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1-2 Bed Adult Family Home Provider��s Guide

1-2 Bed Adult Family Home Provider��s Guide

Owner-Occupied Adult Family Homes 





In this Guide and in the Adult Family Home Standards, the following terms are used that may be helpful for you to know.* 

  1. ADL��s - activities of daily living that include self-care, leisure, and recreation.  Self-care involves dressing, eating, bathing, grooming, toileting, mobility, object manipulation, walking, and rest.
  2. Adult Family Home - the primary residence of the person that provides care that is above the level of room and board.  This care is given to one or two adults.
  3. Social Work Service Coordinator - the person who supervises the care and services needed by the member/resident.  This includes services in and outside of the Adult Family Home.
  4. Certifying Agency - the agency that certifies Adult Family Homes.  This is Community Care of Central Wisconsin.
  5. Guardian - one appointed by a court to have care, custody, and control of the person who is incompetent or the management of the estate of a person who is incompetent.
  6. Household Member - any person living in an Adult Family Home.
  7. Member/Resident - the person who resides in the Adult Family Home and receives services above the level of room and board.
  8. Sponsor/Provider - the person(s) that operates an Adult Family Home.
  9. Substitute Provider - a person designated by the sponsor/provider to take full responsibility for operating the Adult Family Home when the sponsor/provider is temporarily unable to provide the services.

    *A complete list of AFH definitions may be found in the AFH Standards section 202.02. 

    What is Family Care?

    • Family Care is a voluntary long-term care managed care program.
    • Family Care pools all funding currently in the system for long-term care including money that funded Community Options Program, and some Medicaid ��card�� services such as institutions and personal care.

      Family Care coordinates health care and long-term care services. 

      You, the Provider

    You, the Provider

    Community Care of Central Wisconsin Adult Family Home Provider exercise the following criteria:.

    • At least 18 years of age.
    • Are physically, emotionally, and mentally capable of providing Adult Family Home care.
    • Exercise sound judgment and display the capacity to successfully care for people with disabilities or the frail elderly.
    • Passed the background checks.
    • Have shown financial stability demonstrated by having the financial reserves to support all members of your household, including the Adult Family Home member/resident(s), for a period of at least 30 days without receiving payment for the care of the member/resident.
    • A physical exam has been completed within the last year showing that you and all members/residents of your household are free from communicable diseases and that there are no illnesses or conditions that would threaten the health, safety, or welfare of the member/resident(s) or hinder your ability to care for them.
    • You have successfully passed a TB screening within the last 90 days.
    • There is adequate liability insurance covering both your auto and your home.
    • You are aware of the training requirements and have agreed to meet them.
    • Your home has been visited by the Adult Family Home Coordinator from Community Care of Central Wisconsin and has met all the requirements for certification.

      Your certification is good for one year.  Approximately 45 days before your certification is due to expire, you will be contacted by the Adult Family Home Coordinator regarding your recertification.  This is done whether you currently have a member(s) or are still waiting for placements. 

      Program Statement 

      A Program Statement is created.  This is much like a mission statement or cover page for your home.  It needs to include:

      • The type and number of individuals you are willing and able to accept into your home.
      • Whether your home is accessible to individuals that require assistance with mobility.
      • A description of your home and the community resources available to member/residents who live with you.

        Be creative with this requirement!  This is a statement of what you are about as an Adult Family Home.  Describe activities you provide, the gorgeous scenery from your open deck, the loving care you provide to your member/residents.  You may include pictures of your home and it can double as an advertising piece for your home. 

        Renewal Process

        Each year your home needs to be recertified.  Recertification includes:

      1. The Community Care of Central Wisconsin Adult Family Home Coordinator will make contact approximately 45 days prior to your due date.
      2. A letter of needs will be sent out for recertification purposes requiring:
        1. Declaration page of current auto and homeowners or renters insurance.
        1. Well water test results (if applicable).
        2. Proof of smoke detector tests, fire drills, and fire extinguisher checks.
        3. Pet vaccinations are current (if applicable).
      1. A home inspection completed.
      1. Background Check every fourth year.
      2. Any other records and forms that may apply.

    If everything is in order, you will receive a certificate of renewal for another year.

    If you are denied renewal of your certification or if your certification is revoked, you will receive a written notice before your current certification expires.  This notice will clearly state the reasons for not renewing or for revoking your certification.  It will also inform you of your right to appeal this decision by requesting an Administrative Review.

    Non-renewal/Revocation of Certification

    If there are any questions about renewal, you usually have been notified and given ample opportunity to correct any issues long before it reaches the stage of non-renewal.  If this does occur, there is an appeal process where you may ask for an Administrative Review of the decision to not re-new or to revoke your certification. 

    Appeal Process

    The written notice you receive must provide you with the contact information to make a request for an Administrative Review.

    You have 15 days from the date of notice to appeal.

    Your request for Administrative Review first goes to the Community Care of Central Wisconsin Provider Network Director or their designee.

    1. The request must be written.
    2. The request should state why you disagree with the action.

    Community Care of Central Wisconsin Provider Network Director or designee will review the facts and give you a written decision within 30 days of your request.

    You may further contest the decision by Community Care of Central Wisconsin, within 15 days, by requesting an Administrative Review by the State Department of Health Services.

    1. The request must be written.
    2. The request should state why you disagree with the decision made by the Community Care of Central Wisconsin Provider Network Director or designee.

    The Department of Health Services will review the facts and send a written decision to you within 45 days of receipt of your request.  This decision is final. 

    Training Requirements

    The Adult Family Home provider must obtain 10 hours of training in the first year of initial certification and 8 hours of training every year thereafter.  Community Care of Central Wisconsin may require more than the minimum standard hours of training.  The Standards do not mandate where the training must be received, topics that must be taught, or media from which training is received.  At the present time, the Standards do not require either first aid training or CPR Certification.  We highly recommend you consider doing this and it would count towards training hours; however, at this present time, this is not mandatory.

    Many opportunities for training are available to you.  Some of these trainings you may do at home and some will be in the form of group sessions or workshops.  There is an annual Wisconsin Association of Adult Family Care Coordinators conference that features numerous workshops and keynote speakers addressing issues related to Adult Family Home Care.  WEBSITE

    We also encourage you to seek out opportunities of interest on your own.  These may be in the form of books, TV specials, on-line courses, or magazine articles.

    It is very important, whether your training is one is provided by another agency or one you discovered on your own, that in order to get credit for the training, you must document you participated in this training.  Most formal trainings will send you a certificate of participation, topic(s) and hours you may claim.  Independent training(s) must be documented as well.  Here are some suggestions for documentation:

    • TV show/movie---state the date, length, a topic of the show and why it qualifies as an appropriate training for your Adult Family Home.
    • Book---state the title, author, length of book and a brief report on the topic it covered and why it is appropriate for your Adult Family Home.
    • Magazine article---a brief review of the article and what you learned from it that would apply to your Adult Family Home.

    Please use the training log (CCCW will provide to you) to track your training hours.  The Adult Family Home Coordinator will determine the number of training hours to credit you. 

    Your Home

Your Home

Adult Family Homes should be located where the member/residents can easily go to community activities and supportive services by public or private transportation.  You, as the provider, need to ensure that the member/resident(s) of your home receive the assistance they need to enable them to get to these activities and services.

Your home should be physically accessible to all member/residents of the home.  Member/Residents should be able to easily enter and exit the home, get to their bedrooms and to all common living areas and to easily move about in the house.  They do not need to have access to private bedrooms.

In general your home should provide the following:

  1. Privacy - this is physical and emotional privacy for the member/resident(s).
  2. Safe and clean - means uncluttered, homelike, meets local building codes, free from hazards, dangerous substances, insects, and rodents.
  3. Sufficient space - for comfort.  Should accommodate all household activities and member/residents comfortably.
  4. Safe and functioning - heat, hot and cold water, fire protection, electricity, plumbing, sewerage, and lighting.
  5. Well water - if applicable, samples must be taken and tested annually to assure the safety of the drinking water.
  6. Garbage removal.
  7. Laundry facilities - either in the home or arranged for the member/resident(s).
  8. Windows - ventilation for health and comfort.  At least one window that can be opened to the outside in each member/resident��s bedroom and each common room used by the member/resident(s).  These windows should have screens during the appropriate seasons.
  9. Limited use of the home for business purposes - cannot be used for any business purpose that regularly brings customers to the home so that the member/resident(s) use of the home as their residence, or their privacy, is adversely affected.
  10. Weapons - must be stored and locked, trigger locks alone do not meet this requirement.  Ammunition must be stored and locked separately. 
  11. Telephone - must be available for member/resident(s) use.


There must be at least one full bathroom for every 8 people in the home.

The bathroom door must allow for locking on the inside for privacy, but can be opened from the outside in case of an emergency.


Private rooms must be 80 square feet and for shared rooms 60 square feet per member/resident.  No more than two member/residents in a room.  A member/resident with wheelchair use must have 100 square feet of space in the room and if the room is shared with two non-ambulatory member/residents, then the room would have to have 200 square feet.

Bedrooms cannot be located in hallways, kitchens, living rooms, dining rooms, unfinished basements, closets, garages, or other unattached structures.  The member��s/resident��s bedroom may not be used to get to another part of the home (i.e. entry to basement is through member��s/resident��s room.)

The bedroom(s) should be comfortable and private with full height walls and a solid door that can be opened and closed by the member/resident(s).

There should be one bed for each member/resident and at least three feet around each bed for a shared room.

Adequate storage space should be provided.  At a minimum, this should be a space large enough to hang and store clothes and other personal belongings.  When a room is shared, there should be an individual space for each occupant (a dresser for each meets this standard).

Bed linen must be maintained in a clean condition.

Member/Resident (s) cannot share bedrooms with provider��s household members or a juvenile unless the person is a relative and it��s at the request of both the member/resident and the relative.

Persons of the opposite sex cannot be required to share a bedroom.  If member/residents wish to share a bedroom, accommodations should be made.

A member/resident��s bedroom cannot be used for respite if the member happens to be absent from the home. 

Living Room, Dining Room, and Kitchen

The Living Room should be uncluttered and accessible with comfortable furnishings.  If there is a fireplace in the Living Room, there should be a screen/door in front of it.

The home should provide a telephone for the member/resident(s) to make and receive calls.  You may require that long distance calls be made at the member(s) own expense.  Emergency numbers, including numbers for the fire department, police, hospital, physician, poison control center, and ambulance must be on or near each phone.

The Dining Room should be large enough so that all household members/residents may eat together.  It should be clean and uncluttered.

The Kitchen must have enough space to prepare food in a sanitary manner and enough storage space for food to be stored safely. There should be enough cupboard space so that food, dishes, utensils, and other items can be stored out of the way, rather than stacked on the countertops.  

Entryways, Hallways, and Stairs

These should be kept free of clutter and objects that could cause falls or block passage.

Make sure broken steps are repaired or replaced, tack down loose carpeting and repair worn threads.  Lighting in these areas should not produce glare or shadows.  Use non-glare fixture covers and the maximum wattage bulb recommended.

Fixtures should provide light for the entire length of a hallway.  Locate light switches at both the top and bottom of stairways and at both ends of a long hallway.

Yard and Outside Area of the Home

Try to do all you can to enhance the safety of your member/resident(s).  Provide flat, even walkways and yard areas, adequate drainage for sidewalks, and other walkways so they are not slippery when wet.  Sidewalks and entrances must be well lit.

Snow removal should be done promptly and thoroughly.  Be sure there are no icy patches that could cause a fall.  The member/resident(s) should not have to go through snow to reach the house or a vehicle.  Any area used for walking should be as clear and as dry possible.

Leaf removal should also be prompt and thorough.  Wet leaves can create hazardous walking conditions.

If possible, provide areas where the member/resident(s) can sit outdoors that offer shade and protection from the elements. 

Fire Safety

Fire Extinguishers

  • Must be a 2A, 10 B-C (or larger)
  • Must be wall mounted
  • Required on each floor of the home
  • Required at the head of each stairway and in or near the kitchen (one extinguisher can meet these requirements)
  • Must be inspected annually by an authorized dealer or local fire department.  An attached tag should show the date of the last inspection

Smoke Detectors 

  • Must be on each floor of the home
  • Should be located at the head of each open stairway, at the door leading to every enclosed stairway, on the ceiling of the living room or family room, and on the ceiling of each sleeping room in which smoking is allowed
  • Must be tested monthly and fixed if not functioning properly with documentation of the repair 


  • First floor-must have 2 exit doors that go out to grade (either directly or via a garage, balcony, or deck)
  • Second floor-must have 2 exits, one can be a stairway or ramp that leads to the first floor, the other may be a second stairway, balcony, or window that meets building codes for exit windows
  • Attics-must have two exits that are stairways that lead to the second floor or to the grade level
  • Basement-must have one exit (directly to grade or via stairway) Unless: a basement is used for a bedroom in which case there must be two exits (can be stairway, door to the exterior, or an egress window)

Fire Safety Evacuation Plan

You must have a written plan for the immediate and safe evacuation of all occupants of the home in the event of fire.  The plan should include:

  • External designated meeting places that is familiar to the member/resident(s).
  • All evacuation routes clearly diagramed and may be posted.

Go over this plan with every new member/resident immediately following placement.  The plan must be reviewed twice a year with members/residents in your home.

Fire Drills

The requirement for fire drills is twice a year. 

Written documentation of the date and time the evacuation occurred is required for each drill.  Record your fire drills on the log sheet.

Reporting a Fire

A fire that requires the assistance of the fire department must be reported to the Service Coordinator within 24 hours.  

Heating Units

Although it is not a mandate, it is highly advised that before each heating season your heating source be inspected, to offer safe clean air to the occupants of the home.

Household Pets

Cats, dogs, and any other pet susceptible to rabies must be vaccinated, and provide verified current vet records to Community Care of Central Wisconsin .  Recertification will require proof of vaccinations.  Sick animals must be treated or removed from the home.  Pens and cages kept clean. Pets must be under control and not a danger to members/residents or guests. 

The wishes of the member/resident(s) must be considered before bringing a new pet into your home.

The Placement Process

The Placement Process

Once you have met all criteria for an Adult Family Home; you are ready to become a provider.  Your home has been inspected and certified, fire safety is in place, and all that is needed now is member/resident (s).  How are member/residents placed in your home?

Community Care of Central Wisconsin Service Coordinators are a source of prospective member/residents for your home.  When a Service Coordinator has a member/resident they think may be an appropriate candidate for placement for an Adult Family Home, an assessment is done which identifies the person��s needs, abilities, and preference.

This includes:

  • Activities of daily living
  • Instrumental activities of daily living
  • Medications
  • Current health status/health maintenance needs
  • Level of supervision required in home and community
  • Behavior support needs
  • Work/vocational programming
  • Recreational/social preferences
  • Transportation

If the Service Coordinator thinks an Adult Family Home could meet the member/resident��s assessed needs the placement process has begun.  The Adult Family Home Coordinator will give the Service Coordinator the following information:

  1. A copy of the Adult Family Home Standards, if requested.
  2. General condition of the home.
  3. Information on any significant violations of any standards or conditional terms set in the certification of the prospective home (i.e. not certified for non-accessible at this time).

During this visit, if all agree this may be the home for the prospective member/resident, a trial visit is arranged.  This gives everyone a chance to meet one another; the member/resident can get acquainted with the home and with other member/residents or household members and pets.

A trial visit may include a visit during the day, an overnight visit, or a weekend stay in the home.  The Service Coordinator is looking for a ��MATCH��. This means the prospective member/resident and the Adult Family Home family members and other member/residents get along well and the feelings for a placement are positive by all.

Once all are in agreement, the Service Coordinator is responsible for developing the following documents:

  1. Adult Family Home Service Plan - developed for each member/resident.  It is reviewed every 6 months or as things change and must contain:
  1. Services to be provided to the person in relation to the indentified needs in the assessment
  1. Information for accessing the community
  2. Identification of any other service providers
  1. Agreement for Services - this is reviewed annually or whenever there is a significant change.  It must include: 
  1. Roles and responsibilities of the sponsor/provider, member/resident, and Service Coordinator
  1. Agreement for control of personal funds
  2. Termination statement; process
  3. Notification of member/resident rights and grievance procedure

Both of these documents are signed by the member/resident, guardian, Service Coordinator, and the provider (you).  The Service Coordinator works with the Adult Family Home Provider to ensure the member has a medical examination to identify any health problem and is screened for any communicable diseases and TB.

You will be given a packet that contains the documentation you are required to maintain.  The packet is to be used for resident record keeping required by the Family Care Standards.  The Service Coordinator will go over the use of these forms with you.

You are now ready to accept a new family member into your home. 

The Services You Provide

The Services You Provide

We expect you to provide a safe, emotionally stable, home environment which encourages the member/resident(s) autonomy, allows for physical and emotional privacy, and takes the member/resident��s preferences, choices, and status as an adult into consideration when providing care, services, and supervision.  The member/resident is an adult with the rights of an adult.  When planning for adult care; keep these rights in mind.* 

Member��s/Resident��s Rights 


Fair Treatment   Safe physical environment


Privacy     Freedom from abuse


Confidentiality    Freedom from seclusion and restraints


Presumption of competency  Labor


Self Direction    Prompt and adequate treatment


Financial affairs   Medication


Clothing and possessions  Mail


Social activity choice   Telephone calls


Choice of providers   Visits


Treatment of choice   Service charges


Religion    Right to file a grievance 

You are expected to provide activities for the member/resident (s) in your home.  There are to be a variety of activities available to the member/resident (s) including cultural, religious, political, and social activities.  Even if the member/resident is low functioning or has dementia, scale the activity to their level and get them out into the community as well.  Make sure the activities are their favorites and not yours!  They have the choice to participate in an activity or observe. 

*These rights are described fully in the AFH Standards in Appendix, Sec. 202.07

You must provide the services identified in the Adult Family Home Service Plan that are your responsibility.  You are to teach, assist, and support the member/resident to promote his/her health, well-being, self-esteem, independence, and quality of life in the community.  The member/resident does have the right to refuse any service.

At least three nutritious meals and two snacks are to be provided daily.  They should have sufficient quantity and variety and take the member(s)/resident(s) personal preferences into consideration.  The food preparation should be sanitary.  Everyone should dine together and any special physical or religious dietary needs must be taken into account. 

Medications your resident is taking should be dealt with as follows:

  • Containers must be labeled;
  • Member/Resident should control and administer their medications except when they are unable to do so (as directed by a physician or requested by a guardian);
  • If you are going to administer medications, a written order must be signed by the physician; allowing you to do so;
  • Safely store medications;
  • Help the member/resident take the correct dosage at the correct time and communicate with his/her physician/pharmacist.

Records You Must Keep

Records You Must Keep

You are expected to keep records for each member/resident in your home.  The length records are to be kept is seven years, but if you have adequate, secure storage you may keep them as long as you like.  It is important to remember these records contain confidential information so they should be kept in a secure place at all times.  This is a list of the records you are expected to keep:

1. Name, member/resident(s) date of birth, name, address, and phone of the guardian, Service Coordinator, Community Care of Central Wisconsin staff involved, and the member/resident(s) physician.  These are the people that should be notified in the event of an emergency.

2. Medical insurance identification numbers and the name of the pharmacy used by the member/resident(s).

3. The Adult Family Home Service Plan.

4. The report of the member/resident(s) health assessment.

5. The Agreement of Services.

6. Evidence the member/resident(s) and their guardian(s), if any, have received and discussed the rights grievance procedure with the Service Coordinator.

5. Monthly Smoke Alarm checks, fire extinguisher checks, fire drill log, annual extinguisher inspection verification checks.

8. Medication log.

9. Incident reports, Doctor��s Referrals, and monthly resident summaries.

10. Financial ledger of client��s money receipts, allowances, and debits.

The packet you receive at placement is usually a good place to keep these records but you may choose to keep them elsewhere.  Your member/resident, guardian(s), and CCCW Service Coordinators may have access to these records upon request.  After seven years, and you choose to dispose of these records, they must be destroyed in a secure way.  They need to be shredded, cut up or otherwise rendered illegible to protect the privacy of your member(s)/resident(s). 


It is important to remember that no matter how long the adult has been living in your home, you are not free to talk about him/her as you may about other members of your family.  You should avoid casual social conversations about the adult and his/her family, medical history, habits, and idiosyncrasies.  Share only as much as is necessary for the adult��s well-being and success.

It is not always easy to know whom to tell what and when.  Remember the ��need to know�� principle to help guide your disclosure of information.  Ask yourself, ��What does this person need to know at this time to help my resident(s) succeed in work, leisure, or social relationship.��  Show respect for the adult and use sensitivity in sharing information, especially protecting and enhancing the adult��s positive reputation.

You should also assist your member(s)/resident(s) to learn appropriate ways to share personal information about them.


Adult Family Home Provider Responsibilities

Adult Family Home providers are responsible for the day-to-day supervision, support, and care of the member(s)/resident(s).  You must also work cooperatively with guardians, financial representatives, Service Coordinators, and other agency staff members.  As an Adult Family Home provider, once you have someone placed in your home, you have responsibilities to the member/resident placed in your home, to Community Care of Central Wisconsin, and to the Service Coordinator.  This is a basic list of your responsibilities.

To the member/resident(s) in your home you have the following responsibilities:

1. Provide room, board, and access to laundry facilities.  Board means three nutritious meals and two snacks per day.  If the member/resident works or attends day services this would include a sack lunch.

2. Provide soap for laundry and personal use.

3. Provide furniture, bedding, and clean linens for the member/resident��s bedroom.

4. Provide services which may include but are not limited to: teaching and supervision of personal care and activities of daily living, health monitoring services, behavioral intervention, money management, leisure and recreational activities, personal supervision, and transportation.

5. Provide a family atmosphere that is safe, warm, stable, and accepting of the member/resident.  This includes confidentiality regarding any information about the member/resident.

6. Encourage the member/resident to assist with household tasks and participate in family and community activities.

7. Provide family based care to member/residents placed in the home.  The Adult Family Home provider will treat the member/resident as an adult member/resident of the family.  This includes a bedroom that may be shared by one other member/resident and provides adequate privacy.  Basic care includes nutritional meals eaten with family members; the opportunity to attend the church of his or her choice; to see the physician of his or her choice; inclusion in family activities and outings; access to all areas of the home with exception of personal bedrooms; access to television, books and other recreational activities of the home.

8. Provide a 30-day written notice when requesting termination of a members/resident��s placement.

9. Obtaining emergency care when needed.  This includes calling a doctor or ambulance for serious illness or injury and the police for other serious emergencies.  Adult Family Home providers must contact the Service Coordinator, guardian, and/or power of attorney for health care within 24 hours after emergency measures are taken.

10. Whenever something out of the ordinary occurs in your home, an injury to a member/resident, an unusual outburst or behavior by a member, you need to fill out an Incident Report.  An Incident Report should be sent to the Service Coordinator and Community Care of Central Wisconsin.  It is important to document these incidents so everyone involved is aware of the type of care is required when working with your member(s)/resident(s).

11. If you are absent from the home, an appropriate substitute provider must be in the home to provide the supervision and services specified in the Adult Family Home Service Plan.  Background checks must be conducted every four years for the substitute provider and you are to provide the CCCW Provider Network with a copy of the background check.  It is the responsibility of the provider to monitor these dates and arrange to have the background checks completed and pay for the background checks.

To the Adult Family Home Coordinator you have the following responsibilities:

1. Submit the Adult Family Home Application and complete the requirements for initial certification and annual re-certification.

2. Complete training as required and enter your trainings on the Community Care of Central Wisconsin training log.  Community Care of Central Wisconsin requires ten hours of training in the first year of initial certification and eight hours of training per year thereafter.

3. Maintain the home according to all zoning codes, health and safety standards, existing laws and regulations of state and local governments; to provide necessary utility services, i.e. heat, water, sewer, gas, electricity, and property in a neat, clean, safe, and orderly condition.

4. Inform the Adult Family Home Coordinator of any major family illness, change in family composition (marriage, divorce, adoption, birth, family member moving out, etc.), or change of address within seven days of the change.

5. Allow the Adult Family Home Coordinator to visit the Adult Family Home as needed.

6. Maintain member/resident records with the required information.

If Applicable, you have the following responsibilities to the Service Coordinator:

1. Prompt notification of any major family illness, change in family composition (marriage, divorce, adoption, birth, family member moving out, etc.), or change of address within seven days of the change.

2. Notify the Service Coordinator when changes occur that will affect the member/resident including but not limited to:


a) Behavior changes of a significant nature.

    b) Incident or accident reports.  Notification is expected as soon as the crisis is settled.  Contact is to be made by phone and copies of the Community Care of Central Wisconsin Incident Report form are to be sent to the Service Coordinator.  Guardians are to be notified immediately as they have the decision making power for treatment.

    c) Medication changes for behavior or disability related purposes.  For significant changes a telephone call and written documentation is expected.  If not significant, written notification is sufficient.

    d) Inform the Service Coordinator of doctor and therapy appointments with the results of the appointment or recommendations.  Use appropriate referral forms for this purpose.

    e) Physical changes i.e., seizures, new diagnostic, hospital admissions, etc.

    f) Employment and/or financial changes for either the provider or the member/resident.

    g) Family issues or changes.

3.  Cooperate with the Service Coordinator regarding the health and emotional well being of the member(s)/resident(s).

4.  Notify the Service Coordinator of substitute care providers.  All providers must be at least eighteen years of age.

5.  Complete documentation on Medical Log, Respite Usage, and Financial Ledger.

6.  Cooperate with Service Coordinator, member/resident, and guardian when a placement is terminated.

Others have responsibilities toward you as a provider.  The member/resident in your home, Community Care of Central Wisconsin, and the Service Coordinator all have responsibilities toward you!

Responsibilities of the Member (s)/Resident(s) to the Provider

The member(s)/resident(s) agree to live cooperatively with the Adult Family Home residents and work toward becoming as independent as possible.  They also work cooperatively with the Service Coordinator and other staff who are involved in their Adult Family Home placement.  Responsibilities to the provider are:

              1. Treat members of the home with courtesy and respect;
              2. Participate in family and community activities of member (s)/resident(s) choice;
              3. Maintain confidentiality about the home (any information may be shared with the Service Coordinator and guardian);
              4. Is responsible for financial obligations for clothing, personal items, and medical needs;
              5. Self-medicating unless assistance with medication is ordered by their physician;
              6. Maintain his or her bedroom in a clean and tidy manner (as much as possible);
              7. Maintain good personal care standards (with assistance if needed);
              8. Responsible for items they damage in your home;
              9. Must adhere to the smoking policy of the home.

Responsibilities of the Member(s)/Resident(s) to the Service Coordinator

        1. Follow the service plan;
        2. Participate in planned work and social activities outside the Adult Family Home;
        3. Attend staffing when able to do so;
        4. Share problems and concerns with the Service Coordinator.

Responsibilities of Community Care of Central Wisconsin to the Provider

        1. Provide certification and annual recertification services;
        2. Provide basic instruction and support;
        3. Assess all referrals for Adult Family Home placements and refer appropriate members to the Adult Family Home;
        4. Have communication with Adult Family Home providers; this may be in the form of newsletters, phone calls, or personal meetings;
        5. Establish the rates for the rate agreement for services to be provided by the provider.

Responsibilities of Service Coordinator to the Provider

        1. Provide care management for all members/residents placed in the home;
        2. Assess service needs and establish services based on those needs.

          Helpful Information

Required Reporting

You are required to report the following events within the time frame expected or your certification may be revoked.

Within 24 Hours: Notify the Service Coordinator and Community Care of Central Wisconsin:

  • Any life-threatening, disabling, or serious illness;
  • Any injury sustained by the member/resident that requires medical attention;
  • Any medical condition of the member/resident that requires absence from the home for more than 24 hours;
  • A fire in the home that requires the assistance of the fire department.

Within 7 days: Notification to the Service Coordinator and Community Care of Central Wisconsin:

  • A change in the type or amount of services you are providing or that you believe the member requires;
  • A change in household members (i.e. children moving in or out, marriage, divorce, etc.);
  • A change in member/residence (i.e. placement from another agency, other family members, etc.);
  • A change in your employment or financial status;
  • A change in your or any member/resident of your household��s legal status, this includes being arrested, charged, or convicted of any crime that would disqualify a person from being a provider if that crime had been found on a background check;
  • A substantial change in your or a member of your household health that affects your ability to provide the services needed by the member(s)/resident(s);
  • A substantial change in your or a member of your household health that places the member(s)/resident(s) at a safety risk.

About Incident Reports

    Whenever something out of the ordinary occurs in your home, an injury to a member/resident and unusual outburst or behavior by the member/resident, you need to fill out an Incident Report.

    An Incident Report should be sent to the Service Coordinator and Community Care of Central Wisconsin.  It is important to document these incidents so that everyone involved is aware of the type of care required when working with your member(s)/resident(s).

Notice of Termination

    If you are going to terminate services, a 30 day written notification must be given to the Service Coordinator, Community Care of Central Wisconsin, and the member��s/resident��s guardian (if applicable).  This is not required if an emergency termination is necessary to prevent harm to the health and safety of the member/resident or other household members.

Reporting Abuse and Neglect

    If you or a respite provider knows, or has reasonable cause to suspect, that a member/resident has been abused or neglected, the Service Coordinator and Community Care of Central Wisconsin should be notified immediately.   You are also under obligation to report the incident to your County Adult Protective Services.

    If you believe that a crime has been committed, the incident must be reported immediately to law enforcement authorities. 

    Provider Checklist

      This is just a reminder to help you stay on top of the various requirement that occur on a regular basis.


    • Medication Log;
    • Daily Log of Resident (if requested).


    • Smoke detector and fire extinguisher check;
    • Fire Drill: Spring and Fall;
    • Financial Ledger: allowance, debts, receipts;
    • Summary Report of Member/Resident to Service Coordinator.


    • Fire extinguisher annual inspection by certified inspector;
    • Pet vaccination verification;
    • Training Log-fill this in with the type of training and number of hours per year;
    • Well tested and verified for safe drinking (if applicable);
    • Physicals for resident(s).

    As Needed

    • Doctor referral forms for Specialists visits-copy to guardian and Service Coordinator;
    • Incident Report form – send to Community Care of Central Wisconsin Service Coordinator.

    Seasonal Fire Safety Checklist: 

    • Change smoke detector batteries (when you change your clocks, change your batteries);
    • Clear out storage areas; old papers, oily rags, magazines and furniture in your basement, attic, and garage;
    • Check plugs and receptacles and insulation of all electric cords.
  • Summer 
    • Check smoke detector batteries; 
    • Use caution when cooking outdoors;
    • Keep gas grill propane tanks in a shady cool place;
    • Read and follow microwave instructions;
    • Practice gasoline safety by storing in approved containers OUTSIDE the home.
    • Change smoke detector batteries (when you change your clocks, change your batteries); 
    • Keep your chimney and fireplaces, pellet stoves, etc. clean;
    • Check all electrical cords and connections;
    • Flame proof Halloween costumes and no candle lit pumpkins in house.  Keep matches and lighters safely stored away;
    • Water temperature set on thermostat at 120 degrees;
    • Have furnace inspected for efficiency.
    • Winter   
      • Check smoke detector batteries;
      • Practice holiday safety with Christmas trees;
      • Use tested laboratory approved lights and decorations;
      • Do not overload electrical circuits, use caution with candles, oil lamps, and fireplaces;
      • Keep flammables away from heaters.

Emergency Preparedness Checklist


Stock disaster supplies to last several days to a week for yourself and those who live with you including:


____Non perishable foods and manual can opener


____Bottled Water


____Prescription and non-prescription medications


____Wood for the fireplace and wood burner


____Fuel for the outdoor grill




____Medical equipment: wheelchair batteries, oxygen, etc.


____Flashlights and battery operated radio



____ Have some extra cash or traveler��s check on hand.  Keep hard copy of all financial statements.

____ Keep your vehicles fuel tanks above half full.

____ In case of a power failure, plan to use alternate cooking devices in accordance with the manufacturer��s instructions.  Do not use open flames or gas grills indoors.  Use outdoor fuel source (wood or propane) grill or open hearth cooking.

____ Have plenty of extra blankets, coats, hats, and gloves to keep warm.  Do not use gas fueled appliances, like an oven, or other heating devices that are not designed to be used in a residential structure as an alternative heating source.  Make sure any alternative heating device is approved for use indoors and is listed with the Underwriters Laboratories (UL).

____If you happen to have a back up gas operated generator, make sure it is operated outdoors and not inside.  Maintain the operation of the generator and test start it monthly.

____ Have plenty of flashlights and extra batteries on hand.  Do not use candles for emergency lighting.

____Examine your smoke alarms regularly.

____Be prepared to relocate to a shelter for warmth and protection in the event of prolonged power outage.  Know where community shelters are located by listening to the battery powered radio or television.

____Keep informed of any support community emergency unit��s efforts to ensure your well-being (via radio and/or TV).

____ If you need of a ventilator, oxygen, or other life-support equipment, please make contact with medical facility for relocation availability.

Name of facility or alternative plan:______________________________________

Individual needs or concerns:



On behalf of all the staff at Community Care of Central Wisconsin, we wish you the very best in your endeavors as an Adult Family Home Provider.  The job you have set out to do is not only a very responsible and challenging job choice but it is one of many rewards and opportunities for family fulfillment.  The role you have chosen is highly appreciated by those adults who need the support and care from our society; to promote and encourage independency and growth so you may provide the best life possible for each and every member!


Community Care of Central Wisconsin

  • Antigo Office      Local Phone No.

    211 State Hwy 64     Fax Number

    Antigo WI  54409   

  • Marshfield Office  (715) 996-1635  Local Phone No.  

    1702 Laemle Avenue     Fax Number

    Marshfield WI  54449 

  • Merrill Office      Local Phone No. 

                                                    Fax Number

    Merrill WI  54452   

  • Stevens Point Office  (715) 345-5968 Local Phone No. 

    3349 Church Street,  (715) 345-5725 Fax Number

    Suite 1

    Stevens Point WI  54481 (877) 622-6700 Toll Free

  • Wausau Office   (715) 301-1899 Local Phone No. 

    1200 Lakeview Drive  (715) 301-1898 Fax Number

    Suite 100

    Wausau WI  54403  

  • Wisconsin Rapids Office (715) 818-5100 Local Phone No. 

    2810 9th Street South  (715)   Fax Number

    Wisconsin Rapids WI  54494



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