Date:

Building/Campus Name:

Address:

Owner/Management Company:

Person completing application: Title: Phone:

Are you aLeadingAge Minnesota Member: Yes No District:

Are you registered as Housing with Services? YesNo

(If you answered "No" to this question, your application will not be considered until you are registered)

Are you designated as Assisted Living? Yes No

Do you have Dementia/Memory Care? Yes No

Do you have your own Home Care Agency? Yes No

Is there another primary home care agency providing services in you building(s) If so, what is the name of the agency?

Name of current on-site Housing Manager:

1)Ethical Conduct

Do you have a current Code of Ethics through LeadingAge Minnesota? Yes No

(If you are unsure, contact Alecia Crumpler at )

If no, have you completed a similar process? Yes No

(If you answered "No" to bothquestions, your application will not be considered until you have a current Code of Ethics or similar process)

When did you adopt the Code of Ethics or equivalent? Month: Year:

If you have an alternative to theLeadingAge Minnesota Code of Ethics, please describeand provide a copy of the document/process.

2)Experienced Leadership

Describe the education and experience of the current Housing Manager:

How long has s/he been in their current position?

How many years of experience does s/he have working in older adult services?

How many years of housing manager experience does s/he have?

What specific training and/or professional development related to older adult services (certified programs, seminars, conferences, education and development experiences) has s/he completed in the last year?(Must list at least ten continuing education unit hours completed)

3)Consumer Satisfaction

Do you administer a resident/family/responsible party satisfaction survey? Yes No

(If you answered "No" to this question, your application will not be considered)

How often do you give the survey?

When was your last survey? Month: Year:

Is it internally or externally designed and delivered? Internally Externally

If it is an external survey, what vendor do you use?

4) Consumer Information

Do you have a process for welcoming and orienting new residents/families/responsible

parties? Yes No

(If you answered "No" to this question, your application will not be considered)

Do you have a resident handbook? Yes No

(Please attach the table of contents for your resident handbook to this application. If your handbook does not have a table of contents, attach at least six pages of your handbook. If you answered "No" to this question, your application will not be considered)

Please explain how you communicate your “house rules” and other policies and procedures to residents/families/responsible parties through your orientation process, handbook, or other means:

5) Regulatory Compliance & Emergency Preparedness

Do you have an operational response plan for weather and other emergencies? Yes No

(If you answered "No" to this question, your application will not be considered)

Do your employees and volunteers receive training on emergency response plans within 30 days of hire? Yes No

(If you answered "No" to this question, your application will not be considered)

Do your residents/families/responsible parties, as appropriate, receive information and/or training on emergency response plans annually? Yes No

(If you answered "No" to this question, your application will not be considered)

Do you conduct fire drills in accord with State Fire Code requirements? Yes No

(If you answered "No" to this question, your application will not be considered)

Do you conduct an annual emergency drill for weather or other non-fire emergency? Yes No

(If you answered "No" to this question, your application will not be considered)

Please describe generally how you address emergency preparedness and how staff, residents, families, etc. are informed/trained on emergency response plans:

State of Regulatory Compliance

(To be signed by person authorized to represent the applicant)

is in compliance with all applicable codes

(Name of Applicant)

and license requirements.

(Signature)

(Print name & title of person authorized to represent the applicant)

(Date)

6) Standards for Dementia Care

Do you providea dementia/memory care program of services as described under MN Statute 325F.72 and 144D.065? Yes No

(If No, move on to the Elective Requirements section.)

(If yes, please attach a copy of your dementia disclosure required under MN Statute 325F.7s and 144D.065)

If yes, have you adopted specific Dementia Care Standards? Yes No

(If you answered "No" to this question, your application will not be considered)

Are you using the LeadingAge Minnesota Dementia Care Standards? Yes No

When did you adopt the Dementia Care Standards? Month: Year:

(If you are unsure, contact Alecia Crumpler at )

If no, which program are you following?

(If you are not using the LeadingAge Minnesota Dementia Care Standards, please attach an outline of the standards you are following to your application.)

Choose at least nine of the following Elective Options (we encourage you to choose more than nine) and clearly and concisely describe your programs or systems that address these Electives. Limited documentation may be attached if indicated in the instructions, but please do not submit lengthy documentation. Check off the Elective Optionsyou are selecting and then refer to ‘Elective Requirements’ in the Application Instructions for guidance on what to submit on/with your application on the following pages.

To meet minimum requirements, select at least two options from Elective Category A:

Quality of Care & Services – Clinical Performance Improvement Plans

Quality of Care & Services – Non-Clinical Performance Improvement Plans

Quality of Care & Services – Resident Transitions Coordination

Quality of Care & Services – Data Collection onKey Measures/Goals

Quality of Care & Services – Involvement of Residents/Families/Responsible Parties in CQI

To meet minimum requirements, select both (two) options from Elective Category B:

Open, Effective Communication – Resident/Family/Responsible Party Meetings or Councils

Open, Effective Communication – Resident Communication Systems

To meet minimum requirements, select at least two options from Elective Category C:

Resident Health, Wellness, and Life Enrichment – Resident Education/Learning

Resident Health, Wellness, and Life Enrichment – Referral Systems/Community Integration

Resident Health, Wellness, and Life Enrichment – Resident Socialization and Recreation

Resident Health, Wellness, and Life Enrichment – Fitness/Wellness Programs

Resident Health, Wellness, and Life Enrichment – Resident-Centered Technology

Resident Health, Wellness, and Life Enrichment – Resident Care Conferences

To meet minimum requirements, select at least two options from Elective Category D:

Employee Satisfaction and Development – Employee Satisfaction Survey

Employee Satisfaction and Development – Employee Education and Training

Employee Satisfaction and Development – New Employee Orientation

Employee Satisfaction and Development – Employee Recognition

Employee Satisfaction and Development – Employee Meetings

Employee Satisfaction and Development – Exit Interviews

To meet minimum requirements, select at least one option from Elective Category E:

Community Connectivity, Benevolence, and Innovation – Social Accountability

Community Connectivity, Benevolence, and Innovation – Resident/EmployeeBenevolence

Community Connectivity, Benevolence, and Innovation – Innovation

Community Connectivity, Benevolence, and Innovation – Volunteers

Electives

Please provide a brief, clear description of how your program meets the electives you have selected to address. Be sure to read the Application Instructions for guidance on what is expected for each elective. Supporting materials are not required to be submitted with your responses unless indicated,butSite Reviewers may ask to see documents during the site visit.

  1. Quality of Care & Services (address at least 2 of the electives in this category):

1)Clinical Performance Improvement Plans

  • Provide examples of recent benchmarking:
  • Describe a new process or system implemented as a result of benchmarking:
  • Describe the outcomes of these new processes or systems:
  • Other information to describe how this Element Requirement is met:

2) Non-Clinical Performance Improvement Plans

  • Provide examples of recent performance improvement plans:
  • Describe the outcomes of completing these plans:
  • Other information to describe how this elective is met:

3) Resident Transitions Coordination

  • Describe your systems and/or relationships with other providers to assure coordinated transitions for residents and increase access to primary care:

4) Data Collection onKey Measures/Goals

  • Describe the quality “dashboard” or system you have implemented to collect data and track progress on key measures/goals:

5) Involvement of Residents/Families/Responsible Parties in Improvement Efforts

  • Describe how residents/families/responsible parties are involved in your Continuous Quality Improvement process:
  1. Open, Effective Communication (address both electives in this category):

1)Resident/Family/Responsible Party Meetings or Councils

  • Describe your resident/family/responsible party meetings and some of the changes made as a result of the feedback obtained:

2)Resident Communication Systems

  • Describe your system to regularly communicate with residents:
  1. Resident Health, Wellness and Life Enrichment (address at least 2 of the electives in this category):

1)Resident Education/Learning

  • Describe the resident education and learning enrichment programs you offer orfacilitate:

2)Referral Systems/Community Integration

  • Describe your systemsfor referring residents to other providers or agencies and for integrating residents in the broader community. Describe how these systemsmeet the needs of residents:

3)Resident Socialization and Recreation

  • Describe the opportunities you provide for resident socialization and recreation both within and outside your setting:

4)Fitness/Wellness Programs

  • Describe any fitness/wellness programs you offer or facilitate and how you actively encourage resident wellness:

5)Resident-Centered Technology

  • Describe any resident-centered technology in use and how it has improved care and/or services to residents:

6)Resident Care Conferences

  • Describe your care conference meetings and some of the changes made as a result of the feedback:
  1. Employee Satisfaction and Development (address at least 2 of the electives in this category)

1)Employee Satisfaction Survey

  • Describe your process for conducting an employee satisfaction survey:
  • How often is your survey conducted?
  • When was your last survey (month/year)?
  • What was the response rate for your most recent employee survey?
  • Do you conduct the survey yourself or do you use an external resource?
  • If you use an external resource, what vendor/source do you use?
  • Provide an example of an action plan developed to address any identified problems:

2)Employee Education and Training

  • Describe how you offer or make available ongoing education and training opportunities for employees (beyond mandatory in-service requirements):

3)New Employee Orientation

  • Describe your formal employee orientation process:

4)Employee Recognition

  • Describe your program to address team building, employee recognition and morale:

5)Employee Meetings

  • Describe your process for staff meetings where employees can identify issues and raise concerns:

6)Exit Interviews

  • Describe your process for conducting employee exit interviews:
  1. Community Connectivity, Benevolence, and Innovation (address at least 1 of the electives in this category)

1)Social Accountability

  • Describe your social accountability program:

2)Resident/Employee Benevolence

  • Describe your resident/employee benevolence fund and how it is used to assist those in need:

3)Innovation

  • Describe an innovative program, procedure or physical plant design your setting has implemented:

4)Volunteers

  • Describe how you use volunteers to enhance the experience for residents:

Please notify Bobbie Guidry at that you have submitted an application.

Member Fee:

  • The fee for first-time member applications is $150
  • The fee for renewal member applications is $75.00
  • If an applicant is not approved and re-applies within one year, the re-application fee is $65.00

Non-Member Fee (HWS establishments not members of LeadingAge Minnesota):

  • The fee for first-time non-member applications is $300.00.
  • The fee for renewal non-member applications is $250.00
  • If a non-member applicant is not approved and re-applies within one year, the re-application fee is$200.00

LeadingAge Minnesota – Confident Choices for Senior Living Application Page 1 of 7