Bcal 3266 Form PDF Details

At the heart of providing quality adult foster care lies the importance of clear agreements between care providers and residents or their designated representatives. The BCAL 3266 form, mandated by the Michigan Department of Human Services, Division of Adult Foster Care Licensing and Home for the Aged Licensing, encapsulates this principle by outlining a comprehensive resident care agreement at the time of a resident's admission into an adult foster care (AFC) home. This document serves not only as a contract outlining the specific care and services to be provided but also formalizes the fee policy, thereby establishing a transparent and mutual understanding of expectations and responsibilities. It is systematically structured to include a plethora of details such as the provision of a current health care appraisal, participation in emergency drills, agreement on handling personal finances, and specifications regarding additional services and their respective fees. Moreover, it emphasizes the protection of residents' rights and includes a mechanism for complaints, thereby ensuring accountability and promoting quality care. Completing this agreement requires collaboration between the licensee, the resident or their designated representative, and possibly a responsible agency, which underlines the importance of communication and the resident's involvement in their care planning. The BCAL 3266 form, thus, stands as a cornerstone document, ensuring that every resident's stay in an AFC home is governed by dignity, respect, and clarity right from the outset.

QuestionAnswer
Form NameBcal 3266 Form
Form Length2 pages
Fillable?No
Fillable fields0
Avg. time to fill out30 sec
Other namesbcal resident, afc resident agreement, forms bcal 3266, bcal 3266

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AFC – RESIDENT CARE AGREEMENT

Michigan Department of Human Services

Division of Adult Foster Care Licensing and Home for the Aged Licensing

Resident Name:

Name of Home:

License Number

This agreement to provide adult foster care for (resident’s name)

 

 

is made

between (licensee name)

 

 

and (resident/resident’s designated representative)

.

 

 

 

This agreement is required to be completed at the time of a resident’s admission, reviewed annually, and updated as needed to reflect changes.

This agreement is to be completed by the licensee in cooperation with the resident or his/her designated representative and the responsible agency, if applicable, Designated representative means that person or agency which has been granted written authority, by a resident, to act on behalf of the resident or which is the legal guardian of a resident. Acceptable written authority includes orders of guardianship or conservatorship, powers of attorney, durable powers of attorney, or other documents executed by the resident that specify the relevant scope of authority. If a resident’s designated representative signs this agreement, a copy of the signer’s written authority is to be maintained in the resident’s file at the AFC home.

A resident shall be provided care and services as stated in this resident care agreement and the resident’s assessment plan.

This agreement constitutes the fee policy statement required by Family Home Rule 400.1407(11), if applicable.

RESIDENT OR DESIGNATED REPRESENTATIVE CHECK ALL BOXES BELOW THAT APPLY:

I have received a copy of the house rules (if applicable) and agree to follow them.

I agree to provide all required resident information to the licensee, including a current health care appraisal, at the time of admission, annually and as the resident’s condition changes.

I agree to participate in all required fire and emergency drills, as determined by BCAL and the licensee. I have signed and received a copy of the home’s refund agreement. (GROUP HOMES ONLY)

I have received a copy of the home’s discharge policy and agree to follow those procedures. (GROUP HOMES ONLY)

Iagree I agree

I do not agree

I do not agree

to receive assistance in bathing, dressing, or personal hygiene by a staff member of the opposite sex, if a member of the same sex is not available.

to entrust the following to the license for safekeeping, if this option is available:

Funds

Valuables (specify)

I agree to have the licensee manage funds and account for financial transactions on my behalf. Expenditures of my personal funds over

the amount of $

 

require my prior written approval.

I agree to pay the licensee the agreed upon fees for the services designated.

I agree to pay the basic fee of $

on a

basis.

daily, week or monthly

The basic fee includes the following basic services:

and are further described in the resident’s assessment plan, and attachment

 

, if applicable.

The basic fees do not include any transportation services.

The basic fees include the following transportation services.

Transportation fees are charged as follows:

and are further explained in attachment

 

, if applicable.

BCAL-3266 (Rev. 10-13) Previous editions obsolete. MS Word

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I agree to additional services according to the fee schedule contained in attachment

 

. Such additional

services may include but are not limited to:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

If applicable. I have read the attachments relating to fees and agree with the terms and conditions established therein, I further

 

acknowledge that additional services are available for additional fees as described in attachment

.

BY MY SIGNATURE BELOW, I AFFIRM THAT:

This home is licensed by the Department of Human Services to provide foster care to adults.

I have provided the resident with a copy of the AFC Resident Rights and agree to respect and safeguard these rights.

I have provided the resident with a copy of the home’s discharge policy and procedures and agree to follow them. (AFC Group Homes only.)

I have provided the resident with a signed copy of the home’s refund agreement. (AFC Group Homes only.)

I agree to provide personal care, supervision, and protection, in addition to room and board, and to assure the availability of transportation services as indicated in this agreement, the resident’s written assessment plan, and the resident’s health care appraisal, as defined in the act.

A copy of this resident care agreement is required to be provided to the resident’s guardian or resident’s designated representative and also be maintained in the resident’s file at the AFC home.

Attachments to this Resident Care Agreement and any other agreements or contracts with this licensee may not have been reviewed and/or approved by the department. If any contractual provision contained in an attachment conflicts with the Adult Foster Care Facility Licensing Act and/or administrative rules, the act and rules would prevail and the specific provision is not binding.

SIGNATURES

Resident

Date

 

 

Resident’s Designated Representative (if applicable)

Date

 

 

Licensee/Licensee Designee

Date

 

 

Responsible Agency (if applicable)

Date

Compliments, comments and/or complaints about this licensed facility can be made by calling the licensing consultant, or at www.michigan.gov/afchfa. Additional information regarding adult foster care is also available at this website.

Complaints (only) can also be made by calling toll-free: 1-866-856-0126.

AUTHORITY:

1979 PA 218

COMPLETION:

Mandatory

PENALTY:

Violation of Adult Foster Care Administrative Rule

Department of Human Services (DHS

) will not discriminate against any

individual or group because of race, re

ligion, age, national origin, color,

height, weight, marital status, sex, sexual orie ntation, gender identity or expression, political beliefs or disability. If you need help with reading, writing, hearing, etc., u nder the Americans w ith Disabilities Act, you are invited to make your needs known to a DHS office in your area.

BCAL-3266 (Rev. 10-13) Previous editions obsolete. MS Word

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This PDF will need particular data to be entered, hence be sure you take whatever time to type in what is expected:

1. The michigan resident care requires specific details to be typed in. Make sure the subsequent blank fields are finalized:

afc resident care writing process explained (portion 1)

2. After completing the previous part, go on to the next step and fill in all required details in these blanks - I agree to participate in all, I do not agree, to receive assistance in bathing, I agree to have the licensee, Valuables specify, Funds, I agree, I do not agree, the amount of , require my prior written approval, I agree to pay the licensee the, on a, daily week or monthly, basis, and The basic fee includes the.

afc resident care conclusion process shown (portion 2)

Be very mindful when completing I do not agree and I agree to participate in all, as this is the part where a lot of people make some mistakes.

3. This next segment will be about The basic fees include the, Transportation fees are charged as, and are further explained in, if applicable, and BCAL Rev Previous editions - complete every one of these blank fields.

BCAL Rev  Previous editions, The basic fees include the, and  if applicable inside afc resident care

4. This next section requires some additional information. Ensure you complete all the necessary fields - I agree to additional services, Such additional, services may include but are not, If applicable I have read the, acknowledge that additional, BY MY SIGNATURE BELOW I AFFIRM, I have provided the resident with, I have provided the resident with, I have provided the resident with, and I agree to provide personal care - to proceed further in your process!

Writing part 4 of afc resident care

5. Now, this last portion is what you should complete prior to closing the document. The fields you're looking at are the following: SIGNATURES Resident, Residents Designated, LicenseeLicensee Designee, Responsible Agency if applicable, Date, Date, Date, Date, Compliments comments andor, Complaints only can also be made, PA , AUTHORITY COMPLETION Mandatory, Violation of Adult Foster Care, and Department of Human Services DHS .

Filling in part 5 in afc resident care

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