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The Dads 3647 form is an essential tool for families considering assisted living facilities in Texas. This Disclosure Statement aims to provide a clear and consistent overview of the policies and services offered by various facilities. It creates a standardized format that allows individuals and their families to compare options effectively. While the form outlines required services and amenities, it is not a substitute for visiting a facility, engaging with current residents, or speaking directly with staff members. Facilities must accurately complete the form without amending the details but have the option to attach addenda to elaborate on their offerings. The Dads 3647 form also addresses critical aspects of the admission process, including pre-admission steps, service costs, and potential discharge scenarios. Additionally, it highlights the importance of creating and implementing care plans tailored to residents' needs. Regular assessments of care plans are essential for ensuring that residents receive adequate support as their conditions change. By complying with this form, assisted living facilities demonstrate transparency and foster informed decision-making among prospective residents.

Dads 3647 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

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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.)

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

File Breakdown

Fact Name Details
Purpose of Disclosure The form provides information on facility policies and services, helping individuals make informed decisions about care.
Governing Law This form is governed by the Texas Administrative Code, specifically under Chapter 92, Subchapter 92.41 (f).
Pre-admission Process Facilities must indicate services not offered and detail the pre-admission steps, which may include a facility tour and family interviews.
Admission Contract Facilities must have a written contract for services and may require a refundable or non-refundable deposit.
Discharge Policies Residents can be discharged based on medical needs or behavior, with families able to provide input on such decisions.
Staff Training New employees receive training on resident care, and staff are often trained in CPR and specific protocols related to resident needs.

Guide to Using Dads 3647

Completing the Dads 3647 form requires careful attention to detail. Each section must reflect the services and policies provided by your facility. Ensure all information is accurate and complete, as this will help prospective residents make informed decisions.

  1. Begin by entering the facility's name.
  2. Fill in the license number associated with your facility.
  3. Provide the average number of residents currently at your facility.
  4. Enter the facility’s phone number for contact purposes.
  5. Complete the full address, including street, city, state, and ZIP code.
  6. List the manager's name and the date when the Disclosure Statement is completed.
  7. Indicate who completed the form along with their title.
  8. In the pre-admission section, check off services your facility does not offer.
  9. Detail what the pre-admission process involves, marking applicable activities like facility tour and family interview.
  10. List the services and amenities included in the base rate, such as meals and housekeeping.
  11. State any additional services that can be purchased, such as beauty services or transportation.
  12. Specify whether different levels of care incur additional charges.
  13. Complete the admission process section by answering questions about contracts, deposits, and refund policies.
  14. Explain the admission process for new residents, including any required doctors' orders.
  15. Detail the discharge and transfer protocol, mentioning the reasons for possible transfers.
  16. Indicate who is responsible for making discharge decisions and whether families can provide input.
  17. Discuss the planning and implementation of care, including who is involved in creating the service plan.
  18. Outline any special provisions for aging in place and additional training provided for staff.
  19. Describe the physical environment, including safety features and any special animals or plants residents can keep.
  20. Provide details about staffing patterns, including qualifications for the manager and staff schedules.
  21. End with information regarding residents' rights, including any councils and grievance procedures.

Get Answers on Dads 3647

What is the purpose of the Dads 3647 form?

The Dads 3647 form, also known as the Assisted Living Disclosure Statement, aims to empower individuals and their families by providing a standardized format for describing a facility's policies and services. It allows prospective residents to compare services across different facilities, facilitating informed decision-making. However, it is important to note that the form does not mandate the provision of all listed services.

Who is required to complete the Dads 3647 form?

The facility management is responsible for completing the Dads 3647 form. They must accurately represent the services and care that their facility offers, as well as provide additional explanations when necessary. A complete and truthful representation helps potential residents and their families make informed choices.

What information is included in the Dads 3647 form?

The form includes several key sections, such as:

  • Pre-admission process and services offered
  • Admission procedures, including contracts and deposits
  • Discharge and transfer policies
  • Planning and implementation of care
  • Staff training and qualifications
  • Physical environment and safety features
  • Residents' rights and grievance procedures

Is a facility required to provide all the services listed in the Dads 3647 form?

No, the Dads 3647 form does not require facilities to provide all services listed. Instead, it offers a format for describing the services that are actually provided. Facilities are permitted to amend their individual offerings but must do so in a clear and truthful manner.

What is the significance of the pre-admission process?

The pre-admission process is critical because it determines whether a prospective resident qualifies for admission to the facility. This process often includes a facility tour, family interviews, and medical assessments. It serves to ensure that the facility can meet the unique needs of the individual seeking residency.

Are there provisions for aging in place within the facility?

Aging in place refers to the policies and procedures that allow residents to remain in the facility as their needs change over time. The Dads 3647 form includes sections that detail how a facility accommodates changes in residents' conditions and circumstances, such as documenting any changes and submitting waiver requests if applicable.

What training do staff members receive?

Staff training is an essential component of ensuring quality care. New employees typically undergo orientation in which they are introduced to the facility's operations and resident service plans. Ongoing training may include CPR certification and other specialized training relevant to the services provided. Training schedules can vary based on the facility’s policies.

How can families address concerns or grievances?

The Dads 3647 form should indicate whether a facility has formal grievance procedures in place. This includes the existence of a Resident's Council and Family Council, as well as options for submitting suggestions or complaints. These mechanisms ensure that resident and family feedback is taken into account and is addressed appropriately.

What should families consider when reviewing the Dads 3647 form?

Families should carefully assess the information provided in the Dads 3647 form, considering aspects such as the services offered, staff qualifications, safety features, and policies for aging in place. It is also advisable to visit the facility, communicate with current residents, and engage with staff to gain a full understanding of the care environment.

Common mistakes

Completing the DADS 3647 form can be a straightforward process, yet many people encounter common pitfalls that can lead to complications or misunderstandings. One frequent mistake is failing to provide accurate information about the facility. This includes the facility’s name, license number, and contact details. When individuals neglect to verify these details, it can result in confusion for prospective residents and their families. Accuracy is essential as it serves as the foundation for all other information shared in the form.

Another common error occurs in the service and amenity descriptions. When filling out sections regarding services offered and base rates, many people either omit crucial details or provide vague descriptions. For example, stating "transportation services" without specifying the types or limitations can lead to misinterpretations. Clear, detailed information helps families make informed decisions about their loved ones’ care, so it's vital to be thorough and precise.

It's also crucial for individuals to be mindful of the admission process section. People often overlook the need to explain policies on deposits and refunds. If the form indicates that there is a deposit but fails to specify if it is refundable or under what conditions, this lack of clarity can lead to disputes later on. Open, honest communication about financial policies is not only a requirement but also a courtesy to potential residents.

Lastly, many individuals fail to update the form regularly. The information contained in the DADS 3647 form must reflect current practices and regulations. An outdated form can mislead families and potentially violate state guidelines. Thus, routine reviews and updates should be scheduled to ensure compliance and transparency. Taking the time to address these common mistakes will enhance the quality of care and trust within the community.

Documents used along the form

The DADS 3647 form is an important document that helps individuals and their families understand the services provided by assisted living facilities in Texas. This form outlines facility policies and can be accompanied by several other forms and documents that contribute to the understanding of care options and admission processes. Below is a list of common forms that are often used alongside the DADS 3647 form.

  • Residency Agreement: This document outlines the terms of residency, including services, payment arrangements, and the rights and responsibilities of both the resident and the facility.
  • Sample Menu: This provides potential residents with an idea of the meals offered, dietary options, and consistency of food quality within the facility.
  • Service Plan: Created for each resident, this plan details the specific services and support that will be provided based on individual needs, including personal care and medical assistance.
  • Admission Checklist: This checklist serves as a guide for prospective residents and their families, helping them understand the documents and processes involved in the admission process.
  • Complaint Procedure Document: This outlines the steps residents and families can take if they have concerns or complaints regarding the facility’s services or policies.
  • Staff Qualifications Overview: This document provides information about the qualifications and training of the facility staff, ensuring families understand who will be caring for their loved ones.
  • Emergency Preparedness Plan: This outlines how the facility prepares for emergencies, including fire drills, natural disasters, and medical emergencies.
  • Discharge Policy: This document details the facility's policies regarding resident discharge, including circumstances that may lead to discharge and any appeals processes.
  • Grievance Procedure Form: A formal process that allows residents or family members to submit grievances, concerns, or suggestions about the facility and its operations.
  • Facility Evaluation Survey: This report is conducted periodically to assess the quality of care and services provided at the facility, often available for review by families.

These forms and documents provide valuable information that helps in making informed decisions about assisted living options. Each document serves a specific purpose and contributes to a clearer understanding of the care provided in these facilities.

Similar forms

  • Form 3646: This form is also related to assisted living facilities. Like the Dads 3647, it outlines the basic services offered, ensuring transparency for potential residents. Both forms aim to provide a clear overview of the care and amenities available.
  • Form 3645: Similar in structure, this document focuses on resident rights within assisted living environments. Both forms empower residents by clarifying what they can expect and affirming their rights in the care setting.
  • Resident Agreement Form: This form serves to establish the terms and conditions of residency. Much like the Dads 3647, it details services provided and any associated fees, allowing residents to make informed choices.
  • Assisted Living Facility Application: This document is used during the admission process, similar to how the Dads 3647 discusses admission criteria. It collects information needed to assess a prospective resident’s suitability for the facility.
  • Service Plan Template: This template helps in documenting care plans for each resident. It parallels the planning section of the Dads 3647, which emphasizes individualized care based on specific resident needs.
  • Medication Administration Record (MAR): Like the Dads 3647, this record outlines medication management procedures in assisted living. Both documents stress the importance of proper medication administration and monitoring.
  • Emergency Preparedness Plan: This plan is essential for all facilities and shares similarities with the Dads 3647 in terms of outlining safety protocols. Both documents aim to ensure the well-being of residents in emergency situations.
  • Discharge Policy Statement: This document sets the procedures for transferring or discharging residents when necessary, much like the discharge processes mentioned in the Dads 3647. It ensures clarity for families regarding potential transitions.
  • Family Engagement Policy: Similar to the Dads 3647, this policy outlines how families can be involved in care decisions. Both documents support family communication and involvement in a resident's care.

Dos and Don'ts

When filling out the Dads 3647 form, it is crucial to ensure that information is accurate and clear. Here is a list of five things to do and five things to avoid:

  • Do complete the form thoroughly, ensuring that all required fields are filled out.
  • Do provide accurate details about the services your facility offers and any services that are not available.
  • Do review the form for completeness and clarity before submission.
  • Do ensure that any attachments are relevant and clearly referenced in the appropriate sections of the form.
  • Do keep a copy of the completed form for your records and for future reference.
  • Don’t leave any sections blank unless they are not applicable; provide “N/A” when necessary.
  • Don’t use ambiguous language. Be as specific as possible when describing services and policies.
  • Don’t amend the form once it has been finalized without following the appropriate procedures.
  • Don’t forget to provide copies of the form to anyone who inquires about the facility.
  • Don’t submit the form without a thorough review to prevent errors or omissions.

Misconceptions

Misconceptions can lead to confusion, especially when dealing with important documents like the DADS 3647 form. Here are four common misunderstandings about this form:

  • Myth: The DADS 3647 Form Guarantees All Services Listed Will Be Provided. Many people assume that if a service is listed on the form, the facility is required to provide it. In reality, the DADS 3647 serves as a guideline. Not all listed services may be available at every facility, and it does not mandate that a facility must offer every service described.
  • Myth: The Disclosure Statement Replaces the Need for Facility Visits. Some believe that the DADS 3647 form alone is enough to choose a facility. However, this statement is meant to supplement visits to the facility and conversations with residents and staff. Actual experiences and observations are invaluable when making a decision about care.
  • Myth: All Facilities Have the Same Admission Process. Individuals often think that the admission process is uniform across all assisted living facilities. However, the DADS 3647 form shows that each facility may have its own unique procedures, requirements, and fees. It's important to inquire specifically about the admission protocol at each facility you're considering.
  • Myth: Complaints Are Only Handled by the Facility. There's a belief that any issues or complaints must solely be addressed within the facility. In fact, if residents or families feel their concerns are not being resolved adequately, they can contact the Texas Department of Aging and Disability Services at the provided hotline. This external oversight can help ensure quality care and an appropriate response to complaints.

Key takeaways

  • The DADS 3647 form is designed to help prospective residents and their families compare assisted living facilities in Texas. It gives a standard format that outlines the services and policies of each facility, simplifying the decision-making process.

  • Information provided in the form helps to clarify what services are included in the base rate, such as meals, housekeeping, and transportation. Each facility is required to fill out this information to give potential residents a clear understanding of what to expect.

  • The form requires a detailed description of the pre-admission and admission processes. These details include whether there is a written contract, if deposits are required, and how admission decisions are made.

  • It is important to remember that the form is not a substitute for visiting the facility. Talking to current residents and staff can provide invaluable insights into daily life at the facility.

  • Facilities should ensure the DADS 3647 form is accessible to anyone who wants it, enhancing transparency and allowing families to make informed choices about their care options.