Fillable Commonwealth of Massachusetts Qualified Residence Certification Form Assisted Living

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Commonwealth of Massachusetts Qualified Residence Certification Form Assisted Living

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The Commonwealth of Massachusetts Qualified Residence Certification Form Assisted Living form is 2 pages long and contains:

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File type: PDF

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Money Follows the Person
Qualified Residence Certification Form
Assisted Living
Transition Coordinators will use this form to verify that the MFP Demonstration Enrollee residence in an apartment unit
located within an assisted living setting meets the definition of an MFP Qualified Residence, as defined under the MFP
Demonstration. Transition Coordinators will initial next to each item and sign at the bottom confirming that the
apartment unit meets all items on the list. This form will then be maintained in the Enrollee file.
Enrollee Name:
Full Address of Qualified Residence:
Transition Coordinator Please Initial:
________1. A Walk Through Checklist has been completed and signed by the enrollee and the landlord which indicates
any existing damage to the unit. If there appear to be any health or safety issues with the unit, please
contact the local Board of Health.
________2. Aging in place is a common practice of the assisted living facility
i
________3. No more than 4 unrelated individuals are sharing a unit.
________4. Enrollee and assisted living provider have a lease outlining the:
o Amount of rent
o Term of Lease
o Amount of security deposit, if applicable
o Rights regarding security deposit, if applicable
o Rights regarding termination
o All the contact information including name, address, and phone number of the landlord or any person
responsible for maintaining the property
o Procedure for resolving any conflict regarding care plan
o Procedure for appealing any termination from the property
The following clauses are NOT in the lease:
• A clause which allows for the participant to be assigned or moved to a different unit at the assisted living
provider’s discretion
• A clause which requires services be provided by the assisted living’s provider of choice
• A clause which requires services be provided
• A clause which states the participant must notify the assisted living provider of absences from the
facility
ii
_______5. Please certify the apartment has the following which the participant has full control over:
o Living area
o Sleeping Area
o Bathing area
o Cooking area
Print
Clear
______6. The apartment has a lockable* access and egress.
o Full control of apartment access and egress must be present.
*example: key pad, ID card, watchman, or key
_______7. Based on answers documented above, the assisted living apartment meets all requirements as an MFP
Qualified Residence, as defined under the MFP Demonstration.
By signing below, I certify that all of the above requirements have been met.
Signature of Transition Coordinator _________________________________
Date __________________
i
a resident contract may not be terminated due to declining health or increased care needs
ii
May be in related policies in the assisted living provider operating practices
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Commonwealth of Massachusetts Qualified Residence Certification Form Assisted Living

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Completed 19 May 2020

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