Revised model forms that conform to the new Standards for Licensed Assisted Living Facilities (22 VAC 40-73) are now available on the Virginia Department of Social Services (DSS) website. To access the new documents, click on “Current ALF Providers” and scroll down to “Forms”.

DSS advises while the forms are intended to be helpful to providers, they are not required.  The only required forms are the Disclosure Statement and the Liability Insurance Disclosure Notification Form.

The following forms were revised:

• Approval for Placement in Special Care Unit
• Assessment of Serious Cognitive Impairment
• Authorization for Release of Confidential Information
• Auxiliary Grant Program Provider/DSS Communication Form
• Department Approved Educational Program for Geriatric Assistant or Home Health Aide or for Nurse Aide (Not Covered Under 22 VAC 40-73-200 C 2)
• Discharge Notification and Statement
• Documentation of Physician’s or Other Prescriber’s Oral Order for PRN (as needed) Medication
• Individualized Service Plan
• Medication Administration Record
• Mental Health Screening Determination Form
• Non-Availability of Recommended Mental Health Services Form
• Record of Initial ALF Staff Training
• Record of On-Site Health Care Oversight
• Record of On-Site Health Care Oversight Additional Requirements for Restrained Residents
• Record of Required  Fire and Emergency Evacuation Drills
• Record of Restraint Usage
• Record of Staff Training and Education Following Employment
• Report of Resident Physical Examination
• Resident Personal/Social Data
• Resident Agreement
• Review of Appropriateness of Continued Residence in Special Care Unit
• Rights and Responsibilities of Residents of ALFs
• Staff Record
• Sworn Statement or Affirmation for Adult Facility Employees (note: this form relates to Regulation for Background Checks)

Note: Two forms were removed from the DSS website as they are no longer needed.  Those forms were the Agreement for Mental Health Services and the License Modification Request for Facility Change of Location.

Please contact your Licensing Inspector if you have any questions about the forms.