"Cmp Request Form - Long Term Care Residents' Trust Fund" - Delaware

Cmp Request Form - Long Term Care Residents' Trust Fund is a legal document that was released by the Delaware Health and Social Services - a government authority operating within Delaware.

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Download "Cmp Request Form - Long Term Care Residents' Trust Fund" - Delaware

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DELAWARE HEALTH AND SOCIAL SERVICES
Health Care Quality
Division of
CMP REQUEST FORM
LONG TERM CARE RESIDENTS’ TRUST FUND
Date of Request: ___________________________
MM/DD/YYYY
PART I:
Background Information
Name of the Organization Submitting Request:
______________________________________________________________________
Address Line 1:_________________________________________________________
Address Line 2:_________________________________________________________
City, County, State, Zip Code: _____________________________________________
Tax Identification Number: ________________________________________________
CMS Certification Number, if applicable: _____________________________________
Medicaid Provider Number, if applicable: _____________________________________
Contact Name: ____________________________ Phone #: _____________________
Name of the Project Leader: _______________________________________________
Address: ______________________________________________________________
City, County, State, Zip Code: _____________________________________________
Internet E-mail Address: __________________________________________________
Phone #: _______________________ Cell Phone #:___________________________
1
Organization Name: _______________________________________________________________________
Date: ____________________________
DELAWARE HEALTH AND SOCIAL SERVICES
Health Care Quality
Division of
CMP REQUEST FORM
LONG TERM CARE RESIDENTS’ TRUST FUND
Date of Request: ___________________________
MM/DD/YYYY
PART I:
Background Information
Name of the Organization Submitting Request:
______________________________________________________________________
Address Line 1:_________________________________________________________
Address Line 2:_________________________________________________________
City, County, State, Zip Code: _____________________________________________
Tax Identification Number: ________________________________________________
CMS Certification Number, if applicable: _____________________________________
Medicaid Provider Number, if applicable: _____________________________________
Contact Name: ____________________________ Phone #: _____________________
Name of the Project Leader: _______________________________________________
Address: ______________________________________________________________
City, County, State, Zip Code: _____________________________________________
Internet E-mail Address: __________________________________________________
Phone #: _______________________ Cell Phone #:___________________________
1
Organization Name: _______________________________________________________________________
Date: ____________________________
Please list the names of Delaware certified nursing homes that will benefit from this
request:
______________________________________________________________________
______________________________________________________________________
Have other funding sources been applied for and/or granted for this proposal?
___ Yes ___ No
If yes, please explain/identify sources and amount.
______________________________________________________________________
______________________________________________________________________
______________________________________________________________________
PART II:
Applicable to Certified Nursing Home Applicants
Name of the Facility: _____________________________________________________
Address Line 1: _________________________________________________________
Address Line 2: _________________________________________________________
City, County, State, Zip Code: _____________________________________________
Telephone Number: _____________________________________________________
CMS Certification Number: ________________________________________________
Medicaid Provider Number: _______________________________________________
Date of Last Recertification Survey: _________________________________________
MM/DD/YYYY
Highest Scope and Severity Determination: (A – L) ____________________________
Date of Last Complaint Survey: ____________________________________________
MM/DD/YYYY
Highest Scope and Severity Determination: (A – L) ____________________________
2
Organization Name: _______________________________________________________________________
Date: ____________________________
Currently Enrolled in the Special Focus Facility (SFF) Initiative? ___ Yes ___ No
Previously Designated as a Special Focus Facility?
___ Yes
___ No
Participating in a Systems Improvement Agreement?
___ Yes
___ No
Administrator’s Name: ___________________________________________________
Owner of the Nursing Home: ______________________________________________
CEO Telephone Number: _________________________________________________
CEO Email Address: _____________________________________________________
Name of the Management Company: ________________________________________
Chain Affiliation (please specify): ___________________________________________
Name and Address of Parent Organization: ___________________________________
______________________________________________________________________
Outstanding Civil Money Penalty?
___ Yes
___ No
Nursing Home Compare Star Rating: (can be 1, 2, 3, 4 or 5 stars) _________________
Date of Nursing Home Compare Rating: _____________________________________
MM/DD/YYYY
Is the Nursing Home in Bankruptcy or Receivership?
___ Yes
___ No
If an organization is represented by various partners and stakeholders, please attach a
list of the stakeholders in the appendix.
NOTE: The entity or nursing home which requests CMP funding is accountable and
responsible for all CMP funds entrusted to it. If a change in ownership occurs after
CMP funds are granted or during the course of the project completion, the project leader
shall notify CMS and the DHCQ within five calendar days. The new ownership shall
be disclosed as well as information regarding how the project shall be completed. A
written letter regarding the change in ownership and its impact on the CMP Grant
application award shall be sent to CMS and the DHCQ.
3
Organization Name: _______________________________________________________________________
Date: ____________________________
Part III:
Project Category
Please place an “X” by the project category for which you are seeking CMP funding.
_____
Direct Improvement to Quality of Care
_____
Resident or Family Councils
_____
Training/Education
_____
Culture Change/Quality of Life
_____
Consumer Information
_____
Resident Transition Preparation
_____
Resident Transition due to Facility Closure or Downsizing
_____
Other: Please specify: _________________________________________
______________________________________________________________________
Part IV:
Funding
Amount Requested: $____________________________________________________
Part V:
Proposed Period of Support
From: ________________________
To: ________________________
MM/DD/YYYY
MM/DD/YYYY
4
Organization Name: _______________________________________________________________________
Date: ____________________________
For Parts VI through XII, below, type/put all the required information starting on
page 6 and ending on page 20 (the maximum length of the submission).
Part VI:
Expected Outcomes
Project Abstract
Statement of Need
Program Description
Part VII:
Results Measurement
Part VIII:
Benefits to Nursing Home Residents
Part IX:
Consumer/Stakeholder Involvement
Part X:
Involved organization(s)
Part XI:
Budget and Narrative
Part XII:
Appendices
5
Organization Name: _______________________________________________________________________
Date: ____________________________