IOWA NURSING AND REHAB

HOST HOME APPLICATION – FULL HCBS COMPLIANCE & AUTO-MATCHING

Section 1: Applicant Information

Full Legal Name Date of Birth Gender Phone Number Email Address Social Security Number (Last 4) Residential Address Mailing Address (if different) Provider Type

Section 2: Primary Residence Attestation

Primary residence year-round Family-like shared setting Notify agency of residence change within 10 days

Digital Signature Date

Section 3: Comprehensive Home Safety & Compliance

🔥 Fire Safety

Smoke detectors installed Carbon monoxide detectors Fire extinguishers on each level Evacuation plan posted

🗝️ Structural & Environmental Safety

No exposed hazards Adequate lighting/ventilation Heating/cooling serviced annually Water temperature ≤120°F

♿ Accessibility & Mobility

Accessible entry Grab bars / non-slip flooring Clear 36\" pathways Accessible bedroom/bathroom

💊 Medication & Hazardous Materials

Medications locked Chemicals secured Firearms locked separately

🧼 Sanitation & Hygiene

Home clean and sanitary Bathrooms/kitchens sanitized Laundry facilities operational

🚪 Emergency Preparedness

Emergency numbers posted First aid kit stocked Evacuation drills documented

Section 4: Host Home Capability Profile (Used for Matching)

🩺 Medical Support

Medication administration Seizure monitoring Mobility / transfers

🧠 Behavioral & Supervision

1:1 supervision Elopement risk De-escalation trained

🏠 Environment

Wheelchair accessible Private bedroom Low-stimulation environment

Section 5: Automatic Match Result & Placement Rationale

Match Percentage Match Level Auto-Generated Placement Rationale

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