AGING AND DISABILITY SERVICES ADMINISTRATION
August 30, 2001
AASA: BH #2001-017SUBJECT: Admission Agreement Attestation
Dear Boarding Home Provider:
Admission Agreements
In July 2000, the Northwest Assisted Living Facilities Association, the Washington Association of Housing and Services for the Aging, and the Washington Health Care Association distributed two sample admission agreements to boarding homes. Copies of these sample admission agreements, and the cover letter from the authors of the agreements, are enclosed. One agreement is intended for use with residents who use a private payment source. The other agreement is intended for use with residents whose care is funded through the Medicaid program. The sample admission agreements are available on disc through Nor-ALFA at (253) 874-5211, WAHSA at (206) 248-7434, and WHCA at (360) 352-3304. Use of the sample agreements is optional.
Please review your admission agreement(s) in light of the sample agreements and the Long-Term Care Residents Rights statute (RCW 70.129).
Boarding Home Admission Agreement Attestation Form (DSHS 10-270)
Whether or not you choose to use the sample admission agreement(s), AASA is providing an opportunity for you to voluntarily complete a Boarding Home Admission Agreement Attestation form (enclosed) following your review of your admission agreement(s). Completion of the attestation form is optional.
If you choose to complete an attestation form, please update it or complete a new attestation form whenever you modify your admission agreement(s). AASA will regard the attestation form as your declaration that you have evaluated your admission agreement(s) and believe the agreement(s) comply with applicable requirements.
Inspection Procedures
If you chose to complete an attestation form (DSHS 10-270), please maintain a copy of it in your boarding home, along with the associated admission agreements and referenced documents, for review by boarding home licensors and/or complaint investigators. During annual re-inspection visits, licensing staff will not routinely review your admission agreements if a current attestation form is on file. Instead, licensing staff will review the attestation form. If possible problems are identified during the inspection or review of the attestation form, or if no attestation form has been completed, licensing staff will directly review the admission agreement(s) to determine if the agreement(s) meet all applicable standards.
Obtaining Attestation Forms
You can access the attestation form via the Internet at:http://www.dshs.wa.gov/dshsforms/forms/eforms.html
Scroll down the list of forms until you find the corresponding form number on the left (10-270). The Word version of the attestation form may be completed on screen and printed after its electronic completion; the PDF file can be printed then filled out manually.
You may also order hard copies of the Boarding Home Admission Agreement Attestation by writing or faxing your request to:
DSHS Forms and Records Management Services
PO Box 45805
Olympia, Washington 98504-5805
FAX: (360) 664-6186
Your request should include the following information:
- Name of Requestor:
- Street Address:
- Form Name: Boarding Home Admission Agreement Attestation
- Form Number: DSHS 10-270
- # Copies:
- Phone Number:(include area code)
Please consult with your legal counsel regarding any questions about the specific form and content of your facilitys admission agreement(s). Call your field manager if you have questions about the use of the attestation form or the licensing inspection process.
Sincerely,
Patricia K. Lashway, Director
Residential Care Services
Enclosures:
