Moving into assisted living involves more than choosing a room and signing a contract. The residence will usually need medical information, care-assessment forms, emergency contacts, financial details, and documents showing who may make decisions if the resident cannot do so independently.
Requirements vary by residence, but Pennsylvania’s assisted living regulations establish several core admission records. Preparing them early can reduce delays, especially when a move follows a hospital stay or occurs during winter weather, when transportation and medical-office schedules may be less predictable.
Which documents are usually required before admission?
The most commonly requested records are a preadmission screening, medical evaluation, assessment and support plan, identification, medication information, and a signed resident agreement.
Pennsylvania’s Department of Human Services provides official forms for assisted living residences, including:
- Preadmission Screening Form
- Documentation of Medical Evaluation
- Assessment-Support Plan Form
- Resident-home contract model form
- Medication administration and related record forms
A residence may use its own version of certain forms, but the document must contain the information required by Pennsylvania regulations. ([pa.gov](https://www.pa.gov/agencies/dhs/resources/licensing/pch-alr-licensing/pch-alr-compliance-forms?utm_source=openai))
The admissions office may also ask for:
- A government-issued photo ID
- Medicare, Medicaid, or private insurance information, if applicable
- Social Security or pension information used for payment arrangements
- Contact information for family members or other designated persons
- Emergency contact details
- A list of physicians, pharmacies, therapists, and other current providers
- Copies of guardianship, power of attorney, or advance-directive documents
- The resident’s current address and prior living arrangement
- Information about allergies, dietary restrictions, mobility, communication needs, and cognitive changes
Not every item is a state-mandated admission document. Some are needed so staff can safely provide services and communicate with the right people.
What does the medical evaluation need to include?
A Pennsylvania assisted living medical evaluation must be completed by a physician, physician assistant, or certified registered nurse practitioner. The evaluation is generally required at least annually and when a resident’s medical condition changes. ([pa.gov](https://www.pa.gov/content/dam/copapwp-pagov/en/dhs/documents/licensing/bhsl-licensing/documents/Assisted_Living-Documentation_of_Medical_Evaluation.pdf?utm_source=openai))
The form covers more than a diagnosis. It may include:
- Physical and mental health conditions
- Medical information needed during an emergency
- Allergies and special dietary needs
- Immunization history
- Current medications, possible side effects, and whether the resident can self-administer
- Health status and mobility
- Positioning or movement needs
- Day-to-day assistance required from assisted living staff
- Tuberculosis screening information
The tuberculosis requirement should not be overlooked. The state form indicates that a negative tuberculin skin test within the required period, or related chest X-ray information when applicable, must be documented. If the test has not yet been completed, the form states that it must be administered within 15 days after admission. ([pa.gov](https://www.pa.gov/content/dam/copapwp-pagov/en/dhs/documents/licensing/bhsl-licensing/documents/Assisted_Living-Documentation_of_Medical_Evaluation.pdf?utm_source=openai))
A family member generally cannot complete the medical evaluation in place of the medical provider. Relatives can help gather records, prepare medication lists, and explain changes in functioning, but the clinical assessment must come from the qualified practitioner.
What are the preadmission screening and support plan?
The preadmission screening helps determine whether assisted living is an appropriate level of care. It considers the person’s physical, cognitive, behavioral, and daily-living needs.
The assessment and support plan translates that information into practical instructions for care. It may address bathing, dressing, toileting, mobility, eating, medication assistance, communication, activities, supervision, and emergency needs.
Pennsylvania guidance states that initial assessments and preliminary support plans are generally due within 30 days before admission. Special exceptions may apply when a person is admitted directly from an acute-care hospital, is leaving an abusive situation, or has no alternative living arrangement. In those circumstances, the documents may be completed within 15 days after admission, with supporting documentation maintained by the residence. ([pa.gov](https://www.pa.gov/content/dam/copapwp-pagov/en/dhs/documents/licensing/bhsl-licensing/documents/Assisted_Living_Residences-2800_Regulatory_Compliance_Guide_RCG.pdf?utm_source=openai))
This distinction matters for families arranging a rapid discharge. A missing form does not always mean admission is impossible, but the residence should explain which exception applies and what information must be completed immediately.
What legal documents show who can make decisions?
The most useful legal documents are those that identify the resident’s chosen decision-makers before a crisis occurs.
A health care power of attorney names a person who may make health care decisions when the resident cannot make or communicate decisions. A living will records preferences about life-sustaining treatment in certain serious medical circumstances. Pennsylvania recognizes these as forms of advance directives. ([pa.gov](https://www.pa.gov/agencies/aging/pa-carekit/caregiving-resources/legal-support-for-caregivers?utm_source=openai))
A financial power of attorney is different. It may authorize an agent to manage bills, banking, benefits, or other financial matters, depending on the document’s wording.
Other documents may include:
- Court papers appointing a guardian
- A representative-payee notice for benefit payments
- A trust or estate document relevant to payment
- A written authorization allowing medical-record release
- A do-not-resuscitate or other medical-order document, when applicable
A common misconception is that a financial power of attorney automatically gives someone authority over medical decisions. It does not necessarily do so. The document should be reviewed to determine whether it addresses finances, health care, or both.
Pennsylvania guidance also explains that a guardianship is a court order for a person who has been determined to lack capacity for certain decisions. A residence owner, administrator, or employee generally cannot be appointed as a resident’s power of attorney or guardian under Pennsylvania law. ([pa.gov](https://www.pa.gov/agencies/aging/pa-carekit/caregiving-resources/legal-support-for-caregivers?utm_source=openai))
What should be included in the admission agreement?
The resident or authorized representative will usually sign a written agreement explaining the living arrangement and financial responsibilities. Before signing, review:
- Base monthly charges
- Services included in the regular fee
- Additional charges for medication assistance, transportation, or higher care needs
- Rules for deposits, refunds, and late payments
- How care needs are reassessed
- Circumstances that could require a transfer or discharge
- Personal belongings and lost-property procedures
- Medication storage and administration policies
- Visitation, smoking, pets, and overnight absence rules
- Notice requirements for ending the agreement
Pennsylvania’s Department of Human Services encourages families to review resident contracts and ask about optional services and additional fees. Monthly costs and service charges can vary significantly between residences. ([pa.gov](https://www.pa.gov/agencies/dhs/resources/aging-physical-disabilities/personal-care-homes?utm_source=openai))
The agreement should be understandable to the resident. If a person has difficulty reading, hearing, or understanding the terms, ask for an accessible explanation and confirm who is legally authorized to sign.
How can a family organize the paperwork?
A simple admissions folder—paper, electronic, or both—can prevent repeated searching for records. Keep copies of:
- The completed medical evaluation
- Medication list and recent medication changes
- Insurance cards
- Advance directives and powers of attorney
- Guardianship or representative-payee papers
- Physician and pharmacy contact information
- Recent hospital discharge instructions
- Immunization and tuberculosis documentation
- The signed resident agreement
- Names and contact information for everyone authorized to receive updates
Bring the original legal documents when possible, but provide copies for the residence’s records. Keep the originals in a secure location rather than placing the only copy in a move-in packet.
The most important practical question is not simply, “What forms are required?” It is, “Who is authorized to sign, receive information, make medical decisions, and handle payment matters?” Clarifying those roles before admission helps protect the resident’s preferences and reduces confusion for family members and staff.
