PA.gov
Apply for Benefits

Contact Us
Contact Us 1-800-692-7462
 
E-mail Us E-mail Us
Welfare Fraud TipLine

Welfare Fraud TipLine 1-800-932-0582

View hot line data here

  • 18,077 complaints received
  • 5,117 Field Investigations
  • $17,324,172 saved
  • August 1, 2013 - July 31, 2014

    Personal Care Home Forms


    The following forms below are offered in PDF format; all forms are fill-in enabled. If a Word version of any form is needed, please contact the department's Operator Support Hotline at: 1-866-503-3926 or email the ARL Headquarters Office at:
    ra-pwarlheadquarters@state.pa.us.
     

    Personal Care Home Required Forms

    This is the REPORTABLE INCIDENT form that must be used to report incidents and conditions to DPW in accordance with 55 Pa.Code § 2600.16. This form is also applicable for human service programs under 55 Pa.Code Chs. 2380, 2390, 2600, 2800, 3800, 6400, and 6500.

    Personal Care Homes Reportable Incident Form 

    This is the REQUEST FOR WAIVER form that must be used for the human services setting to request a waiver of a specific regulation in accordance with 55 Pa.Code Chs. 2380, 2390, 2600, 2800, 3800, 6400, and 6500.

    Personal Care Homes Request For Waiver Of Regulation

    This is the PREADMISSION SCREENING form that is completed for each resident 30 days prior to admission in accordance with 55 Pa.Code § 2600.224.

    Personal Care Home Preadmission Screening

    This is the new RESIDENT ASSESSMENT-SUPPORT PLAN (RASP) that is completed for each resident 15-days following admission, annually and if the resident's condition changes in accordance with 55 Pa.Code § 2600.225, as well as is completed for each resident 30-days following admission, annually and if the resident's condition changes in accordance with 55 Pa.Code § 2600.227. Personal care homes have until July 1, 2012 to integrate this new form into its home's resident records.

    Personal Care Home Resident Assessment-Support Plan (RASP)

    This is the new DOCUMENTATION OF MEDICAL EVALUATION (DME) form that is required in accordance with 55 Pa.Code § 2600.141. The Documentation of Medical Evaluation form is to be completed within 60 days prior to admission or within 30 days after admission to the home. The Documentation of Medical Evaluation form is required for all personal care home residents. Residents who receive SSI will need to complete a MA-51 form for purposes of financial eligibility in addition to the Documentation of Medical Evaluation form.

    Documentation of Medical Evaluation (DME)

     

     

    Personal Care Home Sample Model Forms

    This is the RECORD OF FINANCIAL TRANSACTION form that may be used in accordance with 55 Pa.Code Section 2600.20(b)(1).

    Adult Residential Licensing - Record of Financial Transactions

    This is the CASH DISBURSEMENT RECORD form that may be used in accordance with 55 Pa.Code Section 2600.20(b)(3).

    Adult Residential Licensing - Cash Distribution Record

    This is the QUARTERLY FINANCIAL SUMMARY form that may be used in accordance with 55 Pa.Code Section 2600.20(b)(8).

    Adult Residential Licensing - Quarterly Financial Summary

    This is the RECORD OF TRAINING form that may be used in accordance with 55 Pa.Code Section 2600.65(i).

    Adult Residential Licensing - Record of Training

    This is the STAFF TRAINING PLAN form that may be used in accordance with 55 Pa.Code Section 2600.66.

    Adult Residential Licensing - Staff Training Plan

    This is the FIRE DRILL RECORD form that may be used in accordance with 55 Pa.Code Section 2600.132.

    Adult Residential Licensing - Fire Drill Record

    This is the RESIDENT-HOME CONTRACT that may be used in accordance with 55 Pa.Code Section 2600.25.

    Adult Residential Licensing - Resident-Home Agreement

    This is the RESIDENT-HOME CONTRACT Addendum C that shall be used in accordance with 55 Pa.Code Section 2600.25(d). For current residents, the rent rebate language in the resident-home contract and the signed statement are due by July 31, 2009. For residents admitted on or after July 31, 2009, the rent rebate information and the signed statement are due upon admission.

    Addendum C To Resident-Home Contract - Rent Rebates

    This is the MEDICATION ADMINISTRATION RECORD (MAR) form that may be used in accordance with 55 Pa.Code Section 2600.187(a).

    Medication Administration Record

    This is the MODEL FIRE SAFETY INSPECTION AND SUPERVISED DRILL DOCUMENT form that may be used in accordance with 55 Pa.Code Section 2600.132(b).

    Model Fire Safety Inspection and Supervised Drill Document

    This is the MODEL EVACUATION TIME DESIGNATION DOCUMENT form that may be used in accordance with 55 Pa.Code Section 2600.132(d).

    Model Evacuation Time Designation Document