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/Licensing/BHSL-Licensing/Documents/Assisted_Living-Documentation_of_Medical_Evaluation.pdf&sa=U&ved=2ahUKEwjDvb2f_fCFAxXQgf0HHVjUBQY4RhAWegQICRAB&usg=AOvVaw1hneu9_h25AOxRDg-pMZNj&arm=e