CTR076593_Archie_Hendricks_SR_Skilled_Nursing_Facility_dba_Tohono_OODHAM_Assisted_Living__A1.pdf
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- Attached to
- Master Agreement AZ|CTR076593
- Contract number
- CTR076593
- Issued by
- Arizona
About this file
This document is a Contract Amendment issued by the Arizona Department of Economic Security, specifically Amendment Number One to Contract Number CTR076593. The contract involves Archie Hendricks Sr Skilled Nursing Facility, doing business as Tohono O'odham Elder Assisted Living Residence, an assisted living facility contractor.
The amendment focuses on modifying Section 7.3 of the original contract, which pertains to Incident Reporting Requirements. The key change requires the contractor to submit incident reports as defined in specific medical policy manuals, with particular emphasis on reporting sentinel events. Sentinel events must be immediately reported by phone to designated division numbers and then submitted via the AHCCCS QM Portal within one business day. The amendment provides multiple reference links for reporting procedures, user guides, and portal access, while maintaining that all other contract terms and conditions remain unchanged.
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Text version
CONTRACT AMENDMENT
Arizona Department of Economic Security
1789 W Jefferson Street, Mail Drop 1541, Phoenix, AZ 85007
CONTRACT NUMBER: AMENDMENT NUMBER:
CTR076593 One(1)
DESCRIPTION/ LABEL: Assisted Living Facility
CONTRACTOR NAME: Archie Hendricks Sr Skilled Nursing Facility dba Tohono O'odham Elder Assisted Living Residence
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 7.3. Incident Reporting Requirements is hereby removed in its entirety and replaced as follows:
7.3 Incident Reporting Requirements
The Contractor Shall:
7.3.1 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
7.3.1.1 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
7.3.1.2 The AHCCCS QM Portal can be accessed through following links:
AHCCCS QM Portal login page AHCCCS QM Portal FAQ page
7.3.1.3 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_RegistrationAccountMgmt_Provider.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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