The VDSS Model ALF Discharge Notification and Statement form is a critical document underlined by the regulations set forth in 22 VAC 40-72-420, orchestrating a structured approach towards managing the discharge process of residents from Assisted Living Facilities (ALFs). This form meticulously captures all necessary details starting with basic yet paramount information such as the resident's name, followed by a comprehensive notification process that ensures all stakeholders, including the resident, their legal representative, and a designated contact person, are duly informed about the discharge details. The form is designed to document the rationale behind a resident's discharge, potentially covering a range of reasons tailored to the individual's circumstances. Moreover, it emphasizes the facility's commitment to assisting the resident through the discharge and relocation phase, showcasing actions taken in support of this transition. Furthermore, the form specifies the discharge's timing, the prospective destination for the resident, and details relevant to emergency discharges, including immediate communication with involved parties. Completeness is evidenced by enclosing a segment for recording the notation of a Unified Assessment Instrument (UAI) by a public human services agency assessor should the resident be discharged or pass away, along with the date the assessor was notified. The document is rounded off with acknowledgments regarding the dispatch of the discharge statement, affirmed by signatures from the facility’s licensee or administrator, thereby ensuring accountability and transparency in the discharge process. This meticulous documentation underscores the importance of a holistic approach in handling the delicate phase of discharging a resident, ensuring all legal and empathetic considerations are duly accounted for.
| Question | Answer |
|---|---|
| Form Name | Vdss Model Form Alf |
| Form Length | 1 pages |
| Fillable? | No |
| Fillable fields | 0 |
| Avg. time to fill out | 15 sec |
| Other names | relocation, VAC, UAI, NOTIFICATION |
VDSS MODEL FORM - ALF
DISCHARGE NOTIFICATION AND STATEMENT
(SEE 22 VAC
RESIDENT'S NAME: _____________________________________________________________________
|
|
Method of |
1. |
Date of discharge notification to resident: ________________ |
notification: _______________ |
2.a. |
Date of discharge notification to legal representative, if any:_______________________________ |
|
|
Name of |
Method of |
|
legal representative: ________________________________ |
notification: _______________ |
2.b. |
Date of discharge notification to designated contact person, if any: __________________________ |
|
|
Name of |
Method of |
|
designated contact person:___________________________ |
notification: ________________ |
3.Reason(s) for the discharge: __________________________________________________________
_________________________________________________________________________________
__________________________________________________________________________________
4.Actions taken by the facility to assist the resident in the discharge and relocation process:
__________________________________________________________________________________
__________________________________________________________________________________
__________________________________________________________________________________
5.Date of the discharge: ______________________________
Destination (name and address): _______________________________________________________
__________________________________________________________________________________
6.If emergency discharge, name(s) of person(s) notified, relationship(s) to the resident, and date(s) of
notification: _______________________________________________________________________
__________________________________________________________________________________
7.If the UAI was completed by a public human services agency assessor and the resident is discharged or dies, name of assessor, agency, and date assessor notified: _______________________________
__________________________________________________________________________________
8.Date discharge statement provided (or mailed, option if emergency) to resident, legal representative and designated contact person: _________________________
Signed by: ___________________________________________ Date: __________________________
(Licensee or Administrator)
___________________________________________
(Name of Facility)