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Adult Day Services Forms
 
Applying to become an older adult day services provider

The following three application forms are to be completed by individuals/entities applying to become an older adult day services provider.  These same forms are also used when an existing center reapplies for their annual license.

The following checklists contain the information required to obtain an interim license.

The following checklist contains the fundamental information that will be reviewed during an annual licensure inspection.

The following checklist contains the information required to submit for change of ownership.    

The following checklist contains the information required to be submitted prior to the relocation of a center and information that will be reviewed during a relocation inspection.    

Sample Forms for Older Adults Daily Living Centers

The following sample forms are provided to Older Adult Daily Living Centers by the Department of Aging. Centers are not required to use these forms. However, they do provide a template that includes all information required by regulations.

Reporting unusual incidents and abuse

Older adult daily living centers are required to report unusual incidents on a form specified by the Department. The form and reporting instructions are available below.  Please contact the Division of Licensing directly to receive a Word version of the Unusual Incident Reporting Form.

Older adult daily living center regulations 11.15 and 11.18 highlight the responsibilities of the provider in relation to Abuse and Criminal History Background Checks respectively.  It is important to note that older adult day services providers are also governed by PA Code Title 6 Aging, Chapter 15, Older Adult Protective Services Regulations as it relates to abuse and criminal history background checks for employees.  Older adult daily living centers are defined as facilities in the Chapter 15 regulations.
 
In an effort to provide prospective and current providers with additional information on their requirements relating to abuse and criminal history background checks, the following forms and information are provided:

Requesting a waiver of a regulation

Centers must submit a written request for a waiver to the Department’s Division of Licensing. Waivers granted by the Department will be in writing and retained by the center and be part of the center’s permanent record. Waivers are subject to an annual review by the Department to determine whether acceptable conditions exist for renewal of the waiver.   

For more information contact:

Pennsylvania Department of Aging 
Bureau of Quality Assurance
Division of Licensing 
Forum Place
555 Walnut Street, 5th Floor
Harrisburg, PA  17101
Phone: (717) 214-6716
Fax: (717) 783-0894