Oregon Administrative Rules › Chapter 411 - DEPARTMENT OF HUMAN SERVICES, AGING AND PEOPLE WITH DISABILITIES AND DEVELOPMENTAL DISABILITIES › Division 49 - ADULT FOSTER HOMES FOR OLDER ADULTS OR ADULTS WITH PHYSICAL DISABILITIES - PURPOSE, DEFINITIONS, AND LICENSURE › Section 411-049-0135 - License Applications

Current through Register Vol. 63, No. 7, July 1, 2024
(1) INITIAL LICENSE
			 APPLICATION. The initial license application (APD 0448) must include:
(a) Verification of attendance at a
			 Department-approved orientation program conducted by the LLA responsible for
			 the licensing of the proposed AFH and successful completion of the Department's
			 Ensuring Quality Care Course and examination. (See OAR
			 411-049-0125).
(b) Three personal references for the
			 applicant who are not family members as defined in OAR
			 411-049-0102. Current or
			 potential licensees and co-workers of current or potential licensees are not
			 eligible as personal references.
(c) The classification being requested with
			 information and supporting documentation regarding qualifications, relevant
			 work experience, and training of staff as required by the Department. To
			 request a Class 3 license, the application must include:
(A) Proof of at least three years of
			 full-time experience providing direct care to adults who are older or adults
			 with physical disabilities and who required full assistance in four or more of
			 activities of daily living.
(B)
			 Current contact information from at least two licensed health care
			 professionals who have direct knowledge of the applicant's abilities and
			 experience as a caregiver; or
(C) A
			 copy of the applicant's current unencumbered license as a healthcare
			 professional in Oregon, if applicable.
(d) Documentation of the initiation of a
			 background check or a copy of an approved background check for each subject
			 individual as defined in OAR
			 411-049-0102.
(e) A Health History and Physician,
			 Physician's Assistant, or Nurse Practitioner's Statement (form APD 0903)
			 regarding the applicant's ability to provide care.
(f) FINANCIAL INFORMATION. A completed AFH
			 Financial Information form (APD 0448A), and supplemental information listed in
			 OAR 411-049-0125(3)
			 documenting at least two months of liquid resources to pay the operating costs
			 of the home.
(g) If an applicant
			 uses income from another AFH to document possession of at least two months of
			 operating expenses, the applicant must demonstrate the financial ability and
			 maintain sufficient liquid resources to pay the operating costs of each home
			 for at least two months.
(h) Copies
			 of the home's Residency Agreements according to OAR
			 411-050-0750.
(i) Copies of the home's Nondiscrimination
			 Notice that includes:
"(Name of care facility) does not discriminate and does not
				permit discrimination, including but not limited to bullying, abuse or
				harassment, based on an individual's actual or perceived sexual orientation,
				gender identity, gender expression or human immunodeficiency virus status, or
				based on an individual's association with another individual on account of the
				other individual's actual or perceived sexual orientation, gender identity,
				gender expression or human immunodeficiency virus status. If you believe you
				have experienced this kind of discrimination, you may file a complaint with the
				Oregon Department of Human Services at (provide current contact
				information)."
(j) If the
			 applicant is purchasing or owns the home, verification of purchase or
			 ownership.
(k) If the home is
			 leased or rented, a copy of the completed lease or rental agreement. The
			 agreement must be a standard lease or rental agreement for residential use and
			 include the following:
(A) The owner and
			 landlord's name.
(B) Verification
			 that the rent is a flat rate.
(C)
			 The signatures of the landlord and applicant and the date signed.
(l) Complete contact information
			 for the applicant including:
(A) A mailing
			 address if different from the proposed AFH.
(B) A business address for electronic
			 mail.
(m) The maximum
			 resident capacity requested.
(n)
			 Identify an Oregon-licensed registered nurse who has agreed to provide RN
			 consultation, training and delegation to caregivers as needed.
(o) Identification of:
(A) Any relatives needing care.
(B) The maximum number of any room and board
			 tenants.
(C) The maximum number of
			 adult day services individuals.
(D)
			 The names of any other occupants in the home.
(p) A $20 per bed non-refundable fee for each
			 non-relative resident.
(q) If the
			 applicant intends to use an administrator, resident manager, floating resident
			 manager, or shift caregivers, the Department's supplemental application (form
			 APD 0448B) completed by the applicant, as appropriate.
(r) Succession Plan or current AFH Back-up
			 Provider Agreement form (APD 0350).
(s) The current AFH Weekly Plan of Operation
			 form (APD 0351) describing the operational plan for the AFH.
(t) A current and accurate floor plan that
			 indicates:
(A) The size of rooms.
(B) Which bedrooms are to be used by
			 residents, the licensee, caregivers, for adult day services, and room and board
			 tenants, as applicable.
(C) The
			 location of all the exits on each level of the home, including emergency exits
			 such as windows.
(D) The location
			 of any wheelchair ramps.
(E) The
			 location of all fire extinguishers, smoke alarms, and carbon monoxide
			 alarms.
(F) The planned evacuation
			 routes, initial point of safety, and final point of safety.
(G) Any designated smoking areas in or on the
			 AFH premises.
(u) A copy
			 of the applicant's current license as a health care professional in Oregon, if
			 applicable.
(v) Incomplete initial
			 applications are void after 60 calendar days from the date the LLA receives the
			 application form and non-refundable fee, and the Department may deny the
			 application if not withdrawn.