Form AGL-08 "Older Adult Daily Living Center Operations and Demographics Form" - Pennsylvania

What Is Form AGL-08?

This is a legal form that was released by the Pennsylvania Department of Aging - a government authority operating within Pennsylvania. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on September 30, 2016;
  • The latest edition provided by the Pennsylvania Department of Aging;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of Form AGL-08 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Aging.

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Download Form AGL-08 "Older Adult Daily Living Center Operations and Demographics Form" - Pennsylvania

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1
OLDER ADULT DAILY LIVING CENTERS
CENTER OPERATIONS AND DEMOGRAPHICS FORM (AGL-08)
LICENSE NUMBER:
**NAME OF LEGAL ENTITY:
**NAME OF CENTER:
**ADDRESS OF CENTER:
CENTER WEBSITE:
COUNTY:
NAME OF CENTER DIRECTOR:
EMAIL OF CENTER DIRECTOR
PHONE # OF FACILITY
.
**Enter the name of the legal entity, center, and address as stated on the current license if there have been no changes
GENERAL INFORMATION
A. Target Population Served: (Check all that apply)
Aging ____ DD/ID Under Age 60 ____ DD/ID Age 60 & Over _____ Other ____ (Explain)
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016
1
OLDER ADULT DAILY LIVING CENTERS
CENTER OPERATIONS AND DEMOGRAPHICS FORM (AGL-08)
LICENSE NUMBER:
**NAME OF LEGAL ENTITY:
**NAME OF CENTER:
**ADDRESS OF CENTER:
CENTER WEBSITE:
COUNTY:
NAME OF CENTER DIRECTOR:
EMAIL OF CENTER DIRECTOR
PHONE # OF FACILITY
.
**Enter the name of the legal entity, center, and address as stated on the current license if there have been no changes
GENERAL INFORMATION
A. Target Population Served: (Check all that apply)
Aging ____ DD/ID Under Age 60 ____ DD/ID Age 60 & Over _____ Other ____ (Explain)
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016
2
B. Provide a brief narrative of any specialized services offered beyond the required core services.
This includes those services directly offered by the center, or if space is provided to specialized
service providers. Refer to regulations 11.402 & 11.403 for more information:
C. Geographical Service Boundaries - Identify by county, municipality, etc., the service area from
which the facility draws clients.
D. Indicate in CHART 1 all funding sources: (e.g., PDA Waiver, Options, County MH/ID/DD, VA,
Private Pay, Long Term Care Insurance, LIFE, etc.) and the approximate number of clients
currently funded by these sources. If enrolled as a provider for any specific funding source but
presently not serving any clients through that funding source, enter 0:
CHART 1 – CURRENT NUMBER OF CLIENTS ENROLLED BY FUNDING SOURCE
Funding Source
# Clients
Funding Source
# Clients
Served
Served
Private Pay
ODP Waiver
OPTIONS
Aging Waiver
VA
OBRA Waiver
Private Insurance
Other Waiver (specify
name) _____________
County MH/MR
Other ______________
LIFE
Other ______________
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016
3
CHART 2 – CURRENT CLIENT DEMOGRAPHICS
Total
Black
White
Hispanic
Asian
Other
M
F
M
F
M
F
M
F
M
F
M
F
CHART 3 – TOTAL CLIENT ADMISSIONS WITHIN THE PAST 12 MONTHS
Total
Black
White
Hispanic
Asian
Other
M
F
M
F
M
F
M
F
M
F
M
F
CHART 4 – CURRENT CENTER BOARD MEMBERS (If Applicable)
BOARD MEMBER
RACE
SEX
HANDICAPPED
GROUP
DATE
YES OR NO
REPRESENTED
TERM
(IF ANY)
EXPIRES
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016
4
Does the center have a policy or criteria used to select Board members?
If Yes ____, please describe.
No ____
CHART 5 – CURRENT STAFF DEMOGRAPHICS
Job Title
Total
Black
White
Hispanic
Asian
Other
M
F
M
F
M
F
M
F
M
F
M
F
** I certify that to the best of my knowledge the above information is correct.
______________________________________________________
Signature of Center Director
Date
th
Bureau of Quality Assurance / Division of Licensing | 555 Walnut Street, 5
Fl. | Harrisburg, PA 17101 | 717.214.6716 |
www.aging.pa.gov
09/30/2016