(Revised 1/1/20 ML #3570)
Purpose: The form is completed to provide evidence that the respite care QSP's home meets the following minimum standards.
When Prepared:
Upon the request of a provider who is enrolled and eligible to provide respite care.
By Whom Prepared:
A minimum of one (1) home visit to the respite care QSP's home shall be made by the HCBS case manager to complete the "Respite Home Evaluation". The HCBS case manager shall maintain records of the evaluation, the decision, and the reason for that decision.
SPECIFIC INSTRUCTIONS:
Check standards 1-16 either yes or no. This section does not need to be completed if the home is a licensed Adult Foster Care Home.
All responses must be yes prior to consideration of approval for a Respite Care QSPs Home.
If the home is approved, complete valid through, not to exceed two years, check they meet the standard, sign and date the form. The Respite Home Provider must agree to maintain the standard by signing and dating the form.
If the home does not meet the standard check the box that indicates “does not meet the standard”, and sign the form. Make the provider aware they do have the opportunity to reapply to be a Respite Care QSP Home when they have made any needed corrections to meet the standard.
The HCBS case manager must ensure the chosen QSP has the ability to provide the requested service by checking the web-searchable database.
Approval of Respite Care QSP's Home
Upon determining the respite care QSP's home meets the standards, a copy of the completed SFN 659 approving the respite care home is provided to the provider. Should the respite care QSP move, another evaluation is required. Send a copy of the completed SFN 659 to Aging Services/HCBS.
This form is not available from the state office. It is electronically available through the state’s e-forms.