CMS Application Form.pdf

Civil Money Penalty Reinvestment Program Application 1

Civil Money Penalty Reinvestment Program

APPLICATION

All stakeholders interested in applying for Civil Money Penalty (CMP) funds must use these funds exclusively to support projects that enhance the quality of care and life for nursing home residents. Multiple types of stakeholders may submit applications for consideration.

The Civil Money Penalty Reinvestment Program (CMPRP) Application Handbook is the essential reference document that must be consulted throughout the application process. This resource, which can be accessed on the CMS CMPRP webpage on CMS.gov provides the complete list of eligible applicants, detailed guidance for each application section, and all requirements necessary to ensure accurate completion and compliance with program standards.

CIVIL MONEY PENALTY REINVESTMENT PROGRAM APPLICATION SUBMISSION OVERVIEW

1. Use of Application Form Requirement

Applicants submitting a project proposal must use the CMS-Approved Application Form, including the and Budget Spreadsheet. Applications and Budget Spreadsheet that are incomplete or submitted in an unapproved version will not be accepted.

2. Compliance with Requirements Applicants should ensure that the proposed project aligns with CMPRP goals (which benefit nursing home residents and protect or improve their quality of care and life), complies with federal regulations (42 CFR §488.433) and policy guidance, and meets all submission criteria—all of which are detailed in the Application Handbook. To avoid delays in the review process, applicants and State Agencies are strongly encouraged to use the “Application Submission Checklist,” also provided in the handbook, to verify that all required components are complete and compliant.

3. Submission to State Agency Applicants must submit the completed Application Form and accompanying attachments (i.e., the budget spreadsheet, letters of support, list of nursing homes, project results (if applicable), etc.) to the appropriate State Agency for initial review and determination. Once the State Agency determines that the proposed project and application meet both state requirements and the federal requirements outlined in item #2, the State Agency will forward the application to the CMS CMPRP Team via email at: CMP-info@cms.hhs.gov for further review. Applications are only accepted when submitted by the State Agency.

4. Forwarding to the CMS CMPRP Team for Final Determination The CMS CMPRP Team will further review the requirements outlined in item #2. They will make a final determination and issue a decision letter to the designated State Agency CMPRP representative. Refer to the “Application Submission and Review Process” section in the handbook for more details on the review process.

For questions, applicants should contact their designated State Agency CMPRP representative. State contact information can be found in the Application Handbook.

Section I: Applicant Contact and Background

Name of the Individual Completing the Application (First and Last) Job Title Email address

Organization/ Nursing Facility Name Organization Type

Street address City State Zip

Website

CMS Certification Number (CCN) (if the applicant is a nursing facility) Phone Number(s) https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/civil-money-penalty-reinvestment-program https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/civil-money-penalty-reinvestment-program https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/civil-money-penalty-reinvestment-program https://CMS.gov mailto:CMP-info%40cms.hhs.gov?subject=

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SECTION II: Organizational Capabilities

Briefly describe your organization’s experience, expertise, and quality improvement work that shows your capacity to execute this proposed project.

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Section III a: Project Details

Project Title Number of Nursing Homes

Project Duration Anticipated Start Date (mm-dd-yyyy) Anticipated End Date (mm-dd-yyyy)

If the primary applicant is not a nursing home, letters of support from the committed participating nursing homes must be submitted with the application. Refer to the “Letters of Support” section in the Handbook for more information.

Section III b: Previous CMP-Funded Projects

Has this project previously received CMP funding? Yes No

If “Yes,” Please provide the unique identifier (UID; Arbitrary UID for reference: TX-0121-AAA-111) of the original or most recent previously approved project, the dates of the project, and the state(s) of implementation, as applicable.

If additional space is needed, please provide the remaining projects in the same format as an attachment.

UID States Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy)

UID States Start Date (mm-dd-yyyy) End Date (mm-dd-yyyy)

Additionally, the applicant must submit project results to demonstrate successful implementation before duplicating the project in other nursing homes. These results must be reported using the CMS-approved criteria and must show measurable connections to resident care outcomes and quality of life improvements. Emphasis should be placed on how the project’s achievements have directly enhanced resident health, safety, and well-being.

For detailed guidance on required reporting criteria, please refer to the “Project Reporting Requirements” in the Application Handbook.

IMPORTANT: Applicants who have previously received CMP funding and are submitting a new application with the same project focus for expansion must target a different set of nursing homes.

Section IV: Budget

Provide the amount requested for the project duration. The annual project cost may vary. The amount(s) noted in this application MUST be the same as the amount reflected in your budget documentation.

Total CMP Funding Requested Amount Annual Amount Requested (as applicable) Year 1 Year 2 Year 3

Cost-Sharing Amount (if applicable) Per Year, Per Nursing Home Amount (as applicable) Year 1 Year 2 Year 3

Please complete the CMS-approved Application Budget Spreadsheet, which can be accessed on CMS.gov, and include the completed spreadsheet with your application submission. Refer to the Budget Spreadsheet (Excel) for instructions and the “Application Budget Spreadsheet” section in the handbook for guidance on completing it. This budget spreadsheet will reflect a comprehensive, detailed line-item budget outlining specific cost requirements (with justification) within each of the following budget categories (not inclusive): Personnel, Travel, Equipment purchases and rentals, Contractual, Other direct costs, Total indirect costs, and Cost-sharing. Additionally, the budget will include a list of participating nursing homes, including their CMS Certification Number (CCN), name, certified bed count, and duration of project participation.

NOTE: If you are requesting funding that exceeds the maximum category funding amount (i.e., the budget cap), please include justification in the budget spreadsheet for consideration. Justifications may include, but are not limited to, geographic location.

https://www.cms.gov/medicare/health-safety-standards/quality-safety-oversight-general-information/civil-money-penalty-reinvestment-program

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Section V: Project Category and Summary

Please identify the category applicable to this project. Refer to the “Allowable Uses of CMP Funds: Project Categories” section in the Application Handbook.

Categories

Resident and Family Councils

Consumer Information Training to Improve Quality of Care Activities to Improve Quality of Life

Summary of the Project and its Purpose

Please provide specific information regarding the intent and the benefit that implementing this project is expected to have on nursing home residents.

NOTE: Defined goals should be actionable, and objectives must be measurable and aligned with the project’s intended outcomes. Please refer to the “Writing Realistic, Actionable Goals and Quantifiable Objectives” section in the Application Handbook.

A. Describe the problem, gap, or the nursing home need that this project is aiming to address

B. Describe clear, realistic project goals that align with the overall purpose of the initiative. A goal represents a broad, long-term outcome the project aims to achieve.

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C. Describe specific, measurable objectives that outline the actions the applicant will take to achieve the stated goal. Each objective should, minimally include the target, method, and metric used to measure success, and demonstrate a direct impact on resident care or quality of life. Objectives must be achievable within the project timeline and aligned with the intended outcomes.

D. Describe the plan to implement the project, including implementation timeline.

E. List any physical items that will be deliverables as a result of funding this project (e.g., training materials, project evaluation report).

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F. Performance Monitoring, Evaluation, and Sustainability Describe how the project’s performance will be monitored and evaluated throughout its duration, including the specific outcome metrics that will be used to assess progress toward the intended goals. In addition, outline a plan for sustaining the project or its outcomes beyond the conclusion of the project.

Section VI: Supplementary Document Checklist

Please confirm that the following documents are included with the application submission materials. To ensure your Application meets all requirements for successful submission and review by the State Agency and the CMS CMPRP Team, be sure to reference and complete the “Application Submission Checklist” provided in the handbook.

All attachments must be clearly labeled and cross-referenced to the appropriate sections of the application.

Participating Nursing Homes’ Letters of Support

Application Budget Spreadsheet (Excel)

List of Participating Nursing Homes (included in the budget spreadsheet)

Project Results for Previously CMP-Funded Projects (if applicable)

Other Accompanying Documents (if applicable) Please specify the document name, the associated section, and its relevance below.

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Section VII: Submission Confirmation

By signing below, I confirm that this application is accurate and complete and that all required materials have been submitted.

Name of the Applicant (print)

Signature of the Applicant Date of Signature (mm-dd-yyyy)

Date of Application Submission to the State Agency (mm-dd-yyyy) Date of Application Submission to CMS CMPRP Team (mm-dd-yyyy)

Date(s) of Application Resubmission to the CMS CMPRP Team (if applicable)

IMPORTANT: The application must be submitted to the CMS CMPRP Team no later than six (6) months from the date of the submission signature.