Get For Home And Community Support Services Agency

Filling out the For Home And Community Support Services Agency form is a crucial step for providers in reporting necessary information. This guide will provide clear and detailed steps to assist users in completing the form accurately.

Follow the steps to fill out the form effectively.

1. Press the ‘Get Form’ button to access the form and open it in your selected editor.
2. Begin by entering the date on the fax cover sheet. Indicate the recipient's name as the DADS Complaint Intake Unit and attention to the Intake Coordinator. Include the fax area code and telephone number for submissions.
3. Fill in the regarding section with the DADS Intake ID number and indicate the total number of pages being sent, including the cover sheet.
4. Provide your agency's representative details. This includes their name, title, and both fax and office telephone numbers.
5. In the Provider Investigation Report section, enter the agency name, license number, and contact information including street address, city, state, ZIP code, and county.
6. Indicate the type of provider by completing the relevant details section including license number and contact numbers.
7. Document the incident by selecting the category (abuse, neglect or exploitation), and specify who made the allegation along with when it occurred.
8. Fill in essential details regarding the incident date, time, and location. Provide a brief description of the allegation.
9. Complete the client/patient's demographic information, including name, Social Security number, date of birth, and address. Check if the address is a residential facility or an inpatient hospice.
10. Assess the functional assistance needs status and specify any special supervision requirements if necessary.
11. List any services provided and assess the client's ambulatory status, interviewability, and capacity to make informed decisions.
12. Fill in details regarding any known history of aggression or misconduct related to the client/patient.
13. Provide information about the alleged perpetrator(s), including name, date of birth, Social Security number, and relevant license information.
14. Document how the alleged perpetrator was identified and detail any confirmed or denied history of similar allegations.
15. Complete the witness information section if applicable, providing their name, address, and contact information.
16. Conclude by summarizing the investigation findings and indicating agency actions taken post-investigation.
17. Ensure that the reporter’s signature, printed name, title, and date are added to complete the form.
18. After filling out the form, you can save the changes, download it, print it, or share it as necessary.

Complete your documentation online now to ensure timely processing.