HCBS intensive services sample policies / Minnesota Department of Human Services

HCBS intensive services sample policies - 245D providers

245D licensed providers may use these sample policies and forms for intensive support services programs and modify them for 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.

These policies are required at time of application.

Required policies and procedures	Applicable MN statute or rule	Date of last revision
Drug and Alcohol Prohibition Policy (DOC)	MN Statute 245A.04, subd. 1(c)	7/1/2017
Emergency Use of Manual Restraint (EUMR) Not Allowed Policy (DOCX)	MN Statutes 245D.06, subd. 1(a); 245D.06, subd. 5, 245D.061; and MN Rule 9544.0070	7/1/2017
Emergency Use of Manual Restraint (EUMR) Allowed Policy (DOCX)	MN Statutes 245D.06, subd. 1(a); 245D.06, subd. 5, 245D.061; and MN Rule 9544.0070	7/1/2017
Grievance Policy (DOC)	MN Statute 245D.10, subd. 2	10/31/2013
Maltreatment of Minors Reporting and Internal Review Policy DHS-7634A (PDF)	MN Statutes 245A.66 and 626.556	1/1/2018
Service Termination Policy (DOCX)	MN Statute 245D.10, subd. 3	8/1/2015
Temporary Service Suspension Policy (DOCX)	MN Statute 245D.10, subd. 3	8/1/2015
Vulnerable Adults Maltreatment Reporting and Internal Review Policy DHS-7634B (PDF)	MN Statutes 245A.65, subd. 1(a) and (b) and 626.557, subd. 4a	1/1/2018

Additional Required policies and procedures

Required policies and procedures	Applicable MN statute or rule	Date of last revision
Admission Criteria Policy (DOC)	MN Statute 245D.11, subd. 4	7/1/2017
Data Privacy Policy (DOC)	MN Statute 245D.11, subd. 3	10/31/2013
Emergency Response, Reporting and Review Policy (DOC)	MN Statutes 245D.11, subd. 2; 245D.02, subd.8; 245D.22, subd 4-7	10/31/2013
Health Service Coordination and Care (Residential Programs) Policy (DOC)	MN Statute 245D.11, subd. 2(2)	7/1/2017
Incident Response, Reporting and Review Policy (DOC)	MN Statutes 245D.11, subd. 2(7); 245D.02, subd. 11; 245.91, subd. 6; 609.341, subd. 3 and 14	7/1/2017
Safe Medication Assistance and Administration Policy (DOCX)	MN Statute 245D.11, subd. 2(3)	7/1/2015
Safe Transportation Policy (DOC)	MN Statute 245D.11, subd. 2(4)	10/31/2013
Universal Precautions and Sanitary Practices Policy (DOC)	MN Statute 245D.11, subd. 2(1)	10/31/2013

Additional required policies and procedures for community residential settings and day services facilities only

Required policies and procedures	Applicable MN statute or rule	Date of last revision
Program Abuse Prevention Plan (PAPP) (DOCX)	MN Statutes 245A.65, subd. 2 (a) and 245A.65, subd. 2 (a)	7/1/2015

Documentation requirements – Program forms

Program forms	Applicable MN statute or rule	Date of last revision
45-Day Meeting Summary (DOC)		7/1/2019
Admission and Discharge Register Form (DOC)		10/31/2013
Emergency Report and Internal Review Form (DOC)		10/31/2013
Fire Drill Log (DOC)		10/31/2013
Funds and Property Authorization (DOC)		10/31/2013
Health Needs Change Notice (DOCX)		7/1/2015
Health Needs Record (DOC)		10/31/2013
Incident Report and Internal Review (DOC)		10/31/2013
Individual Abuse Prevention Plan (IAPP) Form (DOC)	MN Statutes 245A.65, subd.2(b) and 626.6557, subd. 14	10/31/2013
HCBS Incident Reporting Requirements - Who to Notify Form (DOC)		9/15/2014
HCBS Service Recipient Rights Packet (DOC)		7/1/2017
HCBS Service Recipient Rights Restrictions (DOC)		7/1/2017
Intensive Support Self-Management Assessment (DOCX)		7/1/2017
Medication Administration and Emergency Medical Authorization (DOCX)		7/1/2015
Medication Administration Review Record (DOCX)		10/31/2013
Medication and Treatment Administration Packet (DOC)		10/31/2013
Medication Setup Record (DOC)		10/31/2013
Notice of Service Termination Form (DOCX)		8/1/2015
Notice of Temporary Service Suspension Form (DOCX)		8/1/2015
Person-Centered Planning and Service Delivery Requirements (DOC)		10/31/2013
Policy Receipt and Signature Page (DOCX)		7/1/2017
Program Abuse Prevention Plan (PAPP) (DOCX)	MN Statutes 245A.65, subd. 2 (a) and 245A.65, subd. 2 (a)	7/1/2015
Progress Review Report for Intensive Support Services (DOCX)		7/1/2017
Psychotropic Medication Use and Monitoring Record (DOC)		10/31/2013
Quality Management Evaluation and Program Improvement Plan (DOC)		10/31/2013
Release of Information Authorization (DOC)		10/31/2013
Residency Agreement (DOCX)		3/1/2017
Satisfaction Evaluation (DOC)		10/31/2013
Service Admission Checklist for Intensive Services (DOCX)		1/10/2017
Service Recipient Information Cover Sheet (DOCX)		7/1/2017
Service Recipient Record Checklist (DOC)		10/31/2013
Staff Annual Training Record (DOCX)		7/1/2019
Staff Orientation Record (DOCX)		7/1/2017
Progress Review Meeting Summary (DOCX)		7/1/2019
Supports and Outcome Methods for Intensive Support Services (DOCX)		7/1/2017
Variance Request DHS-3141 (PDF)	MN Statute 245A.04, subd. (9)	3/1/18