DVACO Preferred Skilled Nursing Facility Application Form 2016

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Demographic Information

Date Completed * +

Form Completed By: *

Facility Name/ DBA (If Applicable) *

Number of Licensed Beds in Facility

Number of Medicare certified Beds

Number of Medicaid certified Beds

Number of Short Term Beds

Number of Long Term Care Beds

Please list your commercial contracts:

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*

	Name	Contact Phone	Email
SNF Administrator	Name	Contact Phone	Email
SNF Medical Director	Name	Contact Phone	Email
Director of Nursing	Name	Contact Phone	Email
Admissions Coordinator	Name	Contact Phone	Email

Facility Physical Address *

Corporate or Home Office Address (If Applicable)

Name of facility parent organization (If Applicable)

1. Describe your QAPI program , membership, tools used, quality measures addressed. *

2. Are you participating in bundled payments or other value-based programs?

Yes

No

If so, describe.

3. Is internet service available for patient use? *

Yes

No

4. Describe your medical record keeping system(s), EMR/Paper, etc. *

0/500 words

5. Do you currently participate in Patient PING or the Health Information Exchange of Southeastern Pennsylvania (HSX) for notifications of SNF admissions, discharges and transfers for DVACO members? *

Yes

No

6. If your facility is not enrolled in PatientPing, will you be able to enroll and become active for the event notification by 1/1/2017?

Yes

No

Not applicable: We are already enrolled in PING or the Health Information Exchange of Southeastern PA.

Organizational Structure

7. How many new Medicare Fee-For-Service patients can you admit to your SNF on an annual basis? *

Less than 25 Medicare Fee-For-Service Patients

Greater than 25 Medicare Fee-For-Service Patients

8. What is the tenure of your current SNF administrator (years/months with facility)? *

Greater than 2 Years

Less than 2 Years

9. What is the tenure of your DON? *

Greater than 2 Years

Less than 2 Years

10. Is your DON an active member of the Pennsylvania Association of Directors of Nursing Administration (PADONA)? *

Yes

No

11. Does your Medical Director have CMD certification? *

Yes

No

12. Is your facility acknowledged by the Pennsylvania Dept. of Insurance as a Continuous Care Retirement Community? *

Yes

No

13. Does your facility use INTERACT tools? *

Yes

No

14. If you are using INTERACT tools, which modules are you using? *

Clinical Capabilities and Medical Coverage

15. Is your SNF facility willing to review and implement DVACO clinical guidelines when they are develeoped by the DVACO? (Example: daily weights for heart failure patients) *

Yes

No

16. Does this facility have 24/7 coverage of nurses capable of initiating and managing IV’s? *

Yes

No

17. Are there nurses in your facility with the ability to manage PICC Lines? *

Yes

No

18. Is this facility able to manage nutrition involving TPN? *

Yes

No

19. Is this facility able to manage nutrition involving tube feedings? *

Yes

No

20. Describe your SNF respiratory therapy services? *

21. Are the respiratory therapists available onsite? *

Yes

No

Hours?

22. Are the respiratory therapists provided through a vendor contract?

Yes

No

23. Does your facility manage patients with tracheostomies? *

Yes

No

24. Does your facility manage patients on ventilators?

Yes

No

25. Does your facility manage patients with chest tubes? *

Yes

No

26. Describe your facility's laboratory services. *

27. Please list the Laboratory Providers utilized by your SNF.

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28. Does your facility have STAT Lab availability? *

Yes

No

If yes, describe.

29. Does SNF facility have the ability to complete 7 day a week INR, CoagU Check? *

Yes

No

30. Is physical therapy available on weekends? *

Saturday

Sunday

Not Available on Weekends

31. Are PT/OT therapists employed by facility or contract? *

Yes

No

Please list your contract agencies (if applicable)

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32. Please describe your facility's end of life care planning program. *

33. Does your facility have a policy on POLST? *

Yes

No

34. Do your attending SNF physicians routinely make weekend visits? *

Yes

No

35. What is your facility standard policy for turnaround time for completion of the admission history and physical? *

Less than 2 days

Greater than 2 days but less than 7 days

Greater than 7 days

36. Please select the days of the week of Physician/Nurse Practitioner onsite presence at your facility. *

37. Please describe any telehealth of telemonitoring programs currently in use at your facility. *

38. Is your facility able to assure delivery of durable medical equipment such as wound VACS, CPAP machines, within six hours of a patients admission to the SNF Facility?

Yes

No

39. Describe facility supply chain approach for delivery of equipment such as wound vacs, CPAP machines. Are these available within 6 hours of patient admission to the facility? *

Communication and Transitional Care Management

40. Will your SNF support attendance of a Administrator and Director of Nursing , or qualified representatives, for a monthly (thirty minute to one-hour) DVACO meeting? *

Yes

No

41. Is the SNF Medical Director willing to attend quarterly, one-hour meetings with DVACO? *

Yes

No

42. Is there SNF nurse staff available for “nurse to nurse handover” of new patient admission? *

Yes

No

43. Is the SNF Attending Physician available for “physician to physician handover” discussion upon SNF patient admission or discharge?

Yes

No

44. Does the SNF facility identify AND notify the patient’s Primary Care Provider during the SNF admission and discharge? *

Yes

No

45. How quickly can your facility respond regarding SNF Bed Availability? *

Less than 4 Hours

4-8 Hours

Greater than 8 Hours

Greater than 24 Hours

46. Does the SNF have a single point of contact for DVACO care coordinator interaction? *

Yes

No

If yes, please list name of contact and phone number. *

47. Does SNF facility restrict the time of day for an admission? *

Yes

No

If yes, please describe.

48. Does SNF accept admissions 24/7? *

Yes

No

49. Does SNF accept admissions on weekends? *

Yes

No

50. Is the facility willing to collabroate on the need for and selection of home health providers to serve DVACO complex patients? *

Yes

No

51. Please list the name of the Home Health Agencies utilized by your SNF for DVACO beneficiaries that are discharging to home.

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Quality and Performance Measures

Information for questions 52 and 53 will be completed by DVACO based on CMS claims data from 4/1/15 through 3/31/16 and paid through 6/30/16.

52. Medicare FFS Average Length of Stay

DVACO Internal Use Only: Less than or equal to the DVACO report average for length of stay. To be completed with data from CMS DVACO claims from 4/1/15 through 3/31/16 and paid through 6/30/16

Less than DVACO Average for ALOS

Equal to DVACO Average for ALOS

Greater than DVACO Average for ALOS

53. Medicare FFS Post-Acute Readmission Rate

DVACO Internal Use Only: To be completed with data from CMS DVACO claims from 4/1/15 through 3/31/16 and paid through 6/30/16

Less than DVACO Post- Accute Readmission rate

Equal to DVACO Post- Accute Readmission Rate

Greater than DVACO Post- Accute Readmission Rate

CMS Nursing Home Compare Results (Publicly Reported Data)

54. Overall Star Rating *

55. Health Inspection *

56. Staffing *

57. Quality Measures *

58. Improvement in Function

Greater than 90%

75%-89%

50-88%

Less than 50%

59. Hospitalized After Nursing Home Admission *

0%-15%

16%-20%

21%-24%

Greater than 24%

60. Had an Outpatient ED Visit *

0%-10%

11%-25%

Greater than 25%

61. Percent of Successfully Discharged into the Community *

Greater than 90%

60-89%

50%-59%

Less than 50%

62. Additional Comments about Staffing Metrics (optional)

63. Does your SNF make appointments with the patient’s primary care provider prior to discharge from the facility? *

Yes

No

64. Does your SNF make a phone call to the Primary Care Provider upon the patient’s discharge? *

Yes

No

65. Please describe your facilities bed hold policy?

66. Under what conditions will your facility NOT take a patient back?

67. Does your facility complete a post-discharge satisfaction survey for all residents? *

Yes

No

Attachments

Signature

To ensure your application to DVACO is complete, you must have answered all required questions. Once you select the Submit button, you will not be able to modify your responses. If you would like to attach supporting documentation, please select the attachment button located in the ATTACHMENTS section.

Application Certification:

I have read the contents of this application. I certify that I am legally authorized to execute this document and to bind my facility to comply with the applicable laws and regulations of the Medicare program. By my signature, I certify that the information contained herein is true, accurate, and complete, and I authorize DVACO to verify this information. If I become aware that any information in this application is not true, accurate, or complete, I agree to notify DVACO of this fact immediately and provide the correct and/or complete information. By selecting the check box below, you are certifying the application. Note: DVACO will not process your application if this certification is not complete.

I agree *

clear

I Agree with the Terms and Conditions

*

Submitted By: *

Date * +