CTR066610_Villa_Ocotillo_ALC_LLC_dba_Ocotillo_Place__Assisted_Living__A10.pdf
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- Attached to
- Master Agreement AZ|CTR066610
- Contract number
- CTR066610
- Issued by
- Arizona
About this file
This document is a Contract Amendment issued by the Arizona Department of Economic Security for Contract Number CTR066610, Amendment Number Ten (10). The contract involves Villa Ocotillo ALC LLC doing business as Ocotillo Place, an Assisted Living Facility located in Arizona.
The amendment specifically modifies Section 6.3 of the contract's Scope of Work regarding Incident Reporting Requirements. The updated section mandates that the contractor submit incident reports as defined in multiple medical policy manuals, including the DDD's Medical Policy Manual 961, DDD Provider Manual Chapter 70, and AHCCCS Medical Policy Manual. Notably, the amendment requires immediate reporting of Sentinel Events to the Division via phone (602-375-1403 or 1-855-375-1403) and subsequent submission through the AHCCCS QM Portal within one business day of occurrence. The amendment provides multiple reference links for portal access, user guides, and FAQ resources to support the contractor's compliance with the new reporting requirements.
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CONTRACT AMENDMENT
Arizona Department of Economic Security
1789 W Jefferson Street, Mail Drop 1541, Phoenix, AZ 85007
CONTRACT NUMBER: AMENDMENT NUMBER:
CTR066610 Ten (10)
DESCRIPTION/ LABEL: Assisted Living Facility
CONTRACTOR NAME: Villa Ocotillo ALC LLC dba Ocotillo Place
THE ABOVE REFERENCED CONTRACT IS HEREBY MODIFIED AS FOLLOWS:
In accordance with the Uniform Terms and Conditions, Section 5, Contract Changes, the Scope of Work, Section 6.3.
Incident Reports is hereby removed in its entirety and replaced as follows:
6.3 Incident Reporting Requirements
The Contractor Shall:
6.3.1 Submit Incident Reports as defined in the DDD’s Medical Policy Manual 961, DDD Provider Manual Chapter 70 and AHCCCS Medical Policy Manual -Chapter 961 as may be amended.
Division Medical Policy Manual 961 Division Provider Manual Chapter 70
AHCCCS AMPM 961
6.3.1.1 Sentinel Events shall be reported to the Division immediately at 602-375-1403 or 1-855-375-1403(phone lines are available 24 hours a day, weekdays, weekends and holidays) and must then be submitted via the AHCCCS QM Portal within one (1) business day of the occurrence of the event.
AHCCCS QM Portal Migration User Guide
6.3.1.2 The AHCCCS QM Portal can be accessed through following links:
AHCCCS QM Portal login page AHCCCS QM Portal FAQ page
6.3.1.3 The AHCCCS QM Portal User Guides can be found at the links below:
AHCCCS PROVIDER USER GUIDE
AHCCCS IAD Submit User Guide AHCCCS Return IAD User Guide AHCCCS Approve IAD User Guide
ALL OTHER REQUIREMENTS, SPECIFICATIONS, AND TERMS AND CONDITIONS REMAIN UNCHANGED
ACKNOWLEDGEMENT AND AUTHORIZATION
This Amendment shall be fully executed by means of electronic approval in APP.
https://des.az.gov/sites/default/files/media/Division_Medical_Policy_Manual_961_Incident_Accident_and_Death_Reporting.pdf?time=1761096186787 https://des.az.gov/sites/default/files/media/DDD_Provider_Policy_Manual_Chapter_70_Qualified_Vendor_Incident_Reporting.pdf?time=1717792726488 https://www.azahcccs.gov/shared/Downloads/MedicalPolicyManual/900/961.pdf https://docs.google.com/document/d/17V9leTt-Mf9lPUSaOFTqQRz_7jGNutPfKi4m9WcQ6IA/edit?tab=t.0%23heading=h.arsfm1vhtwua https://qmportal.azahcccs.gov/Account/Login.aspx https://qmportal.azahcccs.gov/Account/FAQ.aspx https://qmportal.azahcccs.gov/UserGuides/QuickStart_RegistrationAccountMgmt_Provider.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Submit.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Return.pdf https://qmportal.azahcccs.gov/UserGuides/QuickStart_IAD_Report_Approve.pdf
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