Texas Form 3647 Details

dads form 3647 is a document that will help fathers better understand their parental rights in the state of Texas. This important form can be used to protect the rights of fathers during divorce proceedings, child custody disputes, and more. The attorneys at our firm are happy to provide guidance and assistance as you work to complete and file dads form 3647.

This table has got information regarding dads form 3647. This article will provide details about the form's size, completion time, and the parts you can be expected to fill.

QuestionAnswer
Form NameDads Form 3647
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namestexas assisted living disclosure statement, dads form 3647, dads 3647 form, texas 3647 disclosure statement

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)

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:

Meals (

 

per day. )

 

 

Housekeeping (

 

days per week. )

Activities program (

 

 

days per week. )

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

Yes

Yes

No

No

No

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?

RN

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?

No

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 No

Shift Times and Staffing Patterns at the Facility

Full-Time Personnel

Shifts

 

 

 

Number of Staff Per Shift

 

(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.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Part-Time Personnel

Shifts

 

 

 

Number of Staff Per Shift

 

(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.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

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