36C24218R0185-005.pdf

Request for Exclusionary Criteria Exemption

Date of request

Community Nursing Home Information

Name of CNH

Name of Administrator

Address 1

Address 2

City

State

Zip Code

Phone

VAMC Information

Name of VAMC

Name of contact for CNH program

Address 1

Address 2

City

State

Zip Code

Phone

Exclusionary Criteria documented

Check all that apply

Three level "G" or worse deficiencies in the current survey The total number of health requirement deficiencies are twice the State average in the current survey RN hours per resident day are below the state average Total Nursing staff hours per resident day are below the state average Six or more of the CMS Quality Measures listed in Nursing Home Compare fall above the state average A level "E" or higher deficiency in the current survey, in one of the following areas:

F221 or F222 (Restraints) F223 ( Abuse) F225 or F226 [Staff treatment of patients (includes background check)] F353 (Nursing services) F241 (Dignity) F491 (Licensure) F494 or F495 or F496 (Nursing aide training) F497 (Regular in-service training) F498 (Proficiency of nursing aides F499 (Staff qualifications)

Please describe the reasons for request for exemption

Plan of Correction and Oversight

Date of receipt of CNH action plan

Timeline for full implementation of action plan

Frequency of VAMC employee visits to CNH during action plan

Date of next oversight visit

Medical Center Director's digital signature

Network Director's digital signature

VA Central Office Review

GEC Policy Comments

GEC Policy's digital signature

GEC Operations's Comments

GEC Operations's digital signature

Date Exemption Expires