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Application
| Exhibit B, Long-Term Care Quality Investment Program |
| Application and Budget |
| INSTRUCTIONS: |
| Please fill out the application completely. There are 4 separate parts to this application. You only need to complete information in Parts 1, 3, and 4. Individual fields may have additional instructions alongside the question. Fields that require completion by you are shaded gray, and will have a black outline, once data is entered the field will change from gray to white while retaining the black outline. Some of the gray fields have drop down menus to answer certain questions, these drop boxes appear to the bottom-right of the answer box. These will be arrows that appear when you click inside the gray field. For these fields, just click on the arrow and select your answer. |
| Part 1: Basic Facility Information |
| Please complete each field shaded in gray. |
| | Complete the cells in gray: |
| Facility Name: | |
| (Organization or Institution) Including Legal DBA Name | | List facility name exactlly as registered with PA Department of State and include DBA exactly as registered with PA Department of State, if applicable |
| SAP Facility Name: | |
| (Organization or Institution) | | List facility name exactly as registered in SAP for payment (see page 5 of RFA 67-212) |
| Type of Legal Entity: | |
(Corporation, Partnership, Professional Corporation, Sole Proprietorship, etc.)
| SAP Vendor Number: | List vendor number that matches facility name listed above in row 23 (see page 5 of RFA 67-212) |
| Mailing Address: | Address MUST be in Pennsylvania |
| City, State and Zip Code: | |
| County: | |
| Billing Address, if different than mailing: | |
| City, State and Zip Code, if different than mailing: | |
| County, if different than mailing: | |
| PA Facility License Number (SNF, PCH, or ALF, as applicable): | A separate application is required for each |
licensed facility/site. Each application must include the specific facility license number associated with that location and level of care. Facilities operationg under the same ownership, management company, or legal entity may not submit a combined application. Seperate applications must be submitted for each SNF, PCH, ALF, or ICF license.
| ICF License/NPISL Number (ICFs only): | |
| Number of licensed beds | |
| Primary Contact Name: | |
| Primary Contact Phone Number: | Value must include area code with no special characters or letters |
| Primary Contact Email: | |
| Secondary Contact Name: | |
| Secondar Contact Phone Number: | |
| Secondary Contact Email: | |
| 1. Did your facility particpate in at least one LTC-RISE quality improvement project within the past year? | |
| 2. Did your facility previously participate in the initial Quality Improvement Program (QIP)? | |
3. Additonally, note any other QAPI programming in which you are currently participating.
| Does your facility serve residents with any of the following? Select all that apply. | Behavioral health condition(s): |
| Dementia: |
| Ventilators: |
| Part 2: Facility Budget Information |
| Part 2 does not require any information from you. It is strictly for you to see how much your total amount of money can be, and for you to track how much you can spend as you select the interventions you want to apply for in Parts 3, and 4. These fields are calculated automatically and will update as information is entered or changed in the other parts of this application. If the calculated requested amount exceeds the maximum total budget, an error will appear. If this occurs, please recheck that the amounts you entered are within the limit for that field. |
| Per Bed Budget |
| Maximum Budget |
| Facility Maximum Budget | | $250,000 total max per facility |
| Facility Contribution | $0.00 | |
| Total State Contribution | | |
| Current Estimated Award: | $0.00 |
| Current Remaining Budget: | |
| Part 3: Workforce Track Budget | | | | | | |
| Part 3 is where you may select the interventions or tracks that you want to apply for related to workforce development. Please look over Table 1 in the General Information document for more details about each track. You will need to enter the number of people you want to participate in the tracks you have selected. You will also need to enter the requested dollar amount you think you will need for each person. You can request up to the maximum available budget per person in this field. The total budget for each track will be calculated automatically, and a warning will appear if the total budget exceeds the maximum amount possible. If this occurs, please confirm that the entered information is correct. As you select tracks to apply for here, amounts will be updated in your Current Remaining Budget in Part 2. | | | | | | |
| Maximum Available Budget per Person | Requested Amount Per Person | Number of People | Total Budget | Specify specific program/focus for track | Proposed Program Entity/Name |
| Track 1.A: Leadership Development / Management Training | $5,000.00 | | | $0.00 | | |
| Track 1.B: 120-Hour Nursing Home Administrator Course | $5,000.00 | | | $0.00 | | |
| Track 2: Clinical & Non-Clinical Skills Training – Specialized Skills | $5,000.00 | | | $0.00 | | |
| Track 3: Nurse Aide Training Program | $5,000.00 | | | $0.00 | | |
| | | | $0.00 | | |
| | | | $0.00 | | |
| Part 4: Infrastructure/Technology and Communications Track Budget |
| Part 4 is where you can select interventions/tracks related to infrastructure imrpovements. Please review Table 2 in the General Information document for more details about each track option. This part only requires the requested amount to be entered, if this amount is greater than the maximum allowable for the track then an error will appear. As you select tracks to apply for here, amounts will be updated in your Current Remaining Budget in Part 2. |
For infrastructure interventions over $25,000 a quote is required to be submitted with the application.
| Max available budget | Request Amount for Facility: | | |
| Track 4.A: Telehealth Kiosks | $25,000.00 | | Quote Required | Proposal Required |
| Track 4.B: Internet Access / Wi‑Fi Connectivity | $15,000.00 | | Quote Required | |
| Track 4.C: Call Bell Installation / Upgrades | $50,000.00 | | Quote Required | |
| Track 4.D: Software / Virtual Visits / Resident Wearables | $25,000.00 | | Quote Required | |
| Track 5: Electronic Health Record (EHR) | $125,000.00 | | Quote Required | Proposal Required |
| Track 6.A: Communal / Visitation Space Upgrades | $50,000.00 | | | |
| Track 6.B: Resident Movement / Mobility Equipment | $25,000.00 | | | |
| Track 6.C: Support of Resident Councils | $5,000.00 | | Quote Required | Proposal Required |
| Track 6.D: PCR Point-of-Care Testing Unit | $50,000.00 | | Quote Required | Proposal and CLIA Waiver Required |
Budget
| Exhibit B |
| BUDGET SUMMARY |
| (DOH to fill in if awarded - Insert SAP Funds Commitment #) |
| (Insert Facility Name, from Column B, Row 22 of Application Tab) |
| (Insert SAP Facility Name, from Column B, Row 23 of Application Tab) |
| (Insert SAP Vendor #) |
| (Insert Budget Period) |
| CATEGORY | TOTALS |
| Track 1.A: Leadership Development / Management Training | 0 |
| Track 1.B: 120-Hour Nursing Home Administrator Course | 0 |
| Track 2: Clinical & Non-Clinical Skills Training – Specialized Skills | 0 |
| Track 3: Nurse Aide Training Program | 0 |
| Track 4.A: Telehealth Kiosks | 0 |
| Track 4.B: Internet Access / Wi‑Fi Connectivity | 0 |
| Track 4.C: Call Bell Installation / Upgrades | 0 |
| Track 4.D: Software / Virtual Visits / Resident Wearables | 0 |
| Track 5: Electronic Health Record (EHR) | 0 |
| Track 6.A: Communal / Visitation Space Upgrades | 0 |
| Track 6.B: Resident Movement / Mobility Equipment | 0 |
| Track 6.C: Support of Resident Councils | 0 |
| TOTAL BUDGET (ALL TRACKS) | 0 |