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April 6, 2005

ADSA: AFH #2005-003
SAMPLE NEGOTIATED CARE PLAN AND EMERGENCY EVACUATION DRILL FORMS

Dear Adult Family Home Provider:

Residential Care Services has revised the Sample Negotiated Care Plan and Sample Emergency Evacuation Drill Forms since they were used at the 2004 Adult Family Home Training.

The purpose of revising the Sample Negotiated Care Plan Form was to include all requirements per WAC 388-76 and align with the Comprehensive Assessment Reporting Evaluation (CARE).

The purpose of revising the Sample Emergency Evacuation Drill Form was to include all requirements per WAC 388-76, while making the form easier to use.

Use of these sample forms is optional. You may choose to develop your own negotiated care plan or a document to record emergency evacuation drills using these samples, or continue to use your current version, provided it is in compliance with the state laws/regulations.

Enclosed are copies of both revised sample forms. These forms are also available on the ADSA Internet at http://www.aasa.dshs.wa.gov/professional/afh.htm.

Please contact your local Residential Care Services Field Manager if you have any questions.

Sincerely,

Joyce Pashley Stockwell, Acting Director
Residential Care Services

Enclosures:
Sample Negotiated Care Plan
Sample Emergency Evacuation Drill

AGING AND DISABILITY SERVICES ADMINISTRATION

2005 AFH "Dear Provider" Letters