Host Home Application

Full Legal Name

Date of Birth

Gender

Phone Number

Email Address

Social Security Number (Last 4)

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

🗝️ 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 4: Mandatory Iowa HCBS Host Home Trainings (Certificates + Auto-Expiry)

Training Compliance Status

Section 5: Host Home Placement Readiness (No Member Data)

Host Provider Name

Behavior Support Capacity (0-3)

Medical Support Capacity (0-3)

Home Accessibility

Night Supervision Available?

Medication Support Available?

Primary Language

Smoking in Home?

Pets in Home?

Firearms Present

City / Area

Section 7: Automatic Match Result & Placement Rationale

Overall Compliance + Readiness Decision Auto-Generated Placement Rationale

Section 8: Admin Compliance Dashboard

TRAINING: NON-COMPLIANT

READINESS: REVIEW

OVERALL: HOLD

❌ Submission blocked. Resolve training compliance blockers and HOLD-level readiness risks.

IOWA NURSING AND REHAB