Instructions For Adult Day Center Applications

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Instructions For Adult Day Center Applications

Transcript Of Instructions For Adult Day Center Applications

INSTRUCTIONS FOR ADULT DAY CENTER APPLICATIONS
The governing body of each adult day center shall submit a completed application for a license on forms provided by the Department of Community Health. A separate application and license is required for each adult day center located at different premises. A mobile adult day center
can include no more than five (5) off-site locations per application and license.
1. The application form shall be accompanied by the following:
a. Proof of the legal right to occupy the property where the adult day center is housed;
b. Proof of ownership or right of occupancy shall include a warranty deed, lease agreement or bill of sale; or written permission from the owner of the premises authorizing the adult day center to operate exclusively within a designated space is permissible where the adult day center provides services in a donated space or does not own or lease the premises where services are provided;
c. A floor sketch of the facility showing windows, doors, room measurements, and the location of the adult day center facilities and any other services provided on the premises;
d. In the case of corporations, partnerships, and other entities authorized by law, the applicant shall provide a copy of its certificate of incorporation or other acceptable proof of its legal existence and authority to transact business within the state of Georgia; this information should be updated with any changes.
e. Documentation from the local authority having jurisdiction over fire safety or by the State Fire Marshal that the center is in compliance with all applicable fire safety regulations. Such documentation shall be dated within the six (6) months preceding the date of the application;
f. Documentation of approval for the water source and sewage disposal system from your local County Public Health Department;
g. Documentation from local zoning authorities that the center is in compliance with local zoning codes;
h. A list of the locations of any additional adult day centers operated by the governing body;
i. If vehicle transportation services are provided by the center, the center shall submit proof of insurance coverage for property damage, uninsured motorists and bodily injury for the vehicle which transports participants; and proof of current vehicle registration.
j. For a mobile adult day center, a list of no more than five (5) locations where services are provided. If the mobile adult day center provider also operates any standard freestanding adult day centers, the names and addresses of those centers shall also be included on the application.

k. A completed affidavit of personal identification. Georgia law requires every applicant to complete an affidavit (sworn written statement) before a notary public that establishes that you are lawfully present in the United States of America. This affidavit is a material part of your application and must be completed truthfully. If a corporation will be serving as the governing body of the licensed business, the individual who signs the application on behalf of the corporation is required to complete the affidavit. Review the list of secure and verifiable documents under O.C.G.A. §50-36-2. Choose and locate one original document on the list to submit to the notary public to establish your identity. Print and complete the affidavit and have it notarized using the identification you selected from the list of secure and verifiable documents. The original signed affidavit and a copy of the identification you presented must be included in the completed application package.
2. MAIL THE COMPLETE APPLICATION PACKAGE TO:
Adult Day Center Applications Healthcare Facility Regulation Division Georgia Department of Community Health
2 Peachtree Street, NW Atlanta, Georgia 30303-3142
3. Keep a copy of all documents you submit to the Department for your records.
4. Your application for licensure may be denied or your license may be revoked by the the Department if it determines that you have made a material misstatement of fact in connection with your application to become licensed or in the falsification or alteration of facility records made or maintained by the facility.
5. When the application is received, you will receive a notice of the required fees. When the fees are paid, the application will be reviewed and you will receive notification regarding the status of your application;
6. After your application is completed and approved, you will be notified and a surveyor will contact you to schedule the initial inspection as soon as possible.
Any new rule and/or rule changes are available on the Department of Community Health (DCH) website at www.dch.ga.gov. Just click on Healthcare Facility Regulation, then Laws and Regulations, and then Adult Day Center. You can download the information so that you can become familiar with the requirements and take steps to ensure that you are meeting all the regulatory requirements.
Submission of the application is subject to approval by the Department Operating an adult day center without a license is prohibited.

ADULT DAY CENTER APPLICATION

Check All That Apply
 New Permit  Change of Governing Body (ownership)  Change of Center’s Name
1. Name of Center

 Change of Address (not location)  Change of Capacity
○ Adult Day Care ○ Adult Day Health
(Area Code) Telephone

2. Home Address Street

City

County

Zip

3. Governing Body 4. Home Address Street

(Area Code) Telephone

City

County

Zip

5. Type of Ownership

 Individual  Church

 Corporation  Government

6. Registered Agent for Service (for Corporation)

 Non-Profit  Other

 Partnership

7. Attach the Director & Owner Survey Form.

8. Indicate if you have previously owned and operated an Adult Day Center
 No  Yes IF YES, please indicate in space #14 where you previously operated a center.

9. Requested Capacity (specific # of participants)

10. Center or Governing Body E-mail Address

11. Change in Capacity

From

To

13. Previous Center Name

12. Previous Governing Body 14. Previous Center Address

15. The above information is true and correct to the best of my knowledge. I understand that submitting false information may result in denial of my application pursuant to O.C.G.A. § 31-2-8(c)

Print Name of Owner

Date

Signature of Owner

Submission of the application is subject to approval by the Department. Operating an adult day center without a license is prohibited.

Adult Day Center Application Checklist
For an initial permit to operate an adult day center, please submit the following information:
____ 1. Application – completed and signed by the Owner
If a corporation – include Certificate of Incorporation and Articles of Incorporation for ALL corporations having an interest in the personal care home If partnership – include Partnership Agreement If Limited Liability Company (LLC) include Certificate of Organization and Articles of Organization for ALL LLCs with an interest in the personal care home If a non-profit – documentation of non-profit status [5O1(c)3] If Individual – Statement of all owners and percentage of ownership
____ 2. An original completed Affidavit of Personal Identification
____ 3. A copy of Proof of Ownership or right of occupancy for the property or a copy of the lease agreement, or written permission from the owner of the premises authorizing the adult day center to operate in a designated space.
____ 4. Fire Safety Inspection Report with no violations or hazards identified noted from the appropriate fire safety authority showing capacity load
____ 5. Documentation from local zoning authorities that the center is compliance with local zoning codes
____ 6. Floor Sketch (including labeling of the rooms, room measurements, location of all doors, windows and location of ADC facility and any other services provided on the premises)
____ 7. Adult Day Center Director and Owner survey form signed and dated by the Director
. ____ 8. Food Service Permit (for ADCs with 25 or more participants) from the local Health
Department
____ 9. Written approval for water source and sewage disposal system.
____ 10. A list of the locations of any additional adult day centers operated by the governing body
____ 11. If transportation services are provided; proof of insurance coverage for property damage uninsured motorists, and bodily injury and proof of current vehicle registration
____ 12. A list of all locations for a mobile adult day center and the name and address of any additional center(s) owned by the governing body
____ 13. When all of the above information has been submitted and approved, a surveyor will
contact you to schedule an inspection. Policies and Procedures and Disaster Plan Procedures will be reviewed on-site
Submission of the application is subject to approval by the Department.
Operating an adult day center without a license is prohibited.

ADC POLICIES AND PROCEDURES CHECKLIST
111-8-1
Center Name: _____________________________________ Date: ______________

County: _______________________________ Surveyor:_____________________

Check “YES” or “NO” to determine if center has a set of policies and procedures that are acceptable to the department. The policies and procedures of the center can not violate participant rights or other laws or regulations.

YES NO

COMMENTS

1. Types & scope of services the center intends to provide: ADC, characteristics of participants to be served & Alzheimer’s Disclosure Form.

. 2. A description of the number &
qualifications of staff & volunteers who provide services whether services will be provided by center staff &/or volunteers or contract provider.

3. A description of the center’s days & hours of operation.

4. A description of the center’s fees for service, including daily charge & any additional fees for specific services, goods or supplies not included in the daily charge. The method of notifying participants/representative of changes in fees.
5. Policies & procedures for accepting voluntary contributions as compensation from or on behalf of participants.
6. How the center handles refunds.

7. Procedure for documenting serious/unusual incidents that would affect the health, safety or welfare of participants & obtaining needed care. Informing representative of incidents or major changes in general functioning/medical condition of participant.
8. Procedures for handling emergency medical situations & how participants/representatives are informed of these procedures.
9. A policy and procedure to assure that no staff member, volunteer, visitor, contractor or any other person be on the premises of the center during the hours of operation if the person exhibits: symptoms of illness, a communicable disease transmitted by normal contact, or behavior which gives reasonable concern for the safety of the participants and others.
10. A policy for the proper storage, handling & documentation regarding medications where assistance with self-administration is offered and/or medications are administered by a licensed nurse.
. 11. A non-smoking policy or a statement
that the center has designated an appropriate outside area for smoking.
12. A description of the criteria for voluntary & involuntary discharge of a participant from the center & the time frame for notifying the participant &/or the participant’s representative prior to involuntary discharge.

13. A policy for addressing and resolving complaints made by participants, the participant’s representative, family or other interested person(s) within a reasonable time not to exceed seven (7) business days, including providing information to such person(s) about appropriate local, county &/or state agency contacts.
14. A policy ensuring that participants & their representatives, if any, shall receive at least 30 days written notice prior to any substantive changes in the participant agreement or fees for service.
15. Responsibilities of staff, management & volunteers.
16. Hiring, training & volunteer services, including. screening volunteers for appropriate skills.
17. Infection Control Policies:
a. Hand hygiene
b. Cleaning, disinfecting & sanitizing participant areas
c. Isolation precautions. Personal protective equipment
d. Handling, transporting & disposal of medical waste or bodily fluids
e. Requirements for communicable disease screening, TB surveillance & recommended immunizations
f. Exposure reporting & follow up

g. Work restrictions for staff with

.

potentially infectious diseases

h. Evaluation of participant related to infection control risks

i. Outbreak investigation procedures
j. Dietary practices k. Reporting communicable
diseases, as required by law

l. Standard precautions
m. Infection control program evaluated as needed/annually

18. Additional policy requirements for Day Health Centers a. Wound care b. Urinary tract care c. Respiratory therapy d. Enteral therapy e. Infusion therapy

ADC DISASTER PREPAREDNESS PLAN REVIEW FORM

Center: ________________________________________________ Date: _________________________

County: _______________________________ Surveyor: _____________________________________

1. Does the plan designate who has primary responsibility for Implementation of the plan, obtaining necessary emergency medical attention or interventions for participants and coordinating with county emergency management agency?

Yes ___ No ___

2. Does the plan stipulate that it will be reviewed and updated annually and a copy submitted to the local emergency management agency?

Yes ___ No ___

3. Does the plan identify emergency situations and how the emergency procedures are to be carried out?

Emergencies Identified

Procedures Identified

A. Fire B. Explosion C. Bomb scare D. Missing participant E. An interruption of each
1. Electricity 2. Gas 3. Water F. Loss of: 1. Air conditioning 2. Heat G. Floods H. Severe weather I. Damage to facility

utility:

Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___

Yes ___ No ___ Yes ___ No ___ Yes ___ No ___

Yes ___ Yes ___ Yes ___ Yes ___ Yes ___

No ___ No ___ No ___ No ___ No ___

Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___

Yes ___ No ___ Yes ___ No ___ Yes ___ No ___

Yes ___ Yes ___ Yes ___ Yes ___ Yes ___

No ___ No ___ No ___ No ___ No ___

4. Does the plan contain a written plan/agreement which address: A. Emergency care of participants B. Notification of responsible party C. Emergency transportation D. File for each participant with required information

Yes ___ No ___ Yes ___ No ___ Yes ___ No ___ Yes ___ No ___

5. Does the plan outline the frequency and procedures for rehearsals.

Yes ___ No ___

6. Does the plan state that the Department will be notified within one business day if an emergency situation occurs which dictates implementation of the plan

Yes ___ No ___

7. Does plan stipulate that a written incident report and critique of performance will be done when the plan is implemented?

Yes ___ No ___

Secure and Verifiable Documents Under O.C.G.A. § 50-36-2 Issued April 3, 2014 by the Office of the Attorney General, Georgia
The Illegal Immigration Reform and Enforcement Act of 2011 (“IIREA”), as amended by Senate Bill 160, signed into law as Act No. 27, (2013), provides that “[n]ot later than August 1, 2011, the Attorney General shall provide and make public on the Department of Law’s website a list of acceptable secure and verifiable documents. The list shall be reviewed and updated annually by the Attorney General.” O.C.G.A. § 50-36-2(g). The Attorney General may modify this list on a more frequent basis, if necessary.
The following list of secure and verifiable documents, published under the authority of O.C.G.A. § 50-36-2, contains documents that are verifiable for identification purposes, and documents on this list may not necessarily be indicative of residency or immigration status.
• An unexpired United States passport or passport card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]
• An unexpired United States military identification card [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]
• An unexpired driver’s license issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]1
• An unexpired identification card issued by one of the United States, the District of Columbia, the Commonwealth of Puerto Rico, Guam, the Commonwealth of the Northern Marianas Islands, the United States Virgin Island, American Samoa, or the Swain Islands, provided that it contains a photograph of the bearer or lists sufficient identifying information regarding the bearer, such as name, date of birth, gender, height, eye color, and address to enable the identification of the bearer [O.C.G.A. § 50-36-2(b)(3); 8 CFR § 274a.2]
1 For identification presented to poll workers when voting, a registered Georgia voter may present an expired Georgia driver’s license as proof of identification when voting pursuant to O.C.G.A. § 21-2-417.
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