Serious injury or death

If you witness or suspect that a resident is being maltreated, abused, or neglected, you must call the state reporting line at 844-880-1574. Also, complete an incident report form.

If a resident is developmentally delayed, mentally ill or elderly, you must report any serious injury or death to the Department of Human Services-Office of the Ombudsman (1-800-657-3591), as well as the case manager, guardian, and your regional licensing specialist.

Access forms and additional information on the OMHDD website >

Incident

In compliance with Minnesota statute 9555.6175, the following items require reporting to your regional licensing specialist within the specified timeframes:

• resident death or serious injury, including any that requires medical treatment - immediately with Required Reporting Form (PDF)
• Incident report form (PDF)
• diagnosis of a resident, caregiver or household member with a communicable disease - immediately
• fire, storm, or other damage to the home - within 24 hours with Natural Disasters form (PDF)
• building repair or remodeling that requires a building permit - within 24 hours
• change in health status of a caregiver that could affect ability to care for a resident - within 24 hours
• change in the regular membership of the household or caregiver's employment status - within five calendar days
• transfer or voluntary discharge of a resident - within seven calendar days
• involuntary discharge of a resident who does not have an individual service plan - at least 30 days before

For your convenience, sample documents or forms have been provided.

• Document guide (DOC)
• Host home guidelines (PDF)
• AFC Checklist for Provider Requirements (PDF)
• Adult foster care background study roster reporting (PDF)
• Adult foster home program plan (PDF)
• Complaint and grievance procedures (PDF) - must also be posted
• Drug and alcohol policy (PDF)
• Emergency fire and escape plan (PDF) - must also be posted
• Emergency fire drill log (DOC)
• Emergency plan and procedures sample template (DOC)
• Program abuse prevention plan - PAPP (PDF) - must also be posted
• Program abuse prevention plan - PAPP sample (PDF)
• Service termination policy (DOC)
• Social history form - Child (PDF) - Complete for all new minor household members and when household members turn 13 years old.
• Social history form - Adult (PDF)
• Substitute caregiver plan (PDF)

Please maintain a copy of the following in your files. Your RLS may ask to review these documents.

• Annual housing support vendor profile form
• Annual well water testing (coliform and nitrates)
• Background schedule clearance letter for AFC license
• Emergency equipment testing & replacement (PDF) - smoke and carbon monoxide alarms
• Fire extinguisher reservicing options (PDF)

• Resident File Sample (DOC)
• Resident Information (PDF)
• Resident Placement and Demographic Information (PDF)
• Cash Resources (PDF)
• Individual Abuse Prevention Plan (PDF)
• Individual Resident Placement Agreement (PDF)
• Medication Permissions (PDF)
• Mobility access assessment (PDF)
• Notice of Privacy Practices (PDF)
• Prescription Drug Disposal Collection Bins (PDF)
• Resident Rights (PDF)
• Signed notification of a communicable/contagious disease, if applicable
• Vulnerable Adult Act Summary (PDF)

Please maintain a copy of the following in your files. Your RLS may ask to review these documents.

• Guardian or other court paperwork
• Resident progress notes
• Release of information ROI's