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.

Form NameDads Form 3647
Form Length5 pages
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesdads form 3647, hhsc form 3647 fillable, dads 3647 form, dads form statement online

Form Preview Example

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)


Date Disclosure Statement Completed

Completed By:


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


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


Application Home assessment

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

Meals (


per day. )



Housekeeping (


days per week. )

Activities program (



days per week. )

Incontinence care

Temporary use of wheelchair/walker

Barber/beauty shop

Transportation (specify):


Special diet Personal laundry Select menus

Licensed nurse ( hours per day. )


D. What additional services can be purchased?

Beauty/barber services

Incontinence care

Incontinence products



Form 3647

Page 2 / 07-2013


Transportation to doctor visits

Minor nursing services provided by facility staff Home health services

E. Do you charge more for different levels of care?



II. Admission Process



A. Does the facility have a written contract for services?



B. Is there a deposit in addition to rent?



If yes, is it refundable?



If yes, when?








C. Do you have a refund policy if the resident does not remain for the entire prepaid period?



If yes, explain?







D. What is the admission process for new residents?



Doctors' orders


Residency agreement

History and physical


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

Staff who can sign for the deaf


Services for persons who are blind

F. Is there a trial period for new residents?



If yes, how long?








A. What could cause temporary transfer from specialized care?

Medical condition requiring 24–hour nursing care

Drug stabilization


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:


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


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? .........................................................................







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?


Family member

Licensed nurses

Social worker



Activity director Dietary

Attendants Physician


B. Does the service plan address the following?

Medical needs

Nursing needs

Activities of daily living

Psychosocial status

Nutritional status

Dental Services


C. How often is the service plan assessed?





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


Arts program




F. Who assists/administers medications?



V. Aging in Place


Medication aide


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:

VI. Change In Condition Issues

What special provisions do you allow aging in place?



VII. Staff Training

Additional services agreements


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

Yes No

A. What training do new employees receive?

Orientation: hours


Review of resident service plan

On–the–job training with another employee:









Form 3647




Page 4 / 07-2013

B. Is staff trained in CPR?




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


On–the–job training

F. In what type of endeavors are volunteers engaged?



Religious services




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


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?




Vegetable/flower gardens for use by residents

C. Are the residents allowed to have:


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?



How often does it meet?









B. Do you have a Family Council?



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


No No

Shift Times and Staffing Patterns at the Facility

Full-Time Personnel





Number of Staff Per Shift


(Enter the hours of











Medication Aides

Activity Workers

Universal Workers

Other Workers

each of your facility's shifts.)









































Part-Time Personnel





Number of Staff Per Shift


(Enter the hours of











Medication Aides

Activity Workers

Universal Workers

Other Workers

each of your facility's shifts.)









































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:

portion of fields in dads disclosure

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.

step 2 to finishing dads disclosure

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.

Watch Dads Form 3647 Video Instruction

Please rate Dads Form 3647

1 Votes
If you believe this page is infringing on your copyright, please familiarize yourself with and follow our DMCA notice and takedown process - click here to proceed .