Attachment 1 "Older Adult Daily Living Center Request for Waiver of Regulation 6 Pa. Code 11.5" - Pennsylvania

What Is Attachment 1?

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 January 1, 2013;
  • 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 Attachment 1 by clicking the link below or browse more documents and templates provided by the Pennsylvania Department of Aging.

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Download Attachment 1 "Older Adult Daily Living Center Request for Waiver of Regulation 6 Pa. Code 11.5" - Pennsylvania

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Attachment 1
OLDER ADULT DAILY LIVING CENTER
REQUEST FOR WAIVER OF REGULATION
6 PA. CODE § 11.5
NAME OF LEGAL ENTITY:
NAME OF DIRECTOR/ADMINISTRATOR:
ADDRESS OF LEGAL ENTITY:
COUNTY:
NAME OF CENTER (IF DIFFERENT FROM LEGAL ENTITY):
LICENSE #:
ADDRESS OF CENTER (IF DIFFERENT FROM LEGAL ENTITY):
LICENSED CAPACITY:
DATE OF WAIVER REQUEST:
NAME OF PERSON COMPLETING FORM:
Annual Inspection and Announced Inspection
6 PA. CODE CH. 11 SECTION TITLE (REGULATION HEADING):
6 PA. CODE CH. 11 SECTION/SUBSECTION NUMBER (COMPLETE A SEPARATE FORM FOR EACH
§§ 11.241 & §§ 11.242
SECTION/SUBSECTION/PARAGRAPH):
WHAT IS THE REASON FOR THIS REQUEST?*:
(Name of ATF) is licensed by the Department of Human Services (DHS) Office of Developmental Programs
under 55 Pa. Code Chapter 2380 as an Adult Training Facility. We are requesting a waiver of 6 Pa. Code §§
11.241 and 11.242 per Aging Program Directive #13-20-01.
EXPLAIN WHY THERE IS NO JEOPARDY TO THE CLIENT(S) IF THIS WAIVER IS GRANTED*:
(Name of ATF) is licensed as an ATF by the DHS Office of Developmental Programs and is subject to annual
inspection and licensure by Commonwealth staff. Client health & safety is monitored by authorized agents of
DPW.
EXPLAIN HOW ONE OR MORE CLIENTS WILL BENEFIT FROM THE WAIVER OF THIS REGULATION*:
The center will no longer have to allocate time and resources for duplicative inspection-related requirements
that are in some cases not applicable or in direct conflict with 55 Pa. Code Chapter 2380 regulations.
HAVE ANY OTHER WAIVERS BEEN GRANTED TO YOUR
SECTION(S) OR SUBSECTION(S) PREVIOUSLY WAIVED:
CENTER UNDER CHAPTER 11 REGULATIONS?
YES
NO
IS (ARE) WAIVER(S) STILL VALID?
YES
NO
*ATTACH ADDITIONAL PAGES IF NECESSARY
Commonwealth of Pennsylvania
Waiver Request Form
PA Department of Aging
01/13
Attachment 1
OLDER ADULT DAILY LIVING CENTER
REQUEST FOR WAIVER OF REGULATION
6 PA. CODE § 11.5
NAME OF LEGAL ENTITY:
NAME OF DIRECTOR/ADMINISTRATOR:
ADDRESS OF LEGAL ENTITY:
COUNTY:
NAME OF CENTER (IF DIFFERENT FROM LEGAL ENTITY):
LICENSE #:
ADDRESS OF CENTER (IF DIFFERENT FROM LEGAL ENTITY):
LICENSED CAPACITY:
DATE OF WAIVER REQUEST:
NAME OF PERSON COMPLETING FORM:
Annual Inspection and Announced Inspection
6 PA. CODE CH. 11 SECTION TITLE (REGULATION HEADING):
6 PA. CODE CH. 11 SECTION/SUBSECTION NUMBER (COMPLETE A SEPARATE FORM FOR EACH
§§ 11.241 & §§ 11.242
SECTION/SUBSECTION/PARAGRAPH):
WHAT IS THE REASON FOR THIS REQUEST?*:
(Name of ATF) is licensed by the Department of Human Services (DHS) Office of Developmental Programs
under 55 Pa. Code Chapter 2380 as an Adult Training Facility. We are requesting a waiver of 6 Pa. Code §§
11.241 and 11.242 per Aging Program Directive #13-20-01.
EXPLAIN WHY THERE IS NO JEOPARDY TO THE CLIENT(S) IF THIS WAIVER IS GRANTED*:
(Name of ATF) is licensed as an ATF by the DHS Office of Developmental Programs and is subject to annual
inspection and licensure by Commonwealth staff. Client health & safety is monitored by authorized agents of
DPW.
EXPLAIN HOW ONE OR MORE CLIENTS WILL BENEFIT FROM THE WAIVER OF THIS REGULATION*:
The center will no longer have to allocate time and resources for duplicative inspection-related requirements
that are in some cases not applicable or in direct conflict with 55 Pa. Code Chapter 2380 regulations.
HAVE ANY OTHER WAIVERS BEEN GRANTED TO YOUR
SECTION(S) OR SUBSECTION(S) PREVIOUSLY WAIVED:
CENTER UNDER CHAPTER 11 REGULATIONS?
YES
NO
IS (ARE) WAIVER(S) STILL VALID?
YES
NO
*ATTACH ADDITIONAL PAGES IF NECESSARY
Commonwealth of Pennsylvania
Waiver Request Form
PA Department of Aging
01/13