2025 SLP Checklist

If you have already completed the checklist and only need to upload documents, please include your contact information and scroll down to the document upload section.

Shared Living Provider

First NameLast Name

Is the applicant over 21 years old?

YesNo

Preferred Email*

example@example.com

Phone Number*

Please enter a valid phone number.

Participant

First NameLast Name

Service Coordinator

First NameLast Name

*We will communicate important information by email and texts. This may include agency updates or notifications about emergency situations, for example. What email address and cell number should we use to communicate with you?

BACKGROUND CHECKS

Background checks are required for anyone 18+ living in the home, including participants. This is a required step and needs to be completed before proceeding.

If you haven't already, please complete the online background check form for everyone in the home. These forms can always be found on our website (gmssvt.org) under "Team Resources". Please be sure to fill in all lines as complete as you can so results are not delayed.

Please list the names of everyone 18+ living in your home

Required Documents Check-List

Required Documents (Missing documentation may delay your contract signing and/or may result in your Difficulty of Care payment being to GMSS’ office for pickup

	Check if you will include information in this form. If not, please explain when	Provided elsewhere. Please explain
Copy of driver’s license or other government-issued photo ID
Proof of current homeowners/renters insurance coverage (at least $100,000 liability)
Proof auto liability insurance with minimum limits of $100,000 per occurrence for bodily injury and property damage and $300,00 per accident of the Vermont minimum amounts whichever is greater for any vehicle used to transport the Consumer.
List of respite providers (including addresses and phone numbers)
Copies of signed Peggy’s Law disclosures. *Must be reviewed and signed annually by SLP and all respite providers.
24 Hour Emergency/Crisis Plan
Protected Health Information Disclosure*

*The PHI Disclosure can be found on our webesite's SLP Resource page under medical.

General Reminders

	Yes	No	NA	Comments
As the recipient of room and board, do you understand that you are responsible for providing meals including packed lunches if the participant is going out for the day?
Do you understand that as with any foster care arrangement, if the participant doesn’t have enough money for personal needs or weather-appropriate and necessary clothing, it is the responsibility of the Shared Living Provider to ensure that they are acquired?
Do you understand that all consequences should be natural, not provider-directed, and never punitive?
Do you understand that all required paperwork not completed and submitted in a timely fashion jeopardizes the participant’s funding and may cause a delay in your DOC payment? (ISA, ISP and PCP data collection documents).
Do you agree to never leave the participant alone and unsupervised in the car or in the house unless indicated otherwise in the approved, person-centered plan?
Do you agree to immediately disclose any unlawful conduct, traffic violations, pending investigations, or charges brought against you or any household member to your Service Coordinator?
Do you understand that all weapons and firearms are to be locked up and not accessible to the participant?
Do you understand that electronic references to the participant (i.e. email, social media, etc.) and/or posting images of the participant online are strictly prohibited unless approved in writing by the guardian?
Do you understand that you must always immediately report (by calling the office or, after hours, by calling the emergency on-call team) any incidents as indicated in the Emergency On-Call Guidance for Direct Support Professionals, and do you have that document stored in an easy to access location within your home?
Do you always ensure that a responsible adult (a recognized and trained caregiver for the individual) is substance-free (including but not limited to;prescription pain relievers or drugs that may impact response times, etc.)?
Do you understand that your contract is for 24/7 care and that it is your responsibility to care for the participant – without additional compensation - when the DSP is unavailable due to training, illness, vacation, or position vacancy?
Do you understand that funding for clients in our Adult Family Care Program is based on the participant’s needs and that decline or improvement in the participant’s needs may cause the Difficulty of Care Stipend to increase or decrease accordingly?
Do you understand that it is your responsibility to ensure that the home continues to meet the State’s safety and, if applicable, accessibility requirements, including, but not limited to, working smoke and CO detectors and functioning fire extinguishers?
Do you understand that previously inspected homes must be re-inspected every five years and that regulations may evolve between five-year inspections?
Do you understand that timely completion of all required paperwork (medication administration records, outcomes reporting, etc.; as specific to the individual’s supports) must be completed in a timely manner and submitted to the agency promptly? All paperwork must be received at the office no later than the last day of the following month. [For example, July MARs may be collected during your August home visit but must be received at the office no later than the last day of August.]

Medical/Safety/Training

	Yes	No	NA	Comments
Do you understand that the agency will require you to complete additional training each year?
Do you understand that it is your responsibility to accompany (and, as appropriate to their needs, support) the participant at any hospital visit or medical appointments?
When speaking with doctors and other clinical providers, do you understand that it is important to give only facts (describe what’s been going on) and not make assumptions about the causes of what you are observing?
Are all medications stored only in their original containers and are they always maintained in a locked container whether in your home or when transported / sent with a DSP (Direct Support Professional)?
Do you agree to hand medications to the covering staff/support person rather than have the participant carry it or packing it in the overnight bag?
Do you have a current, written order from the doctor for all medications including over the counter drugs and supplements (including those applied topically), in the program book?
Do you agree to maintain the program book with most current EFS and other important information? Does it include the participant’s shared support plan/behavior plan, person-centered plan (PCP, ISA, ISP), housing inspection approval, special care procedure training log (if applicable), etc, and do you review this regularly with your employees?
When an agency manager or on-call responder says the participant needs to be seen by a doctor, do you understand that the expectation is that you will immediately set up an appointment or get the client to the emergency room or an urgent care center?
Do you understand that only the guardian or medical power of attorney can sign to give permission for medical procedures, treatments, hospital admissions and/or discharges?
If the participant is admitted to the hospital or a crisis support setting overnight, are you prepared to spend the night at either place with him/her if the agency deems it necessary to ensure health and safety?
Do you understand that in the case of a serious illness or accident, the participant is to be transported to the hospital via ambulance and not in your personal vehicle?

Respite/Other Supports (Including Natural Supports)

	Yes	No	NA	Comments
Do you understand that, before utilizing respite providers, you must notify the agency of any new hires so that we can collect a signed copy of the Disclosure to Home Provider/Respite Worker (Peggy’s Law), update the EFS, and provide verification that required training has been completed?
Do you understand that you may not use any new respite provider before ARIS has confirmed to you that their background checks have been successfully completed and their hiring is complete?
Do you talk to your respite/support staff about all care needs (supervision requirements, likes and dislikes, how to attend to medical and personal care needs, how to handle behavioral issues, etc.) and do you commit to providing evidence of that training to the agency prior to using them?
Have all your respite providers been trained in participant special care procedures (SCP)? A respite provider cannot provide care until SCP training has been completed by an agency nurse.
Do you agree to always notify in advance both your Service Coordinator, and guardian, if applicable, when the participant is expected to be at respite for more than 2 overnights, or out of state for any reason?
When the participant is with respite/support staff, do you always leave a phone number where you can be reached and remember that you are responsible 24/7?
Do you know how to use the GMSS emergency on call procedures and numbers and do you review that with all respite/support staff?
Do you have a copy of the participant’s mandatory disclosure (Peggy’s Law) ready to present to your respite/support staff?
Do you inform respite/support staff that they may never care for more than two participants at the same time and do you ask enough questions to ensure the participants will be safe while together if they will be caring for a second person?
Do you instruct respite staff/support people to remain alcohol and drug free when caring for the participant?
Do you insist that your respite/support staff provide a tobacco free environment in all rooms of the house while the participant is present and in any vehicle occupied by the participant?

List of All Current RespiteProviders

	Name	Phone	Address	Does provider have recently signed Peggy’s Law and will it be uploaded with this form?
Provider
Provider
Provider
Provider

NECESSARY FOLLOW-UP BY (Who must do what by when?)

	What	Who	When
Item 1
Item 2
Item 3
Item 4

Your signature below verifies that you understand and commit to upholding all contractual obligations. Should you have any questions, you must discuss them with an agency representative before signing a contract.

You acknowledge understanding that any failure to comply with contractual obligations will result in your check being sent to the office where you will be able to pick it up once the situation has been corrected or, if needed, a correction action plan has been put into place to ensure compliance.

Signature

Copy of driver’s license or other government-issued photo ID

Proof of current homeowners/renters insurance coverage (at least $100,000 liability)

Proof of current auto insurance coverage (at least $100,000 liability)

Copies of signed Peggy’s Law disclosures (SLP and Respite)

24 Hour Emergency/Crisis Plan

Protected Health Information Disclosure

Signed Residency Agreement (only applies to Developmental Services)

HCBS Person Centered Service Plan

2025 Shared Living Provider Contract Checklist