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 AlabamaAlaskaAmerican SamoaArizonaArkansasCaliforniaColoradoConnecticutDelawareDistrict of ColumbiaFloridaGeorgiaGuamHawaiiIdahoIllinoisIndianaIowaKansasKentuckyLouisianaMaineMarylandMassachusettsMichiganMinnesotaMississippiMissouriMontanaNebraskaNevadaNew HampshireNew JerseyNew MexicoNew YorkNorth CarolinaNorth DakotaNorthern Mariana IslandsOhioOklahomaOregonPennsylvaniaPuerto RicoRhode IslandSouth CarolinaSouth DakotaTennesseeTexasUtahU.S. Virgin IslandsVermontVirginiaWashingtonWest VirginiaWisconsinWyomingArmed Forces AmericasArmed Forces EuropeArmed Forces Pacific 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 LicensureAppropriate 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)* Yes No N/A Fire Code Classification - Level F1 licensure <sup>1</sup>* Yes No N/A Medication Classification - Level M1 licensure <sup>1</sup>* Yes No N/A ServicesFacility has capacity to provider specialized services<sup>1</sup> 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* Yes No N/A Policy and Procedures (policy must be submitted with this attestation for review)Policy and procedure to manage residents who may <sup>1</sup> 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* 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* 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* Yes No N/A Please attach applicable policy (staff absenteeism and staff coverage)*Accepted file types: pdf, Max. file size: 5 MB.StaffFacility 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* Yes No N/A 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* Yes No N/A 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* Yes No N/A Proof of staff training in Dementia is documented and<sup>1</sup> 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* Yes No N/A Environment (must meet at least one)Facility dedicates solely to the care of individuals with <sup>1</sup> dementia, including Alzheimer’s disease* Yes No N/A Facility is organized into designated, separate units <sup>1</sup> 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 with<sup>1</sup> 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* Yes No N/A Authorized Individual/Title* (Print Name)Date* MM slash DD slash YYYY Signature of Authorized Individual*Date* MM slash DD slash YYYY Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network. 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