Credentialing Attestation for Assisted Living Residence Providing Enhanced & Specialized Services

State of Rhode Island Assisted Living Certification Standards

Facilities requesting certification to provide enhanced level and/or specialized-level service (dementia care) must provide the following information and attach applicable policy and procedures and submit to Neighborhood Health Plan of Rhode Island (Neighborhood) for review. By signing below, the facility is attesting to meeting the qualification, licensure requirement and has capacity to provide the services outlined on the State of Rhode Island’s Medicaid Community-Based Supportive Living Program (CSLP) Certification Standards issued in November 2015. CSLP certification standards can be found above. Facility must be a credentialed Neighborhood’s network provider to provide these services. This form must be completed by an authorized individual of the facility. Neighborhood retains the right to conduct a quality on onsite assessment prior to approving the facility for services, or in response to a complaint received from a member pertaining to quality of the environment or service.

Note: Questions indicated with a ¹ is applicable to providers doing Specialized (Dementia) service only.

Facility Name*

Address*

Street Address Address Line 2 City State ZIP Code

Phone*

Fax*

Facility NPI*

Name of Facility Administrator*

Indicate Enhanced-Level(s) of Service*

Tier A Basic
Tier A Enhanced
Tier C Memory Care*

Level of Licensure

Appropriate level of licensure with Department of Health (DOH) in good standing*

Appropriate level of licensure with Department of Health (DOH) in good standing *

Yes
No
N/A

Facility has had no significant enforcement actions from DOH during the twelve (12) months (provide documentation from DOH)*

Facility has had no significant enforcement actions from DOH during the twelve (12) months (provide documentation from DOH) *

Yes
No
N/A

Fire Code Classification - Level F1 licensure 1*

Fire Code Classification - Level F1 licensure ¹ *

Yes
No
N/A

Medication Classification - Level M1 licensure 1*

Medication Classification - Level M1 licensure ¹ *

Yes
No
N/A

Services

Facility has capacity to provider specialized services1 specifically to address the needs of a resident diagnosed with dementia, including but not limited to: - Cognitive assessment and care planning - Therapeutic activities - Behavioral health & home stabilization services provided in coordination with beneficiary’s plan by a licensed professional*

Facility has capacity to provider specialized services¹ specifically to address the needs of a resident diagnosed with dementia, including but not limited to: - Cognitive assessment and care planning - Therapeutic activities - Behavioral health & home stabilization services provided in coordination with beneficiary’s plan by a licensed professional *

Yes
No
N/A

Assistance with bathing & toilet use for residents who require assistance, including encouragement and cueing*

Assistance with bathing & toilet use for residents who require assistance, including encouragement and cueing *

Yes
No
N/A

Policy and Procedures (policy must be submitted with this attestation for review)

Policy and procedure to manage residents who may 1 wander or elope, which include actions to be taken and people to be notified*

Policy and procedure to manage residents who may ¹ wander or elope, which include actions to be taken and people to be notified *

Yes
No
N/A

Please attach applicable policy (to manage residents who may wander or elope)*

Accepted file types: pdf, Max. file size: 5 MB.

Resident’s grievance process is available and documented including those with respect to behavior of other residents*

Resident’s grievance process is available and documented including those with respect to behavior of other residents *

Yes
No
N/A

Please attach applicable policy (Resident’s grievance process is available and documented)*

Accepted file types: pdf, Max. file size: 5 MB.

There is written policy and procedure on safety measures to protect against self-injury*

There is written policy and procedure on safety measures to protect against self-injury *

Yes
No
N/A

Please attach applicable policy (safety measures to protect against self-injury)*

Accepted file types: pdf, Max. file size: 5 MB.

There is a written policy and procedure to address staff absenteeism and staff coverage*

There is a written policy and procedure to address staff absenteeism and staff coverage *

Yes
No
N/A

Please attach applicable policy (staff absenteeism and staff coverage)*

Accepted file types: pdf, Max. file size: 5 MB.

Staff

Facility employs sufficient staffing to respond to the needs of residents, including sleeping and waking patterns*

Facility employs sufficient staffing to respond to the needs of residents, including sleeping and waking patterns *

Yes
No
N/A

Staff has training consistent with level of services to be provided*

Staff has training consistent with level of services to be provided *

Yes
No
N/A

Facility has access to an on-call licensed practitioner (MD, NP, RN, PA) 24 hours day / 7 days per week*

Facility has access to an on-call licensed practitioner (MD, NP, RN, PA) 24 hours day / 7 days per week *

Yes
No
N/A

Personnel records include the qualifications of all professional and non-professional personnel, including evidence of current state licensure as applicable*

Personnel records include the qualifications of all professional and non-professional personnel, including evidence of current state licensure as applicable *

Yes
No
N/A

There is an employee orientation in place and documented*

There is an employee orientation in place and documented *

Yes
No
N/A

Personnel records include the qualifications of all professional and non-professional personnel, including evidence of current state licensure as applicable*

Personnel records include the qualifications of all professional and non-professional personnel, including evidence of current state licensure as applicable *

Yes
No
N/A

Proof of staff training in Dementia is documented and1 current*

Proof of staff training in Dementia is documented and¹ current *

Yes
No
N/A

Performance evaluations are conducted at least every 12 months and in-service education is offered based on the outcome of the evaluation*

Performance evaluations are conducted at least every 12 months and in-service education is offered based on the outcome of the evaluation *

Yes
No
N/A

Environment (must meet at least one)

Facility dedicates solely to the care of individuals with 1 dementia, including Alzheimer’s disease*

Facility dedicates solely to the care of individuals with ¹ dementia, including Alzheimer’s disease *

Yes
No
N/A

Facility is organized into designated, separate units 1 dedicated solely to the care of individuals with dementia, including Alzheimer’s disease*

Facility is organized into designated, separate units ¹ dedicated solely to the care of individuals with dementia, including Alzheimer’s disease *

Yes
No
N/A

Facility is arranged in separate or closed areas with1 separate units dedicated solely to the care of individuals with dementia, including Alzheimer’s disease*

Facility is arranged in separate or closed areas with¹ separate units dedicated solely to the care of individuals with dementia, including Alzheimer’s disease *

Yes
No
N/A

Facility has a written emergency evacuation plan, periodically rehearsed with procedures to be followed in the event of internal or external emergency state licensure as applicable*

Facility has a written emergency evacuation plan, periodically rehearsed with procedures to be followed in the event of internal or external emergency state licensure as applicable *

Yes
No
N/A

Authorized Individual/Title*

(Print Name)

Date*

Signature of Authorized Individual*

Date*

Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.

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