Family Systems

Dear Licensing Worker:

We have prepared and organized documents that are commonly used in licensing for family systems programs. The documents are divided up by general licensing information, by specific programs, and by background studies information.

General Licensing
Family Child Care

Child Foster Care

Adult Foster Care

Family Adult Day Services

Background Studies

Child-Caring-Placing Agencies

Family Systems Applications

Below are the Rules and Statutes that are pertinent to each family systems program. We suggest that you visit the Revisor’s Website at https://www.revisor.leg.state.mn.us/pubs/ and print a copy of each Statute and Rule applicable to the program(s) you license.

County Agencies - Minnesota Rule, parts 9543.0010 to 9543.0150

Family Child Care

Minnesota Statutes, Chapter 245A (Human Services Licensing Act)
Minnesota Statutes, Chapter 245C (Human Services Background Studies Act)
Minnesota Rules, parts 9502.0300 to 9502.0445 (Rule 2)

Child Foster Care

Minnesota Statutes, Chapter 245A
Minnesota Statutes, Chapter 245C
Minnesota Rules, parts 2960.3000 to 2960.3340

Adult Foster Care

Minnesota Statutes, Chapter 245A
Minnesota Statutes, Chapter 245C
Minnesota Rules, parts 9555.5050 to 9555.6265 (Rule 203)

Family Adult Day Services

Minnesota Statutes, Chapter 245A
Minnesota Statutes, Chapter 245C
Minnesota Statutes, section 245A.143

Private Child Placing Agencies

Minnesota Rules, parts 9545.0755 to 9545.0845 – Rule 4
Minnesota Rules, parts 9543.0010 to 9543.0150 – Rule 13 – for those private agencies that license Child Foster Care Programs

Child Foster Care

Minnesota Statutes, Chapter 245A
Minnesota Statutes, Chapter 245C
Minnesota Rules, parts 2960.3000 to 2960.3340

County Licensing Functions under 245D Videoconference PowerPoint

Table of Contents

General Licensing – Section A

A1 Family Systems Technical Assistance Guide (4-14)
A2 Family Systems Phone List (4-14)

A4 Some Frequently Used Resources (3-14)

A5 County and Private Agency Delegated Authority and Roles (3-08)

A6 DHS Licensing Functions (6-12)

A8 Data Privacy Guidelines Regarding Family Systems Programs (4-14)

A13 Considerations for Less than a Two Year License (3-08)

A14 Appropriate Action to Take at the Expiration of a License (10-12)

A15 License Extension Request/Closure Pending Investigation Form (10-12)

A16 Request for Temporary Provisional License (6-10)

A17 Non-Delegated Variances and Variance Request Procedures (1-07)

A18 DHS-Family Systems Variance Request Form (9-14)

A19 Variance Request- Form (DHS 3141) (6-07)

A20 Correction Orders/ Reconsideration of Correction Orders – General Information (1-07)
A21 Correction Order – Sample (10-12)

A22 Correction Order- Form (10-12)

A23 Complaint Log (11-12)

A24 Licensing Tracking Log (3-08)

A25 Negative Actions (9-13)

A26 Negative Action Recommendation Sample Letters:
A26a Recommendation for a Denial of a Child Foster Care License (6-13)

A26b Recommendation for a Temporary Immediate Suspension of a Family Child Care License (6-13)

A26c Recommendation for a Conditional of a Family Child Care License (6-13)

A26d Recommendation for a Revocation of an Adult Foster Care License (6-13)

A26e Recommendation for a Fine of a Family Child Care License (6-13)

A27 Temporary Immediate Suspension Protocol (3-08)

A28 Affidavit of Personal Service Sample (1-13)
A29 Comparison of Requirements by Rule (7-14)

A30 Negative Action Notification Letter Examples (7-12)

A31 Drug and Alcohol Policy Sample for License Holder (2-13)

A32 Grievance Policy Sample for License Holder (2-13)

A33 Fire Marshal Links to Forms and Information (7-13)

A34 Home Safety Checklist (12-13)
A35 Home Safety Checklist Child Foster Care Addendum (4-14)

A37 Licensing Intake Complaint Form (10-13)

Family Child Care – Section B

B1 Unlicensed Family Child Care Letter – Sample (6-12)
B2 Maltreatment of Minors Reporting Policy for Licensed Family Child Care Programs (11-11)

B3 Family Child Care Exclusions from Licensure (3-08)

B4 Family and Group Child Care Age Group Definitions (8-14)

B5 Special Family Child Care Homes (12-11)

B7 Family Child Care Licensing Checklist (8-14)

B8 Monthly Crib Safety Inspection Form (6-14)

B9 Statutory Requirements Regarding Wading Pools and Swimming Pools (11-12)
B10 Family Child Care Best Practices Guide for Wading Pools/ Pool Questions and Answers (3-08)

B11 Fact Sheet – Risks of Wading Pools at Child Care Homes (3-08)

B12 Fact Sheet – Risks of Swimming Pools at Child Care Homes (5-13)

B13 Wading Pool Letter and Parent Permission Form (5-12)

B14 Swimming Pool Letter (5-12)

B15 Swimming Pool Parent Permission Form (5-13)

B18 Prohibition Letters (6-12)

B19 Prohibition Flowchart page 1 (3-09)

B20 Prohibition Flowchart page 2 (3-09)

B21 Physicians Directive for Alternative Infant Sleep Position (7-13)
B22 Parent Consent for Swaddling (7-13)

B23 Family Child Care Admission and Arrangement Form (11-13)

B24 Family Child Care Liability Insurance Notice to Parents/Guardians (7-13)

B25 Optional form for parent statement; infant less than six months of age regularly rolling over (3-14)

Child Foster Care – Section C

C1 CFC Statement of Intended Use (10-13)
C2 Foster Care Medical Monitoring Equipment Training and Skills Form (4-07)

C3 Child Foster Care Capacity Chart (3-08)

C4 Child Foster Care Maximum Capacity Variance Request Form (3-08)

C5 CFC Exemptions Under Dually Licensed CFC and 245D HCBS Programs (4-14)

C6 Procedures for Emergency Relative Foster Care Placements Bulletin (8-11)

C7 Emergency Relative Placement Foster Care Referral Form (7-07)

C8 2960 Child Foster Care Licensing Checklists:
C8a Family Child Foster Care Licensing Checklist (11-12)

C8b Corporate Child Foster Care Additional Requirements Licensing Checklist (3-08)

C8c Treatment Child Foster Care Additional Requirements Licensing Checklist (3-08)

C10 Expiration of Disqualification Variance- Child Foster Care (1-13)

C11 Annual Evaluation of Licensed Foster Home (5-10)

C12 Commissioner’s Designated Format for Completion of an Adoption & Foster Care Study Cover/Instructions (4-11)
C13 Minnesota Adoption and Foster Care Home Study – Application (9-11)

C14 Minnesota Adoption and Foster Care Individual Fact Sheet (3-10)

C15 Minnesota Adoption and Foster Care – Home Study Agency Process Checklist (3-10)

C16 Minnesota Adoption and Foster Care Home Study Assessment (4-11)

C17 Minnesota Adoption and Foster Care Home Study Assessment Update (4-11)

C18 Minnesota Adoption and Foster Parent Family Disaster Plan (12-09)

C19 Agreement Between Foster Parents and Placement Agency (1-10)

C20 Discipline Policy Sample for License Holder (6-12)

C21 Foster Residence Settings – Home Study Assessment and Assessment Update Introduction (6-12)

C22 Foster Residence Settings – Home Study Assessment Instructions (2-13)

C23 Foster Residence Settings – Home Study Assessment Update Instructions (2-13)

C24 Variances to MN Rules for CFC Relative Placements (9-13)

Adult Foster Care – Section D

Please note – several of the forms developed for Adult Foster Care have been removed from the site temporarily.  Each form is being reviewed by Family Systems in light of the new 245D legislation.  Updates will be provided to agency licensing workers via the license renewal report.

D1 AFC Exemptions under Dually Licensed AFC and 245D HCBS Programs (4-14)
D2 Emergency Crisis Respite 5th Bed Variance:
D2a Instructions for completing an Emergency Crisis Respite 5th Bed Variance (1-14)

D2b Emergency Crisis Services 5th Bed Variance Request Form – Initial Request (1-14)

D2c Emergency Crisis Services 5th Bed Variance Request Form – General Request (1-14)
D3 Variance Checklist for Adult Foster Care- Alternate Overnight Supervision (3-08)

D4 Rule 203 Adult Foster Care Licensing Checklists:
D4a Rule 203 Family and Corporate Adult Foster Care Licensing Checklist without HCBS (7-14)

D4b Rule 203 Family Adult Foster Care Licensing Checklist with HCBS (7-14)

D4c Rule 203 Corporate Adult Foster Care Licensing Checklist with HCBS (7-14)

D5 Guidelines to Developing a Program Abuse Prevention Plan (12-13)

D6 Program Abuse Prevention Plan (12-13)

D13 Individual Abuse Prevention Plan (IAPP) (12-13)

D14 Individual Resident Placement Agreement (12-13)

D15 AFC License for Five Checklist (12-13)

D17 Adult Foster care Program Plan (12-13)

D18 Expiration of Disqualification Variance – Adult Foster Care (1-13)

D19 Foster Care Medical Monitoring Equipment Training and Skills Form (4-07)

D20 AFC Alternate Overnight Supervision Technology Checklist (12-13)

D26 Adult Foster Care Mental Health Certification:
D26a Instructions for Completing a Request for Adult Foster Care Mental Health Certification (3-14)

D26b Request for Adult Foster Care Mental Health Certification (8-13)

D26c Adult Foster Care Mental Health Certification Attachment A (3-13)

D26d Adult Foster Care Mental Health Certification Attachment B (3-13)

D26e AFC Mental Health Certification Licensing Checklist (9-12)

D27 Community Residential Setting (CRS)
D27a 245D-HCBS Community Residential Setting (CRS) Licensing Checklist (7-14)

D27b Home Safety Checklist for Community Residential Settings (6-14)

Family Adult Day Services – Section E

E1 Family Adult Day Services Licensing Checklist (10-12)
E2 Family Adult Day Services Questions and Answers (7-12)

E3 Family Adult Day Services Policy and Program Information (7-12)

E4 Family Adult Day Services Individual Service Delivery Plan (7-12)

E5 Family Adult Day Service Requirement Chart (12-13)

Background Studies – Section F

F1 Background Study Clearance Letter (3-08)
F2 Key Changes in Background Study Law (5-06)

F3 Background Study Definitions (3-08)

F4 Disqualification Period Instructions (4-08)

F5 Disqualification Chart (11-12)

F6 Immediate Risk of Harm Determination Worksheet (1-07)
F7 Risk of Harm Flow Chart (1-07)

F8 Reconsideration Process (4-08)

F9 Checklist for Disqualification Reconsideration (4-08)

F10 Request for Reconsideration Form – for DQ Subject’s Use (3-08)

F11 Request for Reconsideration of Disqualification Form – for County/Private Agency’s Use (4-08)

F12 Serious and Recurring Maltreatment Definitions and Scenarios (12-10)

F13 Maltreatment of Minors Act (4-08)

F14 Maltreatment of Vulnerable Adults Act (4-08)

F15 County’s Consolidated Reconsideration of Maltreatment & Disqualification Determination Process (4-08)

F16 Possible County Responses to Consolidated Reconsideration Request (4-08)

F17 Timelines for County Agency’s Response to Request for Reconsideration (4-08)

F18 County Results of Consolidated Reconsideration of DQ and Maltreatment Determination- Form (2-13)

F19 Appeal/Reconsideration Timeframes for Licensing Sanctions (4-08)

F20 Consolidated Contested Case Examples (4-08)

F21 Sample Disqualification Letters:
F21a Notice to Subject, Permanent Bar, Imminent Risk of Harm, SSIS, 122A1 (4-08)

F21b Notice to License Holder, DQ or Permanent Bar, Imminent Risk of Harm, SSIS 123A2 (4-08)

F21c Notice to Subject, DQ, Continuous Supervision, SSIS 125B1 (4-08)

F21d Notice to License Holder, DQ, Continuous Supervision, SSIS 126B2 (4-08)

F21e Notice to Subject, DQ, Low Risk of Harm, SSIS 127C1 (4-08)

F21f Notice to License Holder, DQ, Low Risk of Harm, SSIS 128C2 (4-08)

F22 Child Foster Care (CFC) and Adoptions Background Study Identification Form (10-12)

Child-Caring-Placing Agencies – Section G

G1 Intercountry Adoptions (6-13)

Family Systems Applications – Section H

H1 Family Systems Application & 3324 Forms Power Point (2-25-14)
H2 Family Child Care:
H2a Family Systems Family Child Care Application (2-25-14)

H2b Family Systems Family Child Care 3324 (3-20-14)

H3 Special Family Child Care
H3a Family Systems Special Family Child Care Application (2-25-14)

H3b Family Systems Special Family Child Care 3324 (3-20-14)

H4 Child Foster Care:
H4a Family Systems FAMILY Child Foster Care Supplemental Application (2-25-14)

H4b Family Systems FAMILY Child Foster Care 3324 (3-20-14)

H4c Family Systems CORPORATE Child Foster Care Supplemental Application (2-25-14)

H4d Family Systems CORPORATE Child Foster Care 3324 (3-20-14)

H5 Adult Foster Care:
H5a Family Systems FAMILY Adult Foster Care Application (2-25-14)

H5b Family Systems FAMILY Adult Foster Care 3324 (3-20-14)

H5c Family Systems NEW CORPORATE Adult Foster Care Application (2-25-14)

H5d Family Systems NEW CORPORATE Adult Foster Care 3324 (3-20-14)

H5e Family Systems RENEWAL & OTHER CORPORATE Adult Foster Care Application (2-25-14)

H5f Family Systems RENEWAL & OTHER CORPORATE Adult Foster Care 3324 (3-20-14)

H6 3324 Closing Codes (12-13)


Rate/Report this page   Report/Rate this page

Related Pages

Related Links