Admission Checklist

MHANC CLP Community Residences

Before Date of Admission, Complete:

 Self-Preservation Test

For HUD-Funded Programs Only, Complete & Provide to Stanan Management:

 Criminal/Sex Offender Background Check

On Date of Admission, Complete/Obtain:

 Medications
o Obtain Resident’s Medication Supplies
o Initial Medication Count
o Input Medication into Foothold
o Medication Monitoring (Foothold, Place in Medication Binder)
o Put Medication Supplies in Bag and Place in Medication Cabinet
o Medication Binder (with Contents & Section Dividers)
 Admission Note (Foothold)
 Residency Agreement (of given year)
 WRAP/Crisis Plan
 Emergency Disaster Form
 Orientation Form
 Grievance Acknowledgment
 [Provide Resident with Resident Handbook]
 Resident Handbook Form
 AMD (Admission-Movement-Discharge) Form
 Record of Valuables
 HIPAA Privacy Notice
 HIPAA Acknowledgment
 Cultural Data Form
 Health Care Proxy or Health Care Proxy Declination Form

Within the First Week, Complete/Obtain:

 Chart Binder (with Table of Contents & section dividers)
 Consents (Foothold)
 Face Sheet
 Birth Certificate
 Social Security Card
 Social Security Administration Award Letter
 Medicaid Card & Any Other Health Insurance Cards (e.g., Medicaid, Managed Care)
 General Medical Physical
 Proof of Negative for Tuberculosis: PPD, QuantiFERON-TB Gold or Chest X-Ray

For HUD-Funded Programs Only, Complete/Obtain & Provide to Stanan Management, Retain Copies in
HUD Binder:
 Birth Certificate
 Social Security Card
 Social Security Administration Award Letter
 Bank Account Statements (of the past six months) & Any Other Income or Assets Documentation
 Room Inspection Form
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