This government document is issued by Human Services for use in Pennsylvania
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https://www.google.com/url?client=internal-element-cse&cx=007572080359491747877:yqjcmted-sw&q=https://www.dhs.pa.gov/providers/Providers/Documents/LTC%2520Providers/DCW%2520Qualification%2520Form.pdf&sa=U&ved=2ahUKEwjDvb2f_fCFAxXQgf0HHVjUBQY4RhAWegQIARAB&usg=AOvVaw31x0iS2QiUpyEoT0MtizqM&arm=e