2021 DVACO Preferred Skilled Nursing Facility Application Form - New Applicant

Save & Return

Please create an account and login so you can save and return to the document without losing your information. Do this FIRST!

Demographic Information

Date Completed * +

Form Completed By: *

Title *

Facility Name/ DBA (If Applicable) *

CCN (CMS Certification Number) *

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 *

Prefix

SNF Administrator *

Phone # * 🛈

Email Address *

Prefix

SNF Medical Director *

Phone # * 🛈

Email Address *

Prefix

Nursing Director *

Phone # * 🛈

Email Address *

Prefix

Admission Coordinator *

Phone # * 🛈

Email Address *

Prefix

Best Contact for Care Coordination *

Phone # * 🛈

Email Address *

Care Coordination Contact Title *

Prefix

Other Contact Name

Title

Phone # 🛈

Email Address

Prefix

Other Contact Name

Title

Phone # 🛈

Email Address

Prefix

Other Contract Name

Title

Phone # 🛈

Email Address

Facility Physical Address *

State *

Corporate or Home Office Address (If Applicable)

Name of facility parent organization (If Applicable)

1. Is internet service available for patient use? *

Yes

No

2. Do you have an Electronic Medical Record (EMR) ? *

Yes

No

If yes - What EMR system do you use? *

Point Click Care

Other Other

Do providers (physicians, NPs) document directly into your Medical Record? *

Yes

No

By what method are lab values recorded in the EMR? *

3. Do you enter admissions and discharges manually into PING? *

Yes

No, its automated

We do not use Patient Ping

Who is responsible for manually entering admissions and discharges into PING? *

Title *

Phone # * 🛈

Email Address *

4. Does your facility have access to EpicCare link? *

Yes

No

If yes, please select *

Jefferson Health EpicCare Link

Main Line Health EpicCare Link

Other Other

If no, do you have interest in getting EpicCare Link access through Jefferson Health System/Main Line Health. *

No

Yes, through Jefferson Health System

Yes, through Main Line Health System

Yes, through both

Organizational Structure

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

Greater than 2 Years

Less than 2 Years

6. What is the tenure of your DON? *

Greater than 2 Years

Less than 2 Years

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

Yes

No

10. Does your Medical Director have CMD certification? *

Yes

No

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

Yes

No

Please list the names of providers (Physicians, Physician Assistants and Nurse Practitioners) who provide care to your residents in your skilled and long term care community.

+-

Please list the names of providers (Physicians, Physician Assistants and Nurse Practitioners) who provide care to your residents in your assisted living and independent living community.

+-

Please list the names of providers (Physicians, Physician Assistants and Nurse Practitioners) who provide care to your residents in your skilled and long term care community.

+-

Clinical Capabilities and Medical Coverage

12. Please check the Clinical Best Practices you have implemented at your facility (check all that apply) *

PCP sent a DC summary within 72 hours of DC

PCP visit within 7 days of DC being facilitated

The ability to cohort residents with confirmed or suspected infectious disease

Utilizing DVACO preferred home health partners (Jefferson Home Care, PA & NJ; Main Line Home Care; Bayada Home Care - Cherry Hill Office) upon discharge

Utilizing DVACO preferred hospice partners (Jefferson; Main Line; Holy Redeemer in PA; Samaritan in NJ) upon discharge

None of the above

13. Please Select Your 911 Hospital *

Please list hospital *

14. Approximately what percentage of provider visits are happening via telehealth? *

15. Have you implemented a PPE audit tool to ensure adequate supply? *

Yes

No

16. Do you have the ability to perform N95 fit testing for your staff? *

Yes

No

17. Have you implemented a tool to provide surveillance for infectious disease for your staff? *

Yes

No

18. Have you implemented a tool to provide surveillance for infectious disease for your residents? *

Yes

No

19. Do you have a preexisting relationship with a lab vendor for resident testing? *

Yes

No

20. What is the turn-around time for COVID-19 test results performed at your facility? *

24 hours or less

24-48 hours

48-72 hours

72 hours or greater

Please enter number of days *

21. Is your SNF facility willing to review and implement DVACO clinical guidelines when they are developed by the DVACO and or our owner health systems? (Example: daily weights for heart failure patients, sepsis protocol) *

Yes

No

22. Do you agree to implement the following existing DVACO protocols/guidelines by 6/30/2021:

CHF Best Practices
COPD Best Practices
Sepsis Best Practice
LOS Guidelines
End of Life Care Best Practices

*

Yes

No

23. Does this facility have the ability to perform EKGs 24/7? *

Yes

No

24. Is this facility able to manage nutrition involving TPN 24/7? *

Yes

No

25. Does your facility manage patients with Tracheostomies 24/7? *

Yes

No

26. Does your facility manage patients on ventilators 24/7? *

Yes

No

27. Does your facility manage patients with chest tubes 24/7? *

Yes

No

28. Does SNF facility have the ability to complete 24/7 INR, CoagU Check? *

Yes

No

29. Do you have the ability to perform dialysis onsite? *

Yes

No

If no, do you provide transportation to dialysis? *

Yes

No

30. Please check the days of the week that you have respiratory therapists on site. *

31. Is physical therapy available on weekends? *

Saturday

Sunday

Not Available on Weekends

32. Are PT/OT/SLP therapists who treat your SNF and LTC patients employed by the facility or contract? *

Employed

Contract

Please list your contract agencies

+-

33. Does your facility complete a POLST for all applicable patients? *

Yes

No

34. 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

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

36. Do you have a physician present every weekend? *

Saturday

Sunday

Not available every weekend

37. Does your facility manage patients with “LifeVest” Wearable Defibrillators 24/7? *

Yes

No

38. Does your facility manage patients on Milrinone drip 24/7? *

Yes

No

39. Does your facility manage patients with a wound vac 24/7? *

Yes

No

40. Does your facility manage patients with advanced CPAP devices such as Trilogy 24/7? *

Yes

No

41. Can your facility manage the bariatric population? *

Yes

No

If yes, is there a weight limit? *

42. Does your facility have capability for a secure or locked unit? *

Yes

No

Communication and Transitional Care Management

43. Is your facility willing to communicate patient update information to ACO and/or health system care coordinators? *

Yes

No

44. Will your SNF Administrator and Director of Nursing, or qualified representatives commit to attend DVACO and/or DVACO hospital campus meetings? *

Yes

No

45. Will the SNF Medical Director commit to attend mandatory meetings with the DVACO and/or the Jefferson/Main Line Health Systems? *

Yes

No

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

Yes

No

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

Yes

No

48. Does SNF accept admissions 24/7? *

Yes

No

If no, please describe. *

49. Will you commit to providing guided choice to DVACO preferred Home Health, Hospice and other preferred partners upon discharge from SNF for DVACO patients and DVACO residents in your Long Term Care, Personal Care, and Independent Living Community if also designated as a CCRC? (DVACO Preferred Partners) *

Yes

No

50. Please list the name of the Home Health Agencies utilized by your Nursing Home/CCRC for DVACO beneficiaries that are discharging to home. *

+-

51. Please list the name of the Hospice Agencies utilized by your SNF for DVACO beneficiaries that receive Hospice care at your facility or who are referred to Hospice at the time of discharge from your Nursing Home/CCRC *

+-

52. Please list the name of the outpatient therapy providers utilized by your SNF in your personal care and independent living environments if applicable. If not applicable, please type "N/A". *

+-

53. Are you currently utilizing Real Time Medical Systems Platform *

Yes

No

If yes, please select an option *

Part of the DVACO Pilot

Implemented Real Time Medical Systems independently of the DVACO pilot

54. Do you plan to renew your RTMS contract at the end of the 1-year pilot *

Yes

No

N/A

If no, do you have any plans on implementing Real Time Medical Systems in the coming year? *

Yes

No

Quality and Performance Measures

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

Yes

No

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

Yes

No

57. Please describe your facilities bed hold policy? *

58. Does your facility perform any type of Care Coordination after SNF Discharge? *

Yes

No

If yes, please describe. *

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

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

Yes

No

61. Does your facility create an action plan for all hospital readmissions utilizing a standard format? *

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 * +