To assist with information accessibility and understanding of requirements, we have created an Adult Foster Care manual. The manual is designed to be beneficial from application through the duration of licensure and provide guidance on what to do with different documents.
To better help providers understand what is required for each visit or need, the webpage is laid out in a different format than the manual.
- AFC Manual
The Incident and Required Reporting Form is a tool to help you meet required reporting. You must report the following to your RLS:
- Immediately report death or serious injury of a resident
- Immediately report diagnosis of communicable disease of anyone who lives or works in the home, or has recently visited the home
- Change in the health status of a caregiver within 24 hours
- Occurrence of a fire that causes damage to the home, requires the services of the fire department, or repairs to the home require a building permit within 24 hours
- Change in the regular membership of the household (non-residents) within 5 days
- Change in a caregiver’s employment status within 5 days
If you are utilizing your 245D license to “host” another AFC provider, this is counted as employment and must be reported to your RLS.
MN Rule 9555.7175 provides full information on reporting.
You must also follow any reporting requirements for your 245D license.
All caregivers and household members must complete the MN DHS Vulnerable Adults Mandated Reporting (VAMR) Training annually. You must provide proof of VAMR training and can meet this requirement by providing a training certificate or copy of your training transcript.
If someone receiving services in your home relies on life sustaining medical equipment, you must provide proof that you and all caregivers have been trained by a qualified person.
You must also follow any training requirements for your 245D license which is monitored directly by your 245D licensor.
To ensure compliance with MN Statute 245C, you must complete background studies for all household members age 13 and older, caregivers, volunteers, or others as required. You are also required to remove study subjects from your roster if they are no longer affiliated with your program.
You can find more information about background studies here: Background studies / Minnesota Department of Human Services
Our goal is to help you feel as prepared as possible for your relicensing visit. Please reach out to your Regional Licensing Specialist RLS) if you have any questions about the requirements. You will receive an email from your RLS approximately 2 months in advance of your license expiration to schedule your visit.
Any document with a Sourcewell logo is an optional template. You may use a different form or template if you wish as long as all requirements are met. DHS branded documents and templates should be used when available.
Documents to review
Your RLS will complete these documents during your relicensing visit. It’s a good idea to review these documents ahead of time to make sure you are ready. Requirements on these checklists are the minimum standards outlined in Rule of Statute to ensure resident safety and rights as well as program integrity.
It’s also a good idea to review this additional document to help make sure you are prepared.
Documents to review and/or complete
You must complete and/or review and provide copies of the following documents to your RLS. You can return these documents via secure email or your RLS will scan the documents during the visit.
List of home documents:
- Family AFC Application (PDF)
- Supplement to Application (PDF)
- Census and Home Information Sheet (PDF)
- Certificate of Compliance Minnesota Workers’ Compensation Form (PDF)
- Emergency Procedures (PDF)
- Escape Plan (PDF)
- Fire Drill Log (PDF)
- Internal and External Maltreatment Reporting Procedures (PDF)
- Program Abuse Prevention Plan (PDF)
- Program Plan (PDF)
- VAMR Training
You will be asked to complete the following forms if they apply to your home:
- Elderly Waiver Service Termination Policy (PDF)
- Equipment Maintenance Form (PDF)
- Pet Authorization form (PDF) and proof of rabies vaccination
- Well water test results with safe levels of coliform and nitrates
List of resident documents:
- Placement and Demographic Information (PDF)
- Individual Abuse Prevention Plan (PDF)
- Individual Resident Placement Agreement (PDF)
- Mobility Access Verification (PDF)
- Monitoring Technology Consents, if used
What your RLS will look at during the visit:
Your RLS will review all items on the Licensing and Home Safety Checklist. Some key observations your RLS will make are:
- Water temperature (must be 120F or less)
- Operation of exit doors and windows (they must not be fully or partially obstructed and must easily open)
- General cleanliness and condition of the home
- Operation of flashlight and battery radio
- First aid kit contents
- Variance requests
After your visit, your RLS will email you a copy of your DHS license, Home Safety Checklist, and Licensing Evaluation Report.
Off-year visits are required non-renewal visits. These visits are an additional opportunity for you to ensure you are following minimum licensing standards, ask questions to your RLS, and for your RLS to collect annual paperwork.
Documents to review and/or complete
- Census and Home Information Sheet (PDF)
- Certificate of Compliance Minnesota Workers’ Compensation Form (PDF)
- Fire Drill Log (PDF)
- Individual Resident Placement Agreement (PDF) (your RLS will view it has been reviewed by the team within the past year)
- Program Abuse Prevention Plan (PDF)
- VAMR Training
You will be asked to complete the following forms if they apply to your home:
- Equipment Maintenance Form (PDF)
- Pet Authorization form (PDF) and proof of rabies vaccination
- Well water test results with safe levels of coliform and nitrates
- Background studies for children turning 13
Some key observations your RLS will make are:
- Water temperature (must be 120F or less)
- Operation of exit doors and windows (they must not be fully or partially obstructed and must easily open)
- General cleanliness and condition of the home
- Operation of flashlight and battery radio
- First aid kit contents
- Variance requests
A change of premise happens when you move from one home to another within the same county. If you are moving near the time your license is due to be renewed, your RLS will instruct you to also complete relicensing forms. If you are moving to a different county, you will need to close your existing AFC license and open a new license in that county.
Please notify your RLS at least 90 days in advance of your move. It is not guaranteed that a change of premise can be completed in less than 90 days.
- You must submit a CLIF (Change of License Information Form) to update your address. Reach out to your HCBS licensor about this process.
- Ensure all documents are updated with your new address and information including:
- You must select a date that you want your license to update to your new address (you cannot stay with residents at the new address prior to the change or at the previous address after the change)
- Once all documents have been received and any citations from the Fire Marshal inspection have been completed, a final walk through will be conducted by your RLS
- Capacity Change Guidelines and Request Form (PDF)
- Fire Extinguisher Reservicing Options (PDF)
- Planned Leave Substitute Caregiver Plan (PDF)
- Program Abuse Prevention Plan – sample (PDF)
- Program Plan – sample (PDF)
- Resident File - sample (PDF)
- Social history form – child (PDF)
- Social history form – adult (PDF)
- Prescription Drug Disposal Collection Bins (PDF)
- Notification of Residential Placement (PDF)
- Ceiling Height Variance Request (PDF)
- Complaint Investigations (DOC)
Questions
Contact licensing@sourcewell-mn.gov or call 218-895-4120.
Please include your county of residence in all communications.