Dads Form 3647 – Fill Out and Use This PDF

Dads Form 3647 – Fill Out and Use This PDF

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Dads Form 3647 – Fill Out and Use This PDF

The DADS 3647 form, officially titled the Texas Department of Aging and Disability Services Assisted Living Disclosure Statement, is designed to provide transparency and enable individuals to make informed decisions about assisted living facilities through detailed descriptions of policies and services. This document aims to standardize the presentation of critical information, allowing for easier comparison of facilities by prospective residents and their families. Although not a substitute for personal visits and discussions with facility staff and residents, the Disclosure Statement plays a crucial role in the decision-making process. To start filling out the form, click the button below.

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Dads Form 3647 PDF Details

In July 2013, the Texas Department of Aging and Disability Services introduced Form 3647 for Assisted Living Facilities (ALFs), titled "Assisted Living Disclosure Statement". The purpose behind this form is significant; it strives to ensure that individuals considering living in an assisted living facility, along with their families, are well-informed about what each facility offers. By presenting a facility's policies and services in a consistent and standardized manner, the form aids in the comparison and evaluation of different facilities. It outlines a wide range of information, including pre-admission processes, the types of services and amenities included in the base rate, additional services that can be purchased, and various procedures related to admission, discharge, or transfer. The form also covers the facility's approach to aging in place, change in condition issues, staff training, the physical environment of the facility, staffing patterns, and residents' rights. It's clear that this disclosure statement does not replace the value of visiting a facility personally, speaking with existing residents, or having direct conversations with staff. Rather, it adds a layer of transparency and information to help in making an informed decision regarding care in an assisted living environment.

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Form Name	Dads Form 3647
Form Length	5 pages
Fillable?	No
Fillable fields	0
Avg. time to fill out	1 min 15 sec
Other names	dads form 3647, hhsc form 3647 fillable, dads 3647 form, dads form statement online

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Texas Department of Aging	Form 3647
and Disability Services	July 2013-E

Assisted Living Disclosure Statement

The purpose of this Disclosure Statement is to empower individuals by describing a facility's policies and services in a uniform manner. This format gives prospective residents and their families consistent categories of information from which they can compare facilities and services. By requiring the Disclosure Statement, the department is not mandating that all services listed should be provided, but provides a format to describe the services that are provided.

The Disclosure Statement is not intended to take the place of visiting the facility, talking with residents, or meeting one-on-one with facility staff. Rather, it serves as additional information for making an informed decision about the care provided in each facility.

Instructions to the Facility

1.Complete the Disclosure Statement according to the care and services that your facility provides. You may not amend the statement, but you may attach an addendum to expand on your answers.

2.Provide copies of and explain this Disclosure Statement to anyone who requests information about your facility.

Facility Name

License No.

Average No. Residents

Telephone No.

Address (Street, City, State, ZIP code)

Manager

Date Disclosure Statement Completed

Completed By:

Title

The Assisted Living Licensure Standards are available for review at all assisted living facilities (ALFs).

A copy of the most recent survey report may be obtained from facility management.:

To register a complaint about an assisted living facility, contact:

Texas Department of Aging and Disability Services at 1-800-458-9858

I.Pre-admission Process

A. Indicate services which are not offered by your facility:

Assistance in transferring to and from a wheelchair Bladder incontinence care

Bowel incontinence care

Medication injections

Feeding residents

Other:

Intravenous (IV) therapy

Oxygen administration

Special diets

Behavior management for verbal aggression Behavior management for physical aggression

B. What is involved in the pre-admission process?

Facility Tour

Family interview

Medical records assessment

Other:

Application Home assessment

C. What services and/or amenities are included in the base rate:

Incontinence care

Temporary use of wheelchair/walker

Barber/beauty shop

Transportation (specify):

Other:

Special diet Personal laundry Select menus

Licensed nurse ( hours per day. )

Injections

D. What additional services can be purchased?

Beauty/barber services

Incontinence care

Incontinence products

Injections

Other:

Form 3647

Page 2 / 07-2013

Companion

Transportation to doctor visits

Minor nursing services provided by facility staff Home health services

E. Do you charge more for different levels of care?	Yes	No
II. Admission Process
A. Does the facility have a written contract for services?	Yes	No
B. Is there a deposit in addition to rent?	Yes	No
If yes, is it refundable?	Yes	No
If yes, when?

C. Do you have a refund policy if the resident does not remain for the entire prepaid period?	Yes	No
If yes, explain?

D. What is the admission process for new residents?

Doctors' orders

Other:

Residency agreement

History and physical

Deposit/payment

E. Does the facility have provisions for special resident communication needs?

Staff who can sign for the deaf

Other:

Services for persons who are blind

F. Is there a trial period for new residents?	Yes	No
If yes, how long?

III.Discharge/Transfer

A. What could cause temporary transfer from specialized care?

Medical condition requiring 24–hour nursing care

Drug stabilization

Other:

Unacceptable physical or verbal behavior

Resident requires services the facility does not provide

B. The need for the following services could cause permanent discharge:

24–hour nursing care

Assistance in transferring to and from wheelchair Behavior management for verbal aggression Behavior management for physical aggression Other:

Sitters

Bowel incontinence care Bladder incontinence care Intravenous (IV) therapy

Medication Injections Feeding by staff Oxygen administration Special diets

C. Who would make this discharge decision?

Facility manager

Other:

D. Do families have input into these discharge decisions?...................................................................

E. Is there an avenue to appeal these decisions?..............................................................................

F. Do you assist families in making discharge plans? .........................................................................

Yes

Form 3647

Page 3 / 07-2013

IV. Planning and Implementation of Care (check all that apply)

A. Who is involved in the service plan process?

Resident	Family member
Licensed nurses	Social worker
Other:

Activity director Dietary

Attendants Physician

Manager

B. Does the service plan address the following?

Medical needs

Nursing needs

Activities of daily living

Psychosocial status

Nutritional status

Dental Services

Other:

C. How often is the service plan assessed?

Monthly

Other:

Quarterly

Annually

As Needed

D. How many hours of structured activities are scheduled per day?

1–2 Hours

2–4 Hours

E. What types of programs are scheduled?

4–6 Hours

6–8 Hours

8+ Hours

Music program

Other:

Arts program

Crafts

Exercise

Cooking

F. Who assists/administers medications?

Other:

V. Aging in Place

LVN

Medication aide

Attendant

Department of Aging and Disability Services (DADS) Rules

An inappropriately placed resident is a resident who was appropriate when admitted to the ALF, but whose condition has changed. All residents must be appropriate for the ALF licensure type when admitted to the facility. After admission, if the resident's condition changes, the resident may no longer be appropriate for the facility's license. An ALF is not required to keep a resident who is no longer appropriate for the facility's license.

An inappropriately placed resident may be identified by the ALF or by DADS.

There are two situations which a resident may be determined to be inappropriate:

•Resident experiences a change in condition, needs additional services and meets evacuation criteria.

•Resident experiences a change in condition and does not meet evacuation criteria.

What are the ALF's policies and procedures for aging in place?

Resident experiences a change in condition and meets evacuation criteria. Documentation is submitted to DADS. Resident experiences a change in condition and does not meet evacuation criteria. Waiver request submitted to DADS. No documentation submitted to DADS. Resident is discharged.

An ALF is not required to keep a resident who is no longer appropriate for the facility’s license. A facility will determine its ability to accommodate a resident and decide if it will apply for a waiver request on a case by case basis. DADS rules about inappropriately placed residents may be found in the Licensing Standards for Assisted Living Facilities at 40 Texas Administrative Code Chapter 92, Subchapter 92.41

(f). The following link will direct you to the Licensing Standards for Assisted Living Facilities:

http://www.dads.state.tx.us/handbooks/ls-alf/

VI. Change In Condition Issues

What special provisions do you allow aging in place?

Sitters

Other:

VII. Staff Training

Additional services agreements

Hospice

Home health -If so, is it affiliated with your facility?

Yes No

A. What training do new employees receive?

Orientation: hours

Other:

Review of resident service plan

On–the–job training with another employee:		hours

			Form 3647
			Page 4 / 07-2013
B. Is staff trained in CPR?		Yes	No
	If no, please explain why you do not require CPR training:


C. How much ongoing training is provided and how often? (Example: 30 minutes monthly):
D. Who gives the training and what are their qualifications?



E. What type of training do volunteers receive?

Orientation: hours

Other:

On–the–job training

F. In what type of endeavors are volunteers engaged?

Activities

Meals

Religious services

Other:

Entertainment

Visitation

G. List volunteer groups involved with the family?

VIII. Physical Environment

A. What safety features are provided in your building?

Emergency call systems

Sprinkler system

Fire alarm system

Other:

Wander Guard or similar system

Built according to NFPA Life Safety Code, Chapter 12, Health Care

Built according to NFPA Life Safety Code, Chapter 21, Board and Care

B. Does the facility's environment include the following?

Plants

Other:

Pets

Vegetable/flower gardens for use by residents

C. Are the residents allowed to have:

Plant's

Pets -If so, is a deposit required?

IX. Staffing Patterns

A. What are the qualifications of the manager?

Yes How much? .......

B. Please list the facility's normal 24-hour staffing pattern on:

1.the attached chart; or

2.a separate attachment which explains your facility's unique staffing policies and patterns.

		Form 3647
		Page 5 / 07-2013
X. Residents's Rights
A. Do you have a Resident's Council?	Yes	No
How often does it meet?

B. Do you have a Family Council?	Yes	No
How often does it meet?

C. Does the facility have a formal procedure for responding to resident grievances and suggestions for improvement?

Is there a Grievance Committee? ...................................................................................................

Is there a suggestion box? ............................................................................................................

D. How can the company that owns the facility be contacted?

Yes

Yes Yes

No No

Shift Times and Staffing Patterns at the Facility

Full-Time Personnel

Shifts				Number of Staff Per Shift
(Enter the hours of
(Enter the hours of	R.N.s	L.V.N.s	Attendants	Medication Aides	Activity Workers	Universal Workers	Other Workers
each of your facility's shifts.)	R.N.s	L.V.N.s	Attendants	Medication Aides	Activity Workers	Universal Workers	Other Workers

Part-Time Personnel

Shifts				Number of Staff Per Shift
(Enter the hours of
(Enter the hours of	R.N.s	L.V.N.s	Attendants	Medication Aides	Activity Workers	Universal Workers	Other Workers
each of your facility's shifts.)	R.N.s	L.V.N.s	Attendants	Medication Aides	Activity Workers	Universal Workers	Other Workers

How to Edit Dads Form 3647 Online for Free

Having the goal of making it as quick to use as possible, we established this PDF editor. The process of filling the form 3647 pdf will be trouble-free if you comply with the following steps.

Step 1: First, choose the orange "Get form now" button.

Step 2: So you will be on the document edit page. It's possible to add, modify, highlight, check, cross, add or erase fields or phrases.

The PDF file you decide to fill out will include the next parts:

Fill out the B What is involved in the, Facility Tour, Family interview Medical records, Other, Application, Home assessment, C What services andor amenities, Meals, per day, Housekeeping Activities program, days per week days per week, Incontinence care Temporary use of, Special diet, Personal laundry Select menus, and Licensed nurse Injections space using the details required by the system.

In the Incontinence care Temporary use of part, describe the valuable details.

dads disclosure Incontinence care Temporary use of fields to insert

Inside the paragraph D What additional services can be, Beautybarber services, Incontinence care Incontinence, Injections, Other, Companion Transportation to doctor, Minor nursing services provided by, E Do you charge more for different, Yes, II Admission Process, A Does the facility have a written, B Is there a deposit in addition, If yes is it refundable, Yes, and Yes, identify the rights and responsibilities of the sides.

Entering details in dads disclosure part 4

End by looking at the following sections and filling them in accordingly: Other, E Does the facility have, Staff who can sign for the deaf, Services for persons who are blind, Other, F Is there a trial period for new, Yes, If yes how long, III DischargeTransfer, A What could cause temporary, Medical condition requiring hour, Unacceptable physical or verbal, Drug stabilization, Other, and Resident requires services the.

part 5 to entering details in dads disclosure

Step 3: As you select the Done button, your finished document is simply transferable to any type of of your devices. Alternatively, you can easily send it using mail.

Step 4: Prepare duplicates of the file. This can protect you from potential misunderstandings. We do not check or distribute the information you have, so feel comfortable knowing it's going to be secure.

per day. )

Housekeeping (

days per week. )

Activities program (

days per week. )