HCBS basic services sample policies / Minnesota Department of Human Services

HCBS basic sample forms and policies - 245D providers

Providers may use these DHS sample documents for basic support services programs as templates for their programs by filling in the blanks or modifying them to fit their programs’ format and style. The sample documents represent current licensing requirements and are updated as needed due to changes in rule or law. Providers are responsible for ensuring the documents they use conform to current licensing requirements.

Basic services sample policies

Basic sample policies and procedures	Applicable MN statute and rule	Date of last revision
Admission Criteria Policy (DOCX)	MN Statutes 245D.11, subd. 4	8/1/2022
Data Privacy Policy (DOC)	MN Statutes 245D.11, subd. 3	10/31/2013
Drug and Alcohol Prohibition Policy (DOC)	MN Statutes 245A.04, subd. 1(c)	7/1/2017
Emergency Response, Reporting and Review Policy (DOCX)	MN Statutes 245D.11, subd. 2; 245D.02, subd. 8; and 245D.22, subd. 4-7	8/1/2022
Emergency Use of Manual Restraint (EUMR) Allowed Policy (DOCX)	MN Statutes 245D.06, subd. 1(a); 245D.06, subd. 5, 245D.061; and MN Rules 9544.0070	8/1/2022
Emergency Use of Manual Restraint (EUMR) Not Allowed Policy (DOCX)	MN Statutes 245D.06, subd. 1(a); 245D.06, subd. 5, 245D.061; and MN Rules 9544.0070	8/1/2022
Grievance Policy (DOCX)	MN Statutes 245D.10, subd. 2	8/1/2022
Health Service Coordination and Care (Residential Programs) Policy (DOCX)	MN Statutes 245D.11, subd. 2(2)	8/1/2022
Incident Response, Reporting and Review Policy (DOCX)	MN Statutes 245D.11, subd. 2(7); 245D.02, subd. 11; 245.91, subd. 6; 609.341, subd. 3 and 14	8/1/2022
Maltreatment of Minors Reporting and Internal Review Policy DHS-7634A (PDF)	MN Statutes 245A.66 and 626.556	1/1/2018
Safe Medication Assistance and Administration Policy (DOCX)	MN Statutes 245D.11, subd. 2(3)	8/1/2022
Safe Transportation Policy (DOC)	MN Statutes 245D.11, subd. 2(4)	10/31/2013
Service Termination Policy (DOCX)	MN Statutes 245D.10, subd. 3	8/1/2022
Temporary Service Suspension Policy (DOCX)	MN Statutes 245D.10, subd. 3	8/1/2015
Universal Precautions and Sanitary Practices Policy (DOC)	MN Statutes 245D.11, subd. 2(1)	10/31/2013
Vulnerable Adults Maltreatment Reporting and Internal Review Policy DHS-7634B (PDF)	MN Statutes 245A.65, subd. 1(a) and (b) and 626.557, subd.	1/1/2018

Basic services sample forms

Sample program forms	Applicable MN statute or rule	Date of last revision
60 Day Review for Basic Services (DOCX)		8/1/2022
Admission and Discharge Register (DOCX)		8/1/2022
Emergency Report and Internal Review (DOCX)		8/1/2022
Funds and Property Authorization (DOC)		10/31/2013
HCBS Service Recipient Rights Packet (DOCX)		8/1/2022
HCBS Service Recipient Rights Restrictions (DOCX)		8/1/2022
Health Needs Change Notice (DOCX)		8/1/2022
Health Needs Record (DOCX)		8/1/2022
Incident Report and Internal Review (DOCX)		8/1/2022
Incident Reporting Requirements- Who to Notify (DOCX)		8/1/2022
Individual Abuse Prevention Plan (IAPP) (DOC)	MN Statutes 245A.65,subd.2(b) and 626.6557, subd. 14	10/31/2013
Medication Administration and Emergency Medical Authorization (DOCX)		7/1/2015
Medication Administration Review Record (DOC)		10/31/2013
Medication and Treatment Administration Packet (DOCX)		8/1/2022
Medication Setup Record (DOC)		10/31/2013
Notice of Service Termination Form (DOCX)		8/1/2022
Notice of Temporary Service Suspension Form (DOCX)		8/1/2020
Person-Centered Planning and Service Delivery Requirements (DOCX)		8/1/2022
Policy Receipt and Signature Page (DOCX)		7/1/2017
Positive Support Strategies and Evaluation (DOCX)		8/1/2022
Program Abuse Prevention Plan (PAPP) (DOCX)	MN Statutes 245A.65, subd. 2(a) and 245A.65, subd. 2(a)	8/1/2022
Progress Report for Basic Support Services (DOCX)		8/1/2022
Progress Review Meeting Summary for Basic Services (DOCX)		8/1/2022
Psychotropic Medication Use and Monitoring Record (DOC)		10/31/2013
Quality Management Evaluation and Program Improvement Plan (DOCX)		8/1/2022
Release of Information Authorization (DOC)		10/31/2013
Satisfaction Evaluation (DOC)		10/31/2013
Service Admission Checklist for Basic Services (DOCX)		8/1/2022
Service Recipient Information Cover Sheet (DOCX)		7/1/2017
Service Recipient Record Checklist (DOCX)		8/1/2022
Staff Annual Training Record (DOCX)		8/1/2022
Staff Orientation Record (DOCX)		8/1/2022
Variance Request DHS-3141 (PDF)	MN Statutes 245A.04, subd. (9)	7/1/2018