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- "Initial Application Checklist for Older Adult Daily Living Center Licensure" - Pennsylvania
"Initial Application Checklist for Older Adult Daily Living Center Licensure" - Pennsylvania
This version of the form is not currently in use and is provided for reference only.
Download this version of for the current year.
Initial Application Checklist for Older Adult Daily Living Center Licensure is a legal document that was released by the Pennsylvania Department of Aging - a government authority operating within Pennsylvania.
Form Details:
- Released on February 7, 2017;
- The latest edition currently provided by the Pennsylvania Department of Aging;
- Ready to use and print;
- Easy to customize;
- Compatible with most PDF-viewing applications;
- Fill out the form in our online filing application.
Download a printable version of the form by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Aging.
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4Commonwealth of Pennsylvania
Department of Aging
Initial Application Checklist for Older Adult Daily Living Center Licensure
This checklist will help you complete the initial Older Adult Daily Living Center (OADLC) Application
Packet. Once an applicant submits an application and all required information identified by this checklist,
the Department will complete a comprehensive review of the application and supporting documentation.
The Department will provide constructive feedback on the application, as necessary. An initial on-site
inspection of a proposed center will not occur until the Department has approved the application as
complete.
Please submit the following items:
Application for License (AGL-02)*
The application shall be signed by the legal entity representative.
Provider Self Certification and Civil Rights Compliance Form (AGL-07)*
Center Operations and Demographics Form (AGL-08)*
Articles of Incorporation**
If the center or agency is operated by a corporation, a copy of the Department of State’s approved
corporation papers shall be included.
Partnership Agreement**
If the legal entity is a partnership, a copy of the agreement setting forth this arrangement shall be
included.
Proof of Non-Profit Status**
If the legal entity is non-profit, a copy of the Department of Treasury’s approval letter of non-
profit, § 501(c)(3) status shall be included.
Fictitious Name Approval**
If the legal entity is for profit and wishes to name the center something other than the owner’s or
corporation’s name, a copy of the Department of State’s approved fictitious name document shall
be included.
Foreign Business**
If the legal entity is a corporation formed in a state other than Pennsylvania, a copy of the
Department of State’s approved authorization to do business in Pennsylvania shall be included.
Occupancy Permit
The final Certificate of Occupancy, issued by the Department of Labor and Industry or local
municipality, shall reflect a use group code of I-4.
Fire Safety Inspection
The building shall be inspected by a fire safety expert. (§ 11.83) A copy of the fire safety
inspection shall be included.
Insurance Coverage
The center shall obtain insurance coverage, which includes personal and professional liability
coverage. (§ 11.22) A copy of the center’s insurance coverage shall be included.
Qualifications of the Director/Administrator
02/07/2017
Commonwealth of Pennsylvania
Department of Aging
Initial Application Checklist for Older Adult Daily Living Center Licensure
This checklist will help you complete the initial Older Adult Daily Living Center (OADLC) Application
Packet. Once an applicant submits an application and all required information identified by this checklist,
the Department will complete a comprehensive review of the application and supporting documentation.
The Department will provide constructive feedback on the application, as necessary. An initial on-site
inspection of a proposed center will not occur until the Department has approved the application as
complete.
Please submit the following items:
Application for License (AGL-02)*
The application shall be signed by the legal entity representative.
Provider Self Certification and Civil Rights Compliance Form (AGL-07)*
Center Operations and Demographics Form (AGL-08)*
Articles of Incorporation**
If the center or agency is operated by a corporation, a copy of the Department of State’s approved
corporation papers shall be included.
Partnership Agreement**
If the legal entity is a partnership, a copy of the agreement setting forth this arrangement shall be
included.
Proof of Non-Profit Status**
If the legal entity is non-profit, a copy of the Department of Treasury’s approval letter of non-
profit, § 501(c)(3) status shall be included.
Fictitious Name Approval**
If the legal entity is for profit and wishes to name the center something other than the owner’s or
corporation’s name, a copy of the Department of State’s approved fictitious name document shall
be included.
Foreign Business**
If the legal entity is a corporation formed in a state other than Pennsylvania, a copy of the
Department of State’s approved authorization to do business in Pennsylvania shall be included.
Occupancy Permit
The final Certificate of Occupancy, issued by the Department of Labor and Industry or local
municipality, shall reflect a use group code of I-4.
Fire Safety Inspection
The building shall be inspected by a fire safety expert. (§ 11.83) A copy of the fire safety
inspection shall be included.
Insurance Coverage
The center shall obtain insurance coverage, which includes personal and professional liability
coverage. (§ 11.22) A copy of the center’s insurance coverage shall be included.
Qualifications of the Director/Administrator
02/07/2017
Include copies of the director’s resume, degree(s) and certificate(s). (§ 11.34) Include a copy of
the certificate of successful completion of the online training course for OADLC Directors. A link
to this training course can be found on the Department of Aging website.
Qualifications of Nurse(s)
Include copy of resume and current nursing license. If center’s nurse is an LPN, include name of the RN or
physician who will provide direction to the LPN and an explanation of their relationship to the center. (§
11.35). If the center uses a contracted nurse, please provide proof of the contracted nurse’s professional
liability insurance.
Qualifications of Activities Coordinator and Program Assistants/Aides
Examples include copy of diplomas, degrees, transcripts, licenses, certifications and resumes. (§ 11.36 and
§ 11.37)
Criminal History Reports
The Older Adult Protective Services Act (OAPSA) requires centers to submit State and Federal (if
necessary) reports for the owner/operator and for each person who meets the definition of an employee per
the Chapter 15, Protective Services for Older Adults regulations. For owners/operators who are not
residents of Pennsylvania and who plan to visit the center, a Federal criminal history report shall be
provided. Verification of completion of the on-line OAPSA training by the director/administrator and all
management staff persons must also be submitted. (OAPSA and §§ 15.141 – 15.147)
List of Current Staff Hired
Include a list of current staff, including name, position and date of hire.
Job Descriptions
Job descriptions must include job duties and qualifications. (§§ 11.34 – 11.37)
Training Curriculum
Curriculum shall include the required general orientation and annual training and the qualifications of the
proposed trainer(s) or of the organizations which provide training. (§ 11.33) Include a training schedule for
the annual training.
Floor Plan
Indicate the following information on the floor plan: 1) internal and external exit paths, 2) intended use of
each area (offices, program areas, kitchen, dining areas, hallways, storage, etc), 3) the dimensions of each
program room and 4) the location of each bathroom including the number of sinks, toilets, showers and
bathtubs. (§11.52 and § 11.69)
Service Description
Service description shall describe, in detail, the goals of the center (§ 11.6), all services provided by the
center (§ 11.123), and any specialized (§ 11.402) or supplemental services (§ 11.403) provided through
contractual or other arrangements.
Policies and Procedures
Policies and procedures shall be personalized to the center and written specifically to help employees
understand their roles and responsibilities within the center.
Criminal History Reports (OAPSA and §§15.141 – 15.147) and Conditions for Employment
Client Admissions (§ 11.4, and § 11.101-11.103) – describing type of persons who may be served;
eligibility criteria; requirements for intake screening, physical examination, TB test, and enrollment
agreement; and other internal procedures for admitting clients.
Client Rights (§ 11.9)
Abuse, Neglect and Exploitation (§ 11.15) and Mandatory Reporting Requirements (in accordance
with OAPSA, Act 13 and Title 6 Aging Chapter 15 Protective Services for Older Adults)
Reporting and Investigating Unusual Incidents (§ 11.16 and § 11.17)
Complaints and Grievances (§ 11.20)
Emergency Procedures and Preparedness Plan (§ 11.21)
02/07/2017
o
Client portable emergency information (§ 11.191) and location (§ 11.21)
o
Procedures for medical emergencies (§ 11.21) and the emergency medical plan (§ 11.134)
o
Procedures for non-medical emergencies (Loss of power, snowstorms, natural disasters, bomb
threats, weapons, etc) (§ 11.21)
o
Evacuation procedures (§ 11.82), including procedures for evacuation of clients with deafness
or hearing impairment (§ 11.86)
o
Evacuation diagram specifying directions for egress (§ 11.82)
o
Means of transportation (§ 11.82 and § 11.134)
o
Emergency shelter location (§ 11.82)
o
Procedures for inoperative fire alarm (§ 11.86)
o
Fire safety and fire drills (§ 11.81 - § 11.90)
o
Emergency staffing plan (§ 11.134)
o
Staff training on emergency procedures and client fire safety training (§ 11.21 & § 11.90)
Smoking Safety (§ 11.91)
Development, Implementation and Review of Individual Care Plans (§ 11.104 - § 11.109)
Client Discharge/Transfer (§§ 11.110 – 11.113)
Personal Care (§ 11.123(2)(i)(C) (Ambulating, toileting, bowel and bladder management, personal
hygiene, eating, drinking, transferring, positioning, etc)
Infection Control (§ 11.13(5) & § 11.123(2)(i)(D))
Medications (§§ 11.141 – 11.146),
Client Records (§ 11.191 – 11.195)
Confidentiality of/Access to Client Records (§ 11.196 - § 11.198)
Source of Client Meals (§ 11.152 and § 11.2f)
Provide a written statement that describes the source of client meals. For example, if using a caterer, state
you are having meals delivered and identify the catering company. If preparing meals in your kitchen, state
that. In addition, the applicant is to consult with their local food safety authority and provide verification of
the following:
Copy of the County Department of Health or other locally issued certificate/license for the center
kitchen, if applicable in your municipality; and
Verification or completion of ServSafe training, or other training required, if applicable in your
municipality; and
Verification that your municipality has no additional kitchen inspection or staff certification
requirements. This can be in the form of an email or letter from the local authority.
Sample Forms
Client Rights (§11.9)
Fire Drills (§ 11.88)
Intake Screening (§ 11.101)
Client Physical Examination (§ 11.102)
Client Enrollment Agreement (§ 11.103),
Care Plan (§ 11.104)
Staff Physical Examination (§ 11.132)
Medication Administration Record (§ 11.143)
Water Source
Centers connected to a public water system shall submit a current water bill or other proof of being
connected to a public water system. Centers that are not connected to a public water system shall submit a
written certification of water tests from the Department of Environmental Protection. (§ 11.59)
Sewer Source
Centers connected to a public sewer system shall submit a current sewage bill or other proof of being
connected to a public sewer system. Centers that are not connected to a public sewer system shall submit
written sanitation approval for their sewage system by the local sewage enforcement official of the
municipality in which the center is located. (§ 11.55)
02/07/2017
* Submit the original forms, signed in ink. Copies will not be accepted.
** You must submit a copy of the approved document. A copy of an application is not acceptable.
Send the complete application packet via First Class Mail or courier to:
PA Department of Aging
Bureau of Quality Assurance
Division of Licensing
Forum Place
th
555 Walnut St, 5
Floor
Harrisburg, PA 17101
02/07/2017
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