2022 DVACO Preferred Skilled Nursing Facility Application Form - New Applicant

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Demographic Information


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1. Is internet available in patient and/or resident rooms? *
 
2. Do you have an Electronic Medical Record (EMR) ? *
If yes - What EMR system do you use? *
 
Do providers (physicians, NPs) document directly into your Medical Record? *
By what method are lab values recorded in the EMR/paper chart? *
 
3. Does your facility have the ability to obtain insurance authorization for managed care patients prior to admission? *
4. Do you enter admissions and discharges manually into PING? *
5. Does your facility have access to EpicCare link? *
If yes, please select *
 
If no, do you have interest in getting EpicCare Link access through Jefferson Health System/Main Line Health. *

Organizational Structure


6. What is the tenure of your current SNF administrator (years/months with facility)? *
7. What is the tenure of your DON?  *
8. Is your DON an active member of the Pennsylvania Association of Directors of Nursing Administration (PADONA)? *
9. Does your Medical Director have CMD certification? *
10. Is your facility acknowledged by the Pennsylvania Dept. of Insurance as a Continuous Care Retirement Community? *
Please list the FIRST and LAST name of providers and their credentials (Physicians, Physician Assistants and Nurse Practitioners) who provide care to your residents in your skilled and long term care community. *
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Please list the FIRST and LAST name of providers and their credentials (Physicians, Physician Assistants and Nurse Practitioners) who provide care to your residents in your assisted living and independent living community. *
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Please list the FIRST and LAST name of providers and their credentials (Physicians, Physician Assistants and Nurse Practitioners) who provide care to your residents in your skilled and long term care community. *
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Clinical Capabilities and Medical Coverage


11. Please check the Clinical Best Practices you have implemented at your facility (check all that apply) *
13. Approximately what percentage of provider visits are happening via telehealth? *
14. Do you perform N95 fit testing for your staff? *
15. Will you accept new short term COVID patient admissions at your facility? *
 
16. Do you require COVID-19 vaccination for external healthcare providers? *
 
17. 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) *
18. Do you agree to implement the following existing DVACO protocols/guidelines by 6/30/2022:
  • CHF Best Practices
  • COPD Best Practices
  • Sepsis Best Practice
  • LOS Guidelines
  • High ED Utilizer Best Practices
  • End of Life Care Best Practices
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19. Does this facility have the ability to perform EKGs 24/7? *
20. Is this facility able to manage nutrition involving TPN 24/7? *
21. Does your facility manage patients with Tracheostomies 24/7? *
22. Does your facility manage patients on ventilators 24/7? *
23. Does your facility manage patients with chest tubes 24/7? *
24. Does SNF facility have the ability to complete 24/7 INR, CoagU Check? *
25. Do you have the ability to perform dialysis onsite? *
If no, do you provide transportation to dialysis? *
26. Does your facility manage patients with “LifeVest” Wearable Defibrillators 24/7? *
27. Does your facility manage patients on Milrinone drip 24/7? *
28. Does your facility manage patients with a wound vac 24/7? *
29. Does your facility manage patients with advanced CPAP devices such as Trilogy 24/7? *
30. Please check the days of the week that you have respiratory therapists on site. *
31. Is physical therapy available on weekends? *
32. Are PT/OT/SLP therapists who treat your SNF and LTC patients employed by the facility or contract? *
Please check your contract agency: *
 
33. Does your facility complete a POLST for all applicable patients? *
34. What is your facility standard policy for turnaround time for completion of the admission history and physical? *
35. Please select the days of the week of Physican onsite presence at your facility. *
36. Please select the days of the week of Nurse Practitioner onsite presence at your facility. *
37. Do you have a physician or advanced practitioner present every weekend? *
38. Can your facility manage the bariatric population? *
 
39. Does your facility have capability for a secure or locked unit? *

Communication and Transitional Care Management


40. Will your facility commit to providing patient update information to ACO and/or health system care coordinators for our shared populations? *
41. Will your SNF Administrator and Director of Nursing, or qualified representatives commit to attend required DVACO and Jefferson/MLH hospital campus meetings?  *
42. Will the SNF Medical Director commit to attend required meetings with the DVACO and/or the Jefferson/Main Line Health Systems? *
43. Is there SNF nurse staff available for “nurse to nurse handover” of new patient admission? *
44. Is the SNF Attending Physician available for “physician to physician handover” discussion upon SNF patient admission or discharge? *
45. Does the SNF accept new admissions after 6pm? *
46. Are your clinical liaisons available to review patient information for a weekend admission? *
47. 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) *
48. Please select the name(s) of the Home Health Agencies utilized by your Nursing Home/CCRC for DVACO beneficiaries that are discharging to home. *
 
49. Please select the name(s) of the Hospice Agencies you refer to for DVACO beneficiaries that are discharging to home: *
 
50. Please select the name(s) of the Hospice Agencies that you have a hospice contract with to provide care at your facility: *
 
51. Please select the name(s) 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". *
 

Quality and Performance Measures


52. Does your SNF make appointments with the patient’s primary care provider prior to discharge from the facility? *
53. Does your SNF make a phone call to the Primary Care Provider upon the patient’s discharge? *
55. Does your facility perform any type of Care Coordination after SNF Discharge? *
57. Does your facility complete a post-discharge satisfaction survey for all residents? *
58. Does your facility perform a root cause analysis and create and action plan for all hospital readmissions? *
**If yes, please attach the most recent root cause analysis report in our Attachments section below.

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 *
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Required questions contain an asterisk *
Last Updated 09.28.2017