Form 3681-A, Community Services Contract Application - Addendum A

Instructions

Updated: 6/2017

Purpose

Form 3681-A is an addendum to Form 3681, Community Services Contract Application. Form 3681-A is used by individuals and organizations applying for the following contracts:

• Residential Care
• Adult Foster Care

Procedure

When to Prepare

Form 3681-A is prepared for:

• a new contract, and
• a contract amendment.

Note: The information reported on this form is subject to verification by HHSC contract staff.

Form Retention

Retain Form 3681-A in accordance with the records retention requirements in the Contract Management Handbook.

Detailed Instructions

1. Legal Name of Entity – Enter the full, legal name of the entity, exactly as it was chartered, filed, registered or otherwise legally declared.

2. Doing Business As (DBA) – Enter name of DBA, if applicable.

3. Facility Physical Address – Enter the physical address of the facility.

4. Assisted Living Facility License No. - Enter the facility's license number, if applicable.

5. Size of Assisted Living Facility – Check the size of the facility.

6. Licensed Capacity – Enter the licensed capacity, if applicable.

7. Type of Assisted Living Facility License — Check A or B to indicate the type of license.

Section I.

Residential Care Non-Apartment — Check the program and enter the number of beds you wish to offer.

Section II.

Residential Care — Apartment — Check the program and enter the number of beds you wish to offer. Document the dimensions for each apartment being offered on the Square Footage Calculation for Residential Care Apartments table in this section. Document the dimensions for common areas on the Allocated Common Area Calculation table in this section.

Square Footage Calculation for Residential Care Apartments

A. Identifying Information – Enter the apartment number and the address for the apartment being offered. Check the program under which the apartment is being offered.

B. Private Space Area – No entry is required.

Note: The bedroom, bathroom, kitchen and storage areas must be within the confines of the setting.

C. Area Width – Enter the width for each area of the apartment.

D. Area Length – Enter the length for each area of the apartment.

E. Private Space Square Footage – Enter the total square footage for each of the apartment's areas. Multiply the width (Column C) by the length (Column D) to calculate the square footage.

F. Total Private Space Square Footage – Enter the apartment's total square footage. Add the square footage for all areas (Column E 1-4) and enter the sum.

G. Private Space Square Footage per Resident – Divide total private space square footage (F) by 2 and enter the result here.

H. Allocated Common Area Square Footage – Enter a zero if the private space square footage per resident (G) is 350 square feet or more. If the private space square footage per resident is less than 350 square feet, complete the Allocated Common Area Calculation table and enter the result (G) here.

I. Total Square Footage per Resident – Add the private space square footage per resident (G) and the allocated common area square footage (H) together and enter the result here. The total square footage per resident must be 350 square feet or more to be considered as a residential care apartment setting.

Allocated Common Area Calculation

A. Useable Area Description – Enter the common area descriptor (lobby, dining room, etc.).

B.  Area Width – Enter the width for each common area.

C. Area Length – Enter the length for each common area.

D. Area Square Feet – Enter the square footage for each common area. Multiply the width (Column B) by the length (Column C) to calculate the area square footage.

E. Useable Common Area Square Footage – Enter the total square footage for the common area. Add the square footage for all areas (Column D1-10) and enter the sum.

F. Licensed Capacity – Enter the facility's licensed capacity.

G. Allocated Common Area Square Footage per Resident – Enter the allocated common area square feet per resident. Divide the useable common area square feet (E) by the facility's licensed capacity (F) and enter the result here.

Section III.

Adult Foster Care — Check the program type.

No. of Beds – Enter the number of beds being offered.

Square Footage Calculation for AFC Bedrooms

A. Bedroom No. and Occupancy – Enter the bedroom number and check the applicable occupancy. Occupancy requirements are as follows:

• Single occupancy must have at least 80 square feet.
• Double occupancy must have at least 120 square feet.

B. Program – Check the program under which the bedroom is being offered.

C. Bedroom Width – Enter the width for each bedroom being offered.

D. Bedroom Length – Enter the length for each bedroom being offered.

E. Bedroom Square Footage – Enter the square footage for each bedroom. Multiply the width by the length to calculate the square footage.

Section IV. Certification

The contractor certifies that the information provided in Form 3681-A is complete and correct.

Certification of Beds/Apartments Previously Under a legacy HHSC contract – If the contractor is requesting to add bed(s)/apartment(s) that have previously been under a legacy HHSC contract, the contractor may certify that those bedroom(s)/apartment(s) have not been modified since they were under contract, and must provide the date the bedrooms(s)/apartment(s) were removed from a legacy HHSC contract.

Signature – The owner or authorized representative must sign the form and certify the information provided on the form is complete and correct. If an authorized representative provides this certification, that person must be named on a current Form 2031, Governing Authority Resolution – Business Organization, or Form 2031-G, Governing Authority Resolution – Governmental Entity, whichever is applicable to the legal entity.

Date Signed – Enter the date of signature.

Title – Enter the title of the individual who signed the form.