriate practices.

The Grievance Policy also aligns closely with the DHS form. This document establishes a process for individuals to voice their concerns or complaints regarding the services they receive. It ensures that grievances are addressed promptly and fairly. Similar to the DHS form, it emphasizes the importance of having a structured approach to resolving issues, fostering a sense of trust and accountability between providers and service recipients.

When planning for the future, it's important to consider various legal documents, including a Last Will and Testament form. This form allows individuals to clearly outline their wishes regarding the distribution of their assets and care of minor children after their passing, thereby providing peace of mind and ensuring that their desires are respected. Similar to other important policies, it serves to protect the interests of vulnerable individuals and facilitate a structured approach to decision-making.

In addition, the Maltreatment of Minors Reporting and Internal Review Policy is another document with a similar purpose. It outlines the procedures for reporting suspected maltreatment of minors and conducting internal reviews. Like the DHS form, this policy aims to protect the rights and well-being of vulnerable individuals. Both documents require training for staff to recognize signs of abuse and ensure timely reporting, reinforcing a commitment to safety and care.

The Service Suspension and Termination Policy is comparable as well. This document provides guidelines for when and how services may be suspended or terminated for individuals. Like the DHS form, it seeks to ensure that decisions are made fairly and with proper documentation. Both policies highlight the need for clear communication with individuals and their families about any changes in service delivery.

Another relevant document is the Vulnerable Adults Maltreatment Reporting and Internal Review Policy. This policy outlines the requirements for reporting and reviewing incidents of suspected maltreatment of vulnerable adults. Similar to the DHS form, it emphasizes the importance of protecting individuals and ensuring that appropriate actions are taken when concerns arise. Both documents aim to create a safe environment for all individuals receiving services.

The Admission Criteria Policy also shares similarities with the DHS form. This document specifies the criteria that must be met for individuals to be admitted to services. Like the DHS form, it ensures that providers have a clear understanding of the requirements and can make informed decisions about admissions. Both policies promote fairness and consistency in service delivery.

Furthermore, the Data Privacy Policy is another document that aligns with the DHS form. This policy outlines how personal information about individuals receiving services should be handled and protected. Like the DHS form, it emphasizes the importance of confidentiality and compliance with state regulations. Both documents seek to foster trust between service providers and individuals by safeguarding sensitive information.

Lastly, the Incident Response, Reporting, and Review Policy is similar to the DHS form in its focus on addressing incidents that occur within service settings. This document provides guidelines for how incidents should be reported and reviewed to prevent future occurrences. Like the DHS form, it promotes accountability and a proactive approach to safety, ensuring that all incidents are taken seriously and addressed appropriately.

Minnesota Dhs 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

Key takeaways

When filling out and using the Minnesota DHS form, keep these key takeaways in mind:

  • Understand Licensing Requirements: Familiarize yourself with the 245D licensing requirements. Ensure that any policies and forms you use comply with these standards.
  • Review Applicable Statutes: Read the relevant statute sections or rule parts. This will help you grasp the specific requirements for your program.
  • Develop Required Policies: Certain policies must be created by January 1, 2014, for providers who do not hold a 245B license. These include drug and alcohol prohibition policies, emergency use of manual restraint policies, and grievance policies.
  • Document Last Revisions: Keep track of the last revision dates for all policies. This ensures that your documents remain current and compliant.
  • Use Sample Policies Wisely: While sample policies are available, modify them to fit your program's specific needs. Tailoring these documents is crucial for effective implementation.
  • Optional Forms: Take advantage of optional program forms for documentation. These can assist in various aspects of service delivery and compliance.