DEPARTMENT OF HEALTH SERVICES STATE OF WISCONSIN

Division of Quality Assurance Page 1 of 5

F-02634A (03/2020)
ADULT FAMILY HOME (AFH)
INITIAL SURVEY CHECKLIST
Name – Facility Date Form Completed (MM/dd/yyyy)

Street Address City County Zip Code

The following items will be reviewed during the initial licensing survey and tour of the facility.
Disclaimer: The statements in this document paraphrase the cited administrative rules. Refer to the language of the Wisconsin
Administrative Code for the exact wording of the cited rules. This list should not be considered all-inclusive. The applicant is
responsible for knowing and meeting all requirements.

Y N N/A

HOME – DHS § 88.05

1. AFH is located in a residential area which is typical of residential areas in that community.
2. Adult family home is physically accessible to all residents of the home.

3. Residents are able to easily enter and exit the home, get to their sleeping rooms, a bathroom, the kitchen, and all
common living areas in the home, and easily move about in the home.

4. First floor of the home has at least two means of exiting which provide unobstructed access to the outside. Exits
are doors.

If a resident is not able to walk at all or able to walk only with difficulty or only with the assistance of crutches, a cane, or
walker, or is unable to easily negotiate stairs without assistance – DHS 88.05(2):
1. Exits from the home are ramped to grade with a hard surfaced pathway with handrails.

2. All entrance and exit doors and interior doors serving all common living areas and all bathrooms and bedrooms
used by a resident not able to walk at all have a clear opening of at least 32 inches.

3. Toilet and bathing facilities used by a resident not able to walk at all have enough space to provide a turning
radius for the resident’s wheelchair and provide accessibility appropriate to the resident’s needs.

4. Grab bars are provided for toilet and bath fixtures in bathing and toilet facilities used by residents not able to walk
at all or only with difficulty, or by other residents with physical limitations that make transferring difficult.

5. Any resident who has either manual strength or dexterity limitations, the home has levered handles on all doors,
bathroom water fixtures and other devices normally used by that resident if these can be replaced and if
replacement is readily achievable.

6. Any resident who is unable to easily negotiate stairs without assistance has his or her bedroom, toilet and bathing
facilities, and all common living areas on the first floor.

HOME ENVIRONMENT – DHS § 88.05(3)

1. Home is safe, clean, well maintained, and provides a homelike environment.

2. Home is free from hazards and kept uncluttered and free of dangerous substances, insects, and rodents.

3. Where a public water supply is not available, water samples should be taken from the well and tested at the state
laboratory of hygiene or other laboratory approved under Chapter NR 149 at least annually.

4. Home has functioning support services, including refuse removal and access to laundry facilities.

5. Home has ventilation for health and comfort. There is at least one window which is capable of being opened to
the outside in each resident sleeping room and each common room used by residents. Windows used for
ventilation are screened during appropriate seasons of the year.

6. There are large enough common areas with sufficient furnishings so that all occupants of the home can
comfortably share the space at the same time.

7. Home is not used for any business purpose that regularly brings customers to the home so that the residents’
use of the home as their residence or the residents’ privacy is adversely affected.
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The heating systems should be inspected as follows, with written documentation of inspections maintained in the home:

1. An oil furnace should be inspected and serviced every two years by a heating contractor.
2. A gas furnace should be inspected and serviced every three years by a heating contractor or local utility
company.

3. If the home has a wood-burning stove or fireplace, there is a flue separate from the one used by a gas or oil fired
furnace or boiler.

KITCHEN AND DINING – DHS § 88.05(3)(h) 2-3

1. There is sufficient space and equipment in the kitchen for the sanitary preparation and storage of food.

2. Dining room or other dining area is large enough so all household members may dine together.

3. Food is prepared and stored in a sanitary manner – DHS § 88.07(4)(c).

RESIDENT BATHROOMS

1. There is at least one bathroom with at least one sink, stool and shower or tub for every 8 household members
and towel racks with sufficient space for each household member – DHS § 88.05(3)(h)4.

2. Door of each bathroom has a lock which can be opened from the outside in an emergency – DHS § 88.05(3)(i).

3. Water temperature is not above 115 degrees at all fixtures accessible to the resident.

RESIDENT BEDROOMS
1. Resident bedrooms accommodate no more than two persons. A resident bedroom has a floor area of at least 60
square feet per resident in shared bedrooms and 80 square feet in single occupancy rooms. For a person
requiring a wheelchair, the bedroom space is 100 square feet for that resident – DHS § 88.05(3)(h)5.
2. Each resident is provided conveniently located, individual storage space in the resident’s bedroom sufficient for
hanging clothes and for storing clothing, toilet articles, towels, and other personal belongings – DHS § 88.05(3)
(h)6.
3. Resident’s bedroom may not be used by anyone else to get to any other part of the home – DHS § 88.05(3)(j).

4. Persons of the opposite sex are not required to occupy the same sleeping room; however, accommodations will
be made for couples who wish to share a sleeping room – DHS § 88.05(3)(k).
5. A resident’s bedroom provides comfort and privacy, is enclosed by full height walls, and has a rigid door that the
resident can open and close – DHS § 88.05(3)(L).
6. A separate bed for each resident unless a couple chooses to share a bed. The bed shall be clean, in good
condition, and of proper size and height for the comfort of the resident – DHS § 88.05(3)(n)1.
7. Appropriate bedding and linens are maintained in a clean condition – DHS § 88.05(3)(n)2.
8. If a resident regularly sleeps in a basement bedroom or in a bedroom above the second floor of a single family
dwelling, there are two exits to the grade from that floor level – DHS § 88.05(3)(m).
SAFE PHYSICAL ENVIRONMENT – DHS § 88.10(3)(L)

Clothes dryer vented with rigid metal ducting.

FIRE EXTINGUISHERS – DHS § 88.05(4)(a)

1. Home is equipped with one or more fire extinguishers on each floor.

2. Each required fire extinguisher has a minimum 2A, 10-B-C rating.

3. All required fire extinguishers are mounted.

4. Fire extinguisher is located at the head of each stairway and in or near the kitchen except that a single fire
extinguisher located in close proximity to the kitchen and the head of a stairway may be used to meet the
requirement for an extinguisher at each location.
5. Each required fire extinguisher is maintained in readily usable condition, inspected annually by an authorized
dealer or the local fire department and has an attached tag showing the date of the last dealer or fire department
inspection.
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SMOKE DETECTORS – DHS § 88.05(4)(b)
1. Home is equipped with one or more single station battery operated, electrically interconnected or radio signal
emitting smoke detectors on each floor level.
2. Required smoke detectors are in each habitable room except the kitchen and bathroom.

3. At the head of each open stairway

4. At the door leading to every enclosed stairway

5. On the ceiling of the living room or family room

6. On the ceiling of each sleeping room

7. In the basement

PRESCRIPTION MEDICATIONS – DHS § 88.07(3)

1. Every prescription medication shall be securely stored.

2. Every prescription medication shall remain in its original container as received from the pharmacy.

3. Every prescription medication shall be stored as specified by the pharmacist.

TELEPHONE – DHS § 88.05(5)

1. Residents have access to a non−pay telephone for residents to make and receive telephone calls.
2. Emergency telephone numbers, including numbers for the fire department, police, hospital, physician, poison
control center, and ambulance, are located on or near each telephone.
PLACEMENT – DHS § 88.06(1)(b)
A copy of Chapter DHS 88 is available upon request by the prospective new resident or that person's guardian, if
any.
HOUSEHOLD PETS – DHS § 88.05(6)
1. Pets may be allowed on the premises of an adult family home. Cats, dogs, and other pets vulnerable to rabies
which are owned by any resident or household member shall be vaccinated as required under local ordinance. A
pet suspected of being ill or infected shall be treated immediately for its condition or removed from the home.
2. Pens and cages shall be kept clean.

3. Pets shall be kept and handled in a manner which protects the well−being of both residents and pets.

4. The wishes of residents shall be considered before a new pet is allowed on the premises.
HOME AND COMMUNITY-BASED SERVICES (HCBS)
Surveyor is to verify the following if facility is requesting an HCBS compliance review to be eligible to serve individuals receiving
Medicaid waiver funding.
1. If facility is not requesting an HCBS compliance review, skip to the next section.

2. Provide lockable key entry doors on all resident rooms and individual keys to all residents – 42 CFR 441.301(c)(4)
(vi)(B)(1).
If any of the following conditions exist, the facility meets the definition of heightened scrutiny and notification will be made
to the Division of Medicaid Services (DMS). DMS will complete the HCBS compliance review working with the Centers for
Medicare & Medicaid Services (CMS).

A. The facility is within (under the same roof as) a building that houses a publicly or privately operated facility which
provides inpatient institutional care [skilled nursing facility (SNF), intermediate care facility for individuals with
intellectual disabilities (ICF/IID), institute for mental disease (IMD), hospital] 42 CFR 441.301(c)(5)(v).

B. The facility is located on the grounds of, or immediately adjacent to, a building that is a public institution which
provides inpatient institutional care [skilled nursing facility (SNF), intermediate care facility for individuals with
intellectual disabilities (ICF/IID), institute for mental disease (IMD), hospital] 42 CFR 441.301(c)(5)(v).
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Miscellaneous Initial Licensing Review and Discussion Items

1. Wis. Admin. Code Chapter DHS 88

2. Other relevant code or statute requirements (e.g.; DHS 12, DHS 13, Chapter 50 WI Stat., and DHS 94):
DHS 12 requirements: Criminal background checks on service providers.
a. Background Information Disclosure (BID) (DHS form F-82064)
b. Employee and Contractor Background Check Process
DHS 13 requirements: Misconduct reporting and investigations.
a. Wisconsin Caregiver Program Manual (DQA publication P-00038)
b. Wisconsin Caregiver Program: Misconduct Reporting Requirements (DQA publication P-63158)

3. Changes to be Reported to Licensing Agency – DHS § 88.03(5)

Reporting Requirements for Assisted Living Facilities (DQA publication P-02007)

4. Training – DHS § 88.04(5)

a. The licensee and each service provider is to complete 15 hours of training approved by the licensing agency
related to health, safety, and welfare of residents; resident rights; and treatment appropriate to residents served
prior to or within six months after starting to provide care. This training is to include training in fire safety and first
aid.
b. The licensee and each service provider is to complete eight hours of training approved by the licensing agency
related to the health, safety, welfare, rights, and treatment of residents every year beginning with the calendar
year after the year in which the initial training is received.

5. Service Provider and Licensee – DHS § 88.04

a. A service provider is to be at least 18 years of age.
b. Obtain documentation from a physician, a registered nurse, or a physician's assistant indicating that the licensee
and any service provider has been screened for illness detrimental to residents, including for tuberculosis. The
documentation is to be completed within 90 days before the start of providing service. The documentation shall be
kept confidential except that the licensing agency shall have access to the documentation for verification - DHS §
88.04(2)(g)1.

6. Service Provider and Licensee Records – DHS § 88.09(2)

a. Maintain and keep up to date a separate personnel record for each service provider. Ensure that all service
provider records are adequately safeguarded against destruction, loss, or unauthorized use.
b. A service provider record is to include all of the items listed in DHS § 88.09(2)(a)1-11.
c. A service provider’s record shall be available while the service provider is employed by the home and at least for
three years after ending employment.

7. Resident Record – DHS § 88.09(1)

a. Maintain a record for each resident. Resident records shall be maintained in a secure location within the home to
prevent unauthorized access.
b. A resident's record is to include all of the items listed in DHS § 88.09(1)(d)1-11., including pre-admission
assessment, individual service plan, documentation of physician’s orders and visits, health screening, medication
administration records, resident evacuation assessment.
c. Licensee shall retain a resident’s record for at least seven years after the resident’s discharge.

8. Fire Safety – DHS § 88.05(4)

a. Fire extinguishers inspected annually by an authorized dealer or the local fire department and have an attached
tag showing the date of the last dealer or fire department inspection – DHS § 88.05(4)(a).
b. Smoke Detectors tested monthly – DHS § 88.05(4)(b)2.
c. Fire Safety Evacuation Plan – DHS § 88.05(4)(d)2.
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(1) Each resident is to be evaluated annually for evacuation time, using the department’s form. All service
providers who work on the premises shall be made aware of each resident having an evacuation time of
more than two minutes. Resident Evacuation Assessment (DQA form F-62373)
(2) Conduct semi-annual fire drills with all household members with written documentation of the date and
evacuation time for each drill maintained by the home.

9. Electronic Statement of Deficiencies (E-sod)/Electronic Plan of Correction (E-poc) Process

10. Online License and Certification Continuations via e-Licensure (DQA publication P-01731)

11. Communicating with the Bureau of Assisted Living

Division of Quality Assurance - Bureau of Assisted Living Regional Offices

12. DQA Email Subscription Service