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

Instructions for "Cmp Request Form - Long Term Care Residents' Trust Fund" - Delaware Download Pdf
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DELAWARE HEALTH AND SOCIAL SERVICES
Health Care Quality
Division of
Instructions to
Request Approval for Use of
C
M
P
F
IVIL
ONEY
ENALTY
UNDS
C
N
H
FOR
ERTIFIED
URSING
OMES
F
ROM THE
’
L
T
C
R
ONG
ERM
ARE
ESIDENTS
T
F
RUST
UND
D
ELAWARE
J
2015
UNE
DELAWARE HEALTH AND SOCIAL SERVICES
Health Care Quality
Division of
Instructions to
Request Approval for Use of
C
M
P
F
IVIL
ONEY
ENALTY
UNDS
C
N
H
FOR
ERTIFIED
URSING
OMES
F
ROM THE
’
L
T
C
R
ONG
ERM
ARE
ESIDENTS
T
F
RUST
UND
D
ELAWARE
J
2015
UNE
INTRODUCTION
The Social Security Act specifies that civil money penalty (CMP) funds paid by nursing
homes may only be used to enhance the quality of care and quality of life of the
residents of nursing homes certified to participate in Titles 18 & 19 of the Social Security
Act.
CMP funds shall not be used for non-nursing home residents. An individual discharged
from a nursing home is no longer a nursing home resident and CMP funds are not
available for that individual except for the relocation or transport of such a person to
another setting.
In accordance with Survey & Certification transmittal 12-13-NH dated December 16,
2011, States must obtain approval from the Centers for Medicare & Medicaid Services
(CMS) for the use of federally imposed CMP funds. A copy of this transmittal is
available on the CMS website at www.cms.hhs.gov.
Effective January 1, 2012, CMS has established a process for reviewing applications
that seek funding to improve resident outcomes in certified nursing homes. Only CMP
fund applications that meet the statutory intent of the regulations, Federal law and policy
will be considered.
It is hoped that this CMP funds request process will promote consistency, transparency
and best practices.
Requests to use CMP funds may be made by various organizations and entities.
Applications may be submitted by certified nursing homes, academic or research
institutions, state, local or tribal governments, profit or not-for-profit, or other types of
organizations.
1
CMP REQUEST PROCESS
 Entities from which CMP requests originate shall submit the request to the Division
of Long Term Care Residents Protection (DHCQ) for an initial review and
recommendation.
 All CMP requests shall be submitted electronically and sent to the DHCQ utilizing
the Application Form.
 Requests will not be accepted via facsimile.
 Requests shall include a cover letter addressed to the DHCQ Licensing Unit
Manager. The cover letter should introduce your organization, explain the purpose
of the project and contain a summary of your proposal. The letter should include the
amount of funding that you are requesting, the population it will serve, and the need
it will help solve. Make a concerted effort to bring your project to life in the cover
letter and actively engage the reader.
 Requests shall include an Excel spreadsheet with the budget expenses for the
project, along with a narrative explanation of the costs. Mention any co-funding that
you are planning to use from other sources. The narrative shall include the specific
amount of CMP funds to be used for the project, the time period for such use, and
an estimate of any non-CMP funds that will be contributed to the project.
 CMP request forms will only be accepted if the project described will improve the
quality of care or quality of life of residents residing in federally certified nursing
homes.
 The font for all CMP requests is Times New Roman, 12 point, and shall include the
entity name and page numbers on all documents. Documents from outside sources
(i.e. letters of support) do not have to conform to the font requirements.
 Requests should be limited to no more than 20 pages, including appendices and the
actual CMP request form.
 All sections of the request form shall be completed or the CMP request may be
denied.
 When CMP funds are requested for educational purposes, the organization involved
must also include the following: anticipated number of attendees; target audience;
accrediting authorities; and timeline for implementation and plan for sustainability.
 Provide letters of support as deemed appropriate. Representatives from any group
2
requesting funding, or representatives who are in situations where a conflict of
interest exists, must disqualify themselves from making recommendations or
providing letters of support.
 DHCQ reviewers shall first assess the merit of each project and the ability of the
project to improve resident outcomes and advance the care and services provided in
certified long term care facilities.
 The DHCQ may request additional information.
 Applicants may contact the DHCQ with questions regarding their CMP request.
3
COMPLETING SPECIFIC SECTIONS OF THE CMP REQUEST FORM
Part I
Background Information
Fill in all applicable information. Do not leave any area blank. If the section
does not apply, insert N/A.
Part I
For use by certified nursing facilities applying for grant funding. All other
entities, insert N/A for all information requested.
Part III
Check the type of project for which funding is requested.
Part IV
Specify amount of funding requested.
Part V
Specify beginning and ending dates of project.
Attachments A through G - Beginning on page 5 of the request, through page 20
(maximum length), provide information for the items given below. Attachments A
though F are required. Attachment G (Appendices) is to be included as needed.
A
Expected Outcomes (Project Abstract, Statement of Need; Program
Description). Provide an abstract summary of the project that is no longer
than one page. Include the requester’s background and qualifications, the
need for the project, a brief description of the project and its goals and
objectives. Of the utmost importance is information regarding how the project
will be evaluated to measure the success of the programs. Specify the
person(s) who will be accountable for the project evaluation.
The statement of need should describe the problem that the project will
attempt to address. Also describe any problems that may be encountered in
the implementation of this project. Articulate the contingency plan to address
these issues.
Describe the project or program and provide information on how it will be
implemented. Include information on what will be accomplished and the
desired outcomes. A timeline shall accompany all proposals which outline
benchmarks, deliverables and dates. Attach supplemental materials in the
appendices.
When CMP funds are requested for educational purposes, the organization
involved must also include the following: anticipated number of attendees;
target audience; accrediting authorities; and timeline for implementation and
plan for sustainability.
B
Results Measurement. Include a description of the methods by which the
4
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