Landlords/providers must have a written agreement with people who are receiving services in Community Integrated Living Arrangements (CILA), Community Living Facilities (CLF) and Children's Group Homes (CGH) (when provided in a licensed setting). This sample residency agreement can be used to document that people have been informed of and agree to the process the landlord/provider must follow before ending services/housing.
Once signed and completed:
- The person and legal representative must receive a copy.
- The provider/landlord must maintain a copy in the individual's record.
This residency agreement is between individual/tenant ______(enter tenant's name)______________ or ________(enter guardians' name, if applicable)__________________ and landlord/provider ________(enter name of CILA/CLF/CGH provider name)_______ located at ________(enter tenant's address)______________.
NOTE: Are you your own guardian? ____YES ____ NO (Place an X in the appropriate blank space)
Type of home and community-based service provided by the landlord/provider
(Place an X in the blank space if applicable)
____ Community Integrated Living Arrangements
____ Community Living Facility
____ Children's Group Home
Rent/Room and Board
In this section, document the rent or room and board, the due date for rent or room and board and where/how the rent will be received. Designate the specific unit that the individual will have (including a description of the specific bedroom).
Rights and Responsibilities
In this section, share the individual's rights and responsibilities as tenant.
- Share information regarding the individual's Waiver rights, as outlined on the Rights of Individuals form [IL462-1201].
- Outline the individual's responsibilities (i.e., maintaining his/her living space and not engaging in activities that disrupt or potentially cause harm to other residents).
- Outline the individual's rights as required under the HCBS Settings Rule including:
- Each individual has privacy in their sleeping and living unit:
- Units have entrance doors lockable by the individual, with only appropriate staff having keys to doors.
- Bedrooms have doors that are lockable by the individuals occupying the room, with only appropriate staff having keys to the doors. Access to bedrooms by staff is limited to situations described within the residency agreement and to emergencies where the health/safety/wellbeing of the occupants is jeopardized.
- Individuals sharing units and/or bedrooms have a choice of roommates in that setting.
- Individuals have the freedom to furnish and decorate their sleeping and living units as long as decorations do not damage the unit. In the case of common areas within a shared living unit, individuals are expected to collaborate with housemates/roommates. The provider agency will facilitate this process, as needed.
- Individuals have the freedom and support to control their own schedules and activities.
- Individuals have access to food at any time.
- Individuals are able to have visitors of their choosing at any time. (Supports may be needed to protect the rights and privacy of others living in the home.)
- Any modification of the conditions above must be supported by a specific assessed need and justified in the Personal Plan.
Individual ending a residency agreement
If an individual chooses to move:
- The individual should work with their ISC case manager to plan the move. The ISC case manager will help the individual talk to the landlord/provider and tell them about their plans.
- The landlord/provider will support the individual to move to another setting and ensure a coordinated transition to the new provider.
Landlord/provider ending a residency agreement
If the landlord/provider determines that they no longer can provide CILA, CLF or CGH services to an individual, the individual may be required to move, pending whether they appeal the decision and the outcome of the appeal. If this happens, the individual will receive advanced notice and have the right to appeal the decision. The following will occur if services are terminated:
- The landlord/provider will notify the individual or legal representative, as defined by Rule 115, and the ISC case manager, in writing, of the intended service termination.
- The notice will be provided at least 60 days before the proposed effective date of service termination.
- The written notice of a proposed service termination will include all of the following elements:
- The reason for the action.
- A summary of measures taken to minimize or eliminate the need for service termination, and why these measures failed to prevent the termination (this element will not be required when service termination is a result of the program ceasing operation).
- The individual's right to appeal the termination of services under Rule 115.
- The individual's right to seek a temporary order staying the termination of services according to the procedures in Rule 115.
- The provider must follow the grievance policy, temporary service suspension policy, service termination policy and Rule 115.
Individual's signature ________________________________________________________ Date ____________________
Legal representative's signature ________________________________________________________ Date ____________________
Provider representative's signature ________________________________________________________ Date ____________________