IOWA NURSING AND REHAB

HOST HOME APPLICATION – FULL HCBS COMPLIANCE VERSION

Section 1: Applicant Information

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

Section 2: Primary Residence Attestation

I attest the listed address is my primary residence where I live year-round. I understand individuals will share this home as part of a family-like setting. I will notify the agency within 10 days if my residence changes.

Digital Signature Date

Section 3: Comprehensive Home Safety & Compliance Inspection

🔥 Fire Safety

Smoke detectors installed in each bedroom, hallway, and common area Carbon monoxide detectors installed and tested monthly Fire extinguishers placed on each level (inspected within 12 months) Evacuation plan posted and reviewed quarterly

Upload Fire Safety Documentation

🗝️ Structural & Environmental Safety

No exposed wiring or hazards Adequate lighting and ventilation Heating/cooling serviced annually No pests, mold, or unsanitary conditions Water temperature ≤120°F

♿ Accessibility & Mobility

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

💊 Medication & Hazardous Materials

Medications locked and labeled Chemicals/sharps secured Firearms locked separately

🧼 Sanitation & Hygiene

Home clean and odor-free Bathrooms/kitchens sanitized Laundry facilities operational Waste disposal compliant

🚪 Emergency Preparedness

Emergency numbers posted Emergency lighting/flashlights available First aid kit stocked Evacuation drills documented quarterly

Section 7: Automatic Match Result & Placement Rationale

Match Percentage Match Level Auto-Generated Placement Rationale

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