Adult Care Home Forms and Manuals

Facility Investigation Report

• Facility Complaint Investigation Form (Word)
• Facility Complaint Investigation Form (PDF)

Witness Statement Form

• ANE Witness Form (Word)
• ANE Witness Form (PDF)

Functional Capacity Screen Manual and Form

• Resident Functional Capacity Screen
• Functional Capacity Screen Manual

Fee Payment

Submission of many of the state licensure forms also requires submission of an accompanying fee. Fees must be paid by either check, money order, or credit card payment authorization made payable to the Kansas Department for Aging and Disability Services (KDADS) for adult care homes (including assisted living/residential health care facilities, boarding care homes, home plus facilities and adult day care).

Beginning April 1, 2018, a 3.04% fee will be added to payments made by credit card.

KDADS currently accepts:

• MasterCard
• VISA

Guidelines

• Tuberculosis Guidelines
• Delegation of Nursing Tasks
• EPA Hazardous Waste Pharmaceuticals Sewer Ban
  • Effective August 21, 2019, healthcare facilities, including long-term care facilities and veterinary clinics, may no longer dispose of pharmaceuticals that are hazardous waste by flushing or putting them down the drain. This requirement (40 CFR 266.505) is part of the US EPA’s final rule for managing hazardous waste pharmaceuticals. The other provisions of the rule do not take effect in Kansas until the State adopts them.
    
    The Hazardous Waste Pharmaceuticals Sewer Ban information sheet includes a list of facilities that are considered health care facilities for this rule. For additional information about the management of hazardous waste, you may visit the Kansas Department of Health and Environment-Bureau of Waste Management web site or call 785-296-1600.

Nursing Facilities

• Client Assessment, Referral and Evaluation (CARE) Process and Procedures
• CMS Technical User's Guide
  In July 2016, the Centers for Medicare & Medicaid Services (CMS) made several changes to the quality measure (QM) domain of the Five Star Nursing Home Quality Rating System. Download the current CMS Technical Users Guide - 2021
• Minimum Data Set (MDS) Information
• Centers for Medicare and Medicaid Long Term Care Survey Process Forms
• Contact Information* - District Map

Request for Authorized Electronic Monitoring

• Request for Authorized Electronic Monitoring

Sunflower Connection

Past Issues of The Sunflower Connection