nys doh assisted living formsnys doh assisted living forms

(5) any environmental modifications that will be made to protect the health, safety and welfare of the residents. Guidance, Current Update: Nursing Home Visitor Testing and Screening for COVID-19 March 17, 2023: The purpose of this health advisory is to announce that NYSDOH is fully aligning with the Centers for Medicare and Medicaid Services. Chapter XIII - Medical Use of Marihuana - Part 1004 of Title 10 of the NYCRR has been repealed and replaced by a new Part 113 of Title 9 of the NYCRR, under the jurisdiction of the Office of Cannabis Management. Section 608.4 - Adjustment distribution. (7) information on the ownership of the property interests in such facility, including: the name and address and a description of the interest held, or proposed to be held, by each of the following persons: (i) any person who, directly or indirectly, beneficially owns any interest in the land on which the facility is located; (ii) any person who, directly or indirectly, beneficially owns any interest in the building in which the facility is located; (iii) any person who, directly or indirectly, beneficially owns any interest in any mortgage, note, deed of trust or other obligation secured in whole or in part by the equipment used in the facility, or by the land on which or the building in which the facility is located; (iv) any person who, directly or indirectly, has any interest as lessor or lessee in any lease or sublease of the land on which or the building in which the facility is located; (v) any person who, directly or indirectly has any interest as a lessor or lessee in any lease or sublease of the equipment used in the building in which the facility is located; if any person named in response to paragraph (1) of this subdivision is a partnership, then the name and address of each partner; (vi) if any person named in response to subparagraph (i) of this subdivision is a corporation, other than a corporation whose shares are traded on a national securities exchange or are regularly quoted in an over-the-counter market or which is a commercial bank, savings bank or savings and loan association, then the name and address of each officer, director, stockholder and, if known, each principal stockholder and controlling person of such corporation; and. (1) Assisted living residences may apply for enhanced and/or special needs assisted living certification for either all or a portion of their licensed beds. 505.35 Assisted living programs. Section 505.34 - Chronic care management demonstration programs. Section 603.4 - Other redistribution and adjustment requirements. Enjoy smart fillable fields and interactivity. Our state-specific browser-based blanks and clear guidelines eradicate human-prone mistakes. Assisted Living Residence (ALR): Provides or arranges for housing, on-site monitoring, and personal care services and/or home care services in a home-like setting to five or more adult residents. Section 679.2 - Groups of social services districts. Title: Section 505.35 - Assisted living programs. Latham, NY 12110 Make sure to check the Closure Forms section below for further resources to assist in the closing process. Adult Home (AH): Provides long-term residential care, room, board, housekeeping, personal care, and supervision to five or more adults. Section 502.4 - Disclosure by providers and fiscal agents; information on owner. Section 513.4 - Obligations and responsibilities of the ordering practitioner and potential provider. The application shall be accompanied by a certified copy of a resolution of the board of a corporate applicant authorizing the undertaking which is the subject of the application, and the subscribing and submission thereof by an appropriately designated individual. (k) Expedited application for additional enhanced or special needs ALR Beds. Section 505.32 - Nurse practitioner services. Section 540.7 - Requirements for billing. Enriched Housing Program (EHP): Provides long-term residential care to five or more adults, primarily people sixty-five years of age or older, in community-integrated settings resembling independent housing units. Section 518.3 - Liability for overpayments. The assisted living program must have a contract with the social services district in which the assisted living program is operating, in accordance with section 494.4(h) of this Title. Section 650.7 - Medical convalescent or nursing homes which are incorporated, Part 651 - PUBLIC ASSISTANCE REPORTS - OTDA. Part 601 - PROCEDURES OF REIMBURSEMENT CLAIMING. Part 801 - PROMPT PAYMENT POLICY OF THE NEW YORK STATE HOMELESS HOUSING AND ASSISTANCE CORPORATION - OTDA & OCFS, Chapter XX - Youth Facilities Project Guarantee Fund - OTDA & OCFS, Part 1001 - GENERAL REQUIREMENTS RELATING TO APPLICATIONS FOR GUARANTEE OF A LOAN - OTDA & OCFS, Part 1002 - TERMS AND CONDITIONS FOR GUARANTEE OF A LOAN OF A LENDING INSTITUTION - OTDA & OCFS, Part 1003 - PROMPT PAYMENT POLICY OF COMMUNITY FACILITIES PROJECT GUARANTEE FUND - OTDA & OCFS. Section 679.3 - Commissioners of districts in Group I: minimum qualifications, Section 679.4 - Commissioners of districts in Group II: minimum qualifications, Section 679.5 - Commissioners of districts in Group III: minimum qualifications, Section 679.6 - Commissioners of districts in Group IV: minimum qualifications. (2)identification of all officers, directors and stockholders; (f)if the applicant has any not-for-profit corporation members, fully executed copies of their Certificates of Incorporation and Bylaws which must include sufficient powers and purposes to own membership interests in the applicant LLC; (g)if the applicant has any LLC members, (vi) arrange for the reduction or discontinuance of an MA recipient's services when the assisted living program reassesses the recipient and determines that the recipient's assisted living program services must be reduced or discontinued. Guidance Ordering COVID-19 Vaccine in NYSIIS Updated June 28, 2022 - Providers (outside of NYC) enrolled in the NYSDOH COVID-19 Vaccination Program can place COVID-19 Vaccine orders in NYSIIS, via the Manage Orders module. Within 10 working days of receipt of the assessment from the assisted living program, the social services district must review the assessment and take one of the following actions: (i) agree with the assisted living program's assessment and arrange for the authorization of the appropriate payment for care for 45 days; or, (ii) conduct its own assessment and based upon the findings of that assessment, agree with the assisted living program's assessment, and arrange for the authorization of the appropriate payment for 45 days; or. Section 609.5 - Conditions of cost reimbursement. Section 519.11 - Scheduling and adjourning the hearing. The ALR must be located within either a licensed adult home or enriched housing program. Section 513.0 - Policy, purpose and scope. Section 514.3 - Electronic eligibility verification system. Section 542.2 - Designation of providers as agents to file subrogated claims. (8) Any other information requested by the Department that the Department may deem necessary for the evaluation of the application, provided the information is not duplicative of what is otherwise required of the applicant in obtaining an adult care facility operating certificate. Find Providers by Clicking on a County Below, Printable Directory of All Home Care Agencies, Printable Directory of All Adult Care Facilities, Diagnostic and Treatment Centers (Clinics), Provider Network Datasets on Health Data NY, Consumer Information Guide: Assisted Living Residence, New York State Department of Health website, Adult Care Facilities/Assisted Living Resources, Requesting Copies of Adult Care Facility Surveys. Such plan must be in accordance with the requirements set forth in this Part. 13 British American Blvd Suite 2 (i) Such fee shall be comprised of a base fee per license issued or biennial license renewal, plus an additional fee for each resident whose annual income is above four hundred percent of the federal poverty level for the year in which the license is issued or renewed. Latham, NY 12110 Section 510.1 - Qualifications of chiropractors. (o) Failure to implement an application. Part 609 - CONDITIONS AND STANDARDS FOR REIMBURSEMENT CLAIMING. Section 517.14 - Rate adjustments after audit. (1)fully executed copies of their Partnership Agreements, and Special Needs Assisted Living Residence (SNALR): Provides services to individuals with special needs, including individuals with dementia or cognitive impairments. 03/08) Rev. SubChapter I - Acquisition of Real Property for Department Purposes, Part 700 - PAYMENTS TO AN OWNER OR TENANT OF RESIDENTIAL PROPERTY OR COMMERCIAL PROPERTY UPON THEIR APPLICATION FOR ALLOWANCE OF MOVING EXPENSES IN VACATING PROPERTY ACQUIRED BY THE DEPARTMENT - OTDA, SubChapter J - Commission for the Visually Handicapped - OTDA, Part 725 - PENSION PLAN FOR BLIND VENDING STAND OPERATORS - OTDA, Part 726 - APPLICATION FOR AUTHORIZATION TO REPRESENT GOODS AND ARTICLES AS BLIND MADE OR PROCESSED PRODUCTS PURSUANT TO SECTIONS 396-f AND 396-g OF THE GENERAL BUSINESS LAW - OTDA, Part 727 - CONFIDENTIAL NATURE OF RECORDS OF THE COMMISSION FOR THE VISUALLY HANDICAPPED - OTDA, Part 728 - THE EQUIPMENT LOAN FUND FOR THE DISABLED - OTDA, SubChapter K - Standards for Office Space and Facilities, SubChapter L - Homeless Housing and Assistance Program, Part 800 - HOMELESS HOUSING AND ASSISTANCE PROGRAM. Section 504.7 - Continued enrollment termination. (1) The contract executed between the assisted living program and the social services district in which the program is operating must provide that the program will assume all responsibility for case management of the residents. In the event that an application is to be submitted by an entity which necessarily remains to be legally formed, it shall be subscribed and submitted by one of the proposed stockholders, directors, members, or another appropriately designated person. Section 521.1 - General requirements and scope, Section 521.3 - Compliance Program Required Provider Duties, Section 521.4 - Determination of Adequacy of Compliance Program, Part 522 - PAYMENT FOR PRE-SCHOOL CHILDREN WITH HANDICAPPING CONDITIONS, Section 522.1 - Payment for medical care, service and supplies provided, Part 527 - STATE REIMBURSEMENT FOR PAYMENT TO OUT-OF-STATE PROVIDERS OF MEDICAL CARE AND SERVICES. Applicants who submit applications subsequent to withdrawing an application pursuant to paragraph (2) of this subdivision must pay all applicable fees. Section 508.5 - Provision of C/THP services. (6) that in the case of an applicant which does not have an existing valid adult home or enriched housing program operating certificate as of the time of submission of the application for licensure as an assisted living residence, such applicant complies with the provisions for certification as prescribed by Article 7 of the Social Services Law. (4) Applicants must pay the licensure fees provided for in this section for each adult home and/or enriched housing program operating certificate that is to be issued, amended to include licensure as an assisted living residence, certification as an enhanced assisted living residence, or certification as a special needs assisted living residence, or biennially renewed. Section 732-1.3 - Change in ownership or control of Preferred Provider Organization. Section 504.2 - Application for participation. Section 511.7 - Additional service units pending determination of applications. The granting of such extension of time shall be at the discretion of the Department, provided such extensions are not for more than 60 days and the Department is satisfied as to the reasons why such information or documentation could not be obtained within the prescribed time. Individuals/Families. For more information, see below for link. (m) Administrative withdrawal of applications by the Department. Section 505.11 - Rehabilitation services. (3)adoption or approval of facility operating policies and procedures and independent adoption of policies affecting the delivery of facility services; Section 508.6 - Identification of available providers. There are two ways to submit a complaint: The Nursing Home Complaint Form Nursing Home Complaint Hotline (1-888-201-4563) The Hotline can be called 24 hours per day 7 days per week and is staffed by Nursing Home and ICF/MR Surveillance staff from 8:30 a.m. to 4:45 p.m. Monday through Friday. (1)direct independent authority over the appointment of the administrator, approval of all other persons working in the facility and dismissal of all persons working in the facility; Section 505.29 - Foster family care demonstration programs. Section 603.3 - Program or activity redistribution. All such fees received by the Department shall be nonrefundable. (5)approval of facility debt necessary to finance the cost of compliance with operational or physical plant standards required by law; (iii) conduct its own reassessment and, based upon the findings of that reassessment, disagree with the assisted living program's reassessment and forward to the local professional director, or designee, both reassessments for review and final determination of the appropriate payment, which determination must be made within five working days of receipt of the request. An application may be amended while the application is pending before the Department. Section 502.5 - Time and manner of disclosure. Section 635.5 - Federal participation in payments for MA. The Assisted Living Unit is the lead unit for overseeing and enhancing regulatory compliance for assisted living programs in the State by ensuring compliance to standards to assure the safety and well-being of the individuals residing in the programs. Part 537 - STATE REIMBURSEMENT FOR OPTOMETRIC SERVICES, Section 537.3 - Reimbursement for payment to self employed and salaried optome, Section 537.4 - Reimbursement for payments to dispensing opticians and other, Part 538 - STATE REIMBURSEMENT FOR TELEHEALTH SERVICES, Section 538.2 - Modalities and applicable standards, Part 540 - AUTHORIZATION OF MEDICAL CARE, Section 540.1 - Authorization as basis for payment for medical assist. 1 . be designated within the building as the need arises. Part 677 - MAINTENANCE OF PERSONNEL INFORMATION. New York State Department of Health ASSISTED LIVING RESIDENCE Division of Home and Community Based Services MEDICAL EVALUATION DOH 3122 (Dev. (vii) if any corporation named in response to subparagraph (i) of this subdivision is a corporation, whose shares are traded on a national securities exchange or are regularly quoted in an over-the-counter market or which is a commercial bank, savings bank or savings and loan association, then the name and address of the principal executive officers and each director and, if known, each principal stockholder of such corporation. Section 1001.7 - Admission and Retention Standards, Section 1001.8 - Consumer and Resident Protections, Section 1001.9 - Resident Funds and Valuables, Section 1001.13 - Structural and Environmental Standards, Section 1001.14 - Disaster and Emergency Planning, Section 1001.15 - Inspection and Enforcement, Chapter XI - Limits on Administrative Expenses and Executive Compensation, Part 1002 - Limits on Administrative Expenses and Executive Compensation, Section 1002.2 - Limits on Administrative Expenses, Section 1002.3 - Limits on Executive Compensation, Chapter XII - Innovative Delivery Models, Part 1003 - Accountable Care Organizations, Section 1003.3 - Certificate of Authority, Section 1003.4 - Application Requirements, Section 1003.5 - Medicare-Only ACOs Sharing Losses, Section 1003.6 - Legal Structure and Responsibilities, Section 1003.8 - Leadership and Management, Section 1003.9 - Quality Management and Improvement Program, Section 1003.10 - Quality Performance Standards and Reporting, Section 1003.11 - Payment and Third Party Health Care Payers, Section 1003.14 - Legal Protections; State Action Immunity. Section 504.6 - Acceptance of an application. Part 520 - Tax Refund Offset for Overpayments of Medical Assistance. Section 540.6 - Billing for medical assistance. (3) In accordance with section 494.4(h) of this Title, a copy of the assessments for any MA recipient determined appropriate to participate in the assisted living program must be transmitted to the social services district which is financially responsible for the MA recipient. Part 502 - DISCLOSURE OF INFORMATION BY PROVIDERS AND FISCAL AGENTS. For purposes of this section, the term applicant shall include proposed incorporators, directors, members, sponsors, sole proprietors or partners of the operator or proposed operator. Section 504.9 - Service bureaus, billing services and electronic media billers. Section 511.11 - Pharmacy services - utilization threshold. (c) In order to operate as enhanced assisted living or special needs assisted living, an operator must be licensed as an assisted living residence, and must obtain additional certification as either enhanced assisted living or special needs assisted living. Section 505.24 - Blood, plasma or related products. (5) The fees referenced in this subsection (p) shall be in the amount or amounts specified in statute. Section 511.2 - Notification to applicants and recipients. Section 519.13 - Examination of file before hearing. The New York State Department of Health licenses and regulates adult homes, enriched housing programs, and residences for adults, collectively known as adult care facilities. ( ) FACILITY MUST SUBMIT COMPLETED FORM WITHIN 48 HOURS OF ADMISSION/DISCHARGE OR ANY CHANGE IN PATIENT STATUS. The social services district fiscally responsible for furnishing MA is the district in which the ALP resident resided immediately prior to his or her admission to the ALP if the resident was not a recipient of MA at the time of his or her admission, or the district responsible for furnishing MA to the ALP resident immediately prior to his or her admission to the ALP if the resident was a recipient of MA at the time of his or her admission. (viii) where the applicant is a limited liability company, the application must include the following documentation: (a)a photocopy of the applicants fully executed Articles of Organization, and any amendments thereto, containing purposes which authorize the establishment and operation of an assisted living residence and if applicable, an enhanced assisted living residence or a special needs assisted living residence, in accordance with the provisions of section 1001.3 of this Part, subject to the prior written approval of the Department. (a) Purpose and scope. Such plan shall include, but need not be limited to: (1) a written description of specialized services; (4) work experience of individuals (operators staff or contractors) providing services to residents; (5) professional affiliations or special characteristics relevant to serving persons with special needs; and. Part 616 - REFUGEES, ENTRANTS AND OTHER NONCITIZENS OF NEW YORK STATE. Section 507.4 - Medical rehabilitation and mental health. Applications for licensure as an assisted living residence must be filed with the Department. (j) Application Requirements for Special Needs Assisted Living Certification. (1) Applications may be filed simultaneously with an application for licensure as an adult home or enriched housing program. The Nursing Home Complaint Form is available online to submit your complaint against a nursing home. Section 655.1 - Local districts responsibilities. Residents who are eligible for Medicaid or Supplemental Security Income payments are presumptively at or below 400% of the federal poverty level. This version reportedly . Section 502.3 - Determination of ownership or control percentages. Section 542.3 - Assignment of subrogated claims proceeds to providers. Part 621 - HOME RELIEF REIMBURSEMENT CLAIMING OTDA, Part 625 - ASSISTANCE FOR DEPENDENT CHILDREN REIMBURSEMENT CLAIMING - OTDA, Part 626 - FEDERALLY REIMBURSED AID TO DEPENDENT CHILDREN REIMBURSEMENT CLAIMING - OTDA, Part 627 - CHILD SUPPORT ENFORCEMENT REIMBURSEMENT CLAIMING - OTDA, Part 628 - CHILD CARE AND FOSTER CARE REIMBURSEMENT CLAIMING - OTDA, Part 629 - JOBS OPPORTUNITIES AND BASIC SKILLS TRAINING REIMBURSEMENT CLAIMING - OTDA, Article 4 - Supplementary Assistance Reimbursement Claiming, Part 633 - SERVICES FOR RECIPIENTS AND OTHERS; REIMBURSEMENT CLAIMING - OTDA, Part 634 - SUPPLEMENTARY SECURITY INCOME AND ASSISTANCE FOR THE AGED, BLIND AND DISABLED REIMBURSEMENT CLAIMING, Part 635 - MEDICAL ASSISTANCE REIMBURSEMENT CLAIMING. Submitting Notices to OOLTC: Assisted living providers are required to submit certain notices to the Office of . (1) Assisted living program means an entity, as defined in section 485.2(s) and section 494.2(a) of this Title, which has been approved to operate as an assisted living program in accordance with section 485.6(n) of this Title and is operated in accordance with Parts 485, 486, 487, 488 and 494 of this Title. Forms. 1/09 Page 1 of 4 ALL SPACES MUST BE FILLED OUT Facility Name: _____ Date of Exam: _____ Section 505.35 - Assisted living programs. Need more information about services and providers right for you? Section 505.33 - Personal emergency response services (PERS). Section 650.3 - Child-caring agencies and institutions (annual financial reports). Adult Care Facilities/Assisted Living; Home Care & Hospice; Hospitals & Clinics; New York State Veterans Homes; Nursing Homes; . (1) At any time during the application review and approval process, the Department may request an applicant to submit information that is missing from the application; to submit information in addition to that described in this section and/or on the application form; or to submit more current information than that in its application. Section 508.7 - Agreements with providers. All fees will be forfeited and will not be refunded. Section 508.4 - Informing persons eligible for C/THP services about C/THP. Section 518.7 - Withholding of payments. Section 609.6 - Other conditions and standards. A certified operator of enhanced or special needs assisted living may apply, on an expedited basis, for Department approval of up to five additional beds to serve current residents of the operators licensed residence who would be appropriate for residence in such certified setting. Section 540.5 - Authorization by public welfare officials. Section 655.2 - Expungement of identifying information. ACFs should begin using new form immediately. Section 601.2 - Documentation and summaries. October 17, 2022 DOH Issues Q and A Regarding ACF Mental Health Evaluation Form Q and A on DOH Form 5075 November 23, 2021 Section 533.7 - Preferred Physicians and Children Program. Find and Compare New York Health Care Providers. Guidance on Transportation Assistance Levels The Department of Health (DOH) posted information regarding the Transportation Assistance Levels (TALs) on the Health Commerce System (HCS). Part 680 - SPECIFICATIONS FOR LOCAL SOCIAL SERVICES POSITIONS. Section 519.9 - Authorization of representative. Section 511.13 - Mental health clinic programs - utilization threshold. July 7, 2022 NY Project Hope, a FEMA-funded program of the NYS Office of Mental Health, provides emotional support to help NYS residents navigate through the challenges caused by the ongoing pandemic. Section 655.3 - Reimbursement for parallel processing. Learn more about your options by reading our Consumer Information Guide: Assisted Living Residence or visit the New York State Department of Health website. (1)fully executed copies of their Certificates of Incorporation which must include sufficient powers and purposes to own membership interests in the applicant LLC, and The ALP provides personal care, room, board, housekeeping, supervision, home health aides, personal emergency response services, nursing, physical therapy, occupational therapy, speech therapy, medical supplies and equipment, adult day health care, home health services, and the case management services of a registered professional nurse. (2) Every assisted living residence that applies for an enhanced assisted living certificate or a special needs assisted living certificate shall pay an additional non-refundable initial and biennial fee, in addition to any other required licensure fee, in an amount set forth in statute. Part 637 - FOOD STAMPS REIMBURSEMENT CLAIMING - OTDA, Part 638 - ENERGY ASSISTANCE REIMBURSEMENT CLAIMING - OTDA, Part 639 - OTHER ASSISTANCE REIMBURSEMENT CLAIMING - OTDA, Part 650 - REPORTS OF PRIVATE INSTITUTIONS AND AGENCIES. 518.867.8383 Living Arrangement Form . (h) The applicant shall provide any information and documentation requested by the Department within 60 days of such request, unless the applicant obtains from the Department an extension of the time in which to provide such information or documentation. (iii) conduct its own assessment and based upon the findings of that assessment, disagree with the assisted living program's assessment and forward both assessments to the local professional director, or designee, for review and final determination of the appropriate payment, which determination must be made within five working days of receipt of the request. Section 500.5 - Reimbursement and payment for appointments not kept. Failure to provide such information or documentation within the time prescribed may constitute an abandonment and withdrawal of the application by the applicant. . Section 680.1 - Position specifications. Each resident shall receive and the facility shall provide: (1) food prepared by methods that conserve nutritive value, flavor and appearances; (2) food that is palatable, attractive, and at the proper temperature; (3) food prepared in a form designed to meet individual needs; and The failure, neglect or refusal of an applicant to obtain a license and commence operation as an assisted living residence within one year of issuance of approval or contingent approval of the application shall constitute an abandonment of the application by the applicant and any approval or contingent approval issued by the Department shall be deemed cancelled and withdrawn. For more information about these services including assisted living, visit our page about adult care facility services. Members may recall that LeadingAge NY had concerns when the form was originally issued and provided DOH with recommendations and feedback. Section 533.8 - Human immunodeficiency virus enhanced fees for physicians, Part 535 - STATE REIMBURSEMENT FOR PAYMENT TO DENTISTS. Licensure and certification fees associated with applications that have not been implemented are forfeited and will not be refunded. The district must review every reassessment that is transmitted by the assisted living program for reauthorization of payment by the MA program. Section 520.2 - Withholding of State tax overpayments. Section 603.2 - Redistribution and adjustment. (g) Case management. Section 518.5 - Recovery of overpayments; procedure. Such plan shall include, but need not be limited to: (4) work experience of individuals (operators staff or contractors) who will provide services to residents; and. Report (FSR) to the New York State Department of Health in accordance with Article 28 of the Public Health Law and Part 412 of the Medical Facilities Code of Department regulations (10 NYCRR 412). . If the LLC has any members that are partnerships, identification of each member of the member partnership and a statement that all members of the member partnership are natural persons; (e)if the applicant has any business corporation members, Adhere to our simple steps to have your Nys Doh Reporting Manual well prepared quickly: Choose the template in the library. NAME OF INDIVIDUAL COMPLETING THIS FORM (Please print) TITLE TELEPHONE NO.