AGING AND DISABILITY SERVICES ADMINISTRATION
August 14, 2002
AASA: AFH #2002-027
SUBJECT: SAMPLE ADMISSION AGREEMENTS AND ATTESTATION FORMS
Dear Adult Family Home Provider:
Sample Admission Agreements
Residential Care Services has developed sample admission agreements as a
result of requests from providers and adult family home associations. Enclosed
are two (2) sample admission agreements:
- Sample admission agreement for private pay residents;
- Sample admission agreement for Medicaid (state paid) residents.
These admission agreements were developed in alignment with Chapter 70.129
Revised Code of Washington (RCW), Long-Term Resident Rights, and Chapter
388-76 Washington Administrative Code (WAC), Adult Family Home Minimum Licensing
Requirements.
The enclosed admission agreements are written for use effective August 19,
2002 and thereafter. (See AASA: AFH #2002-028 – Timelines
for Completing a Negotiated Care Plan, which accompanies this mailing.)
The purpose of these documents is to help you create an admission agreement
that is consistent with state law. These agreements look much different
than a standard residential lease because the laws governing adult family
home admission agreements are stricter than those related to Washington’s
Residential Landlord-Tenant Act.
Use of the sample agreements is optional: You may choose
to develop your own admission agreements using these samples or continue
to use your current version. Please review your admission agreement(s) in
light of the sample agreements and the Long-Term Care Resident Rights statute
(Chapter 70.129 RCW). The sample admission agreements are to assist you
in promoting and protecting your residents’ rights and interests.
Adult Family Home Admission Agreement Attestation Form (DSHS 10-270):
The AFH Admission Agreement Attestation Form has a series of questions regarding
your admission agreement(s). AASA will regard the completed and signed attestation
form as your declaration that you have evaluated your admission agreement(s)
and believe the agreement(s) complies with applicable regulatory requirements.
Each question addresses a key component of the Long-Term Care Resident Rights
statute. Completion of the attestation form is optional.
If you choose to use an attestation form, please update it or complete a
new attestation form whenever you modify your admission agreement(s).
Inspection Procedures
If you choose to complete an attestation form (DSHS 10-270), please maintain
a copy in each adult family home with the current admission agreements and
referenced documents. The RCS Licensor will review the current attestation
form during inspection visits. If you choose not to complete an attestation
form, the RCS Licensor will review your admission agreement(s) and related
documents during an initial inspection. Review of any subsequent changes
to admission agreement(s) will occur during re-inspections. Any additional
review will only be part of the re-inspection process if resulting outcomes
for residents identify problems related to the admission agreement.
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). This attestation form for adult family homes is also used for
boarding homes. 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 by hand.
Please consult with your legal counsel regarding any questions about the specific form and content of your facility's 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 (Word Format):
Sample Admission Agreement (Private
Pay)
Sample Admission Agreement (Medicaid)
DSHS Form 10-270
