Please complete these forms in there entirety. Following the instructions, signing and dating, etc. Also submit in addition to the forms above Information regarding Ownership and Control, including:

List of Board of Directors (including any relationship that exists between BOD or individuals with the same last name
Copy of Federal Employee Identification Number (i.e. letter from the Depart. of Treasury, IRS)
Location of Agency, including street address and all satellite offices (as per eMedNY form)
Copy of provider's licensure, certification, etc, which suport the requested services and satisfies the requirements for being a provider as specified in prospective provider application

Please include agency's Policy & Procedures as part of the application packet. Policy & Procedures must include detailed information pertaining to the Nursing Home and Transition and Diversion Waiver in the following areas:

Basic Orientation
Overview of Disabilities, Aging, etc.
Philosophy of NHTD Waiver
Overview of All Waiver Services
Participants Rights
Serious Reportable Incident Policy and Reporting
Development and Implementation of Detailed Plans
Basic safety and emergency procedures
Effective Interventions during crisis
Methods to provide support/supervision to assure participants health and welfare
Team Meetings
Service Specific Training
Roles/Responsibilities of staff and interactions with RRDC, RRDS, etc.
Record Kepping
Effective Communication
Training Manual/State that the agency agrees to comply with all of DOH certified trainings provided by the RRDC
Annual trainings
Hiring staff/Verifying qualifications
Informing Participants of their Rights and responsibilities
Safety/Medical Emergencies
Internal Incident Reporting & Tracking
Dept. of Health HCBS Reportable Incidents
Accessing Services & Supports on behalf of the participant (Choice of Providers)
Canceling services and/or providing Back up staff
Changing providers
Conacting SC outside of normal working hours (On call policy)
Establishing/Maintaining Participants Contacts & Service Notes
Completing RSPs/ISRs including timeline for supervisory review/Submission of Plan/Addendums to RRDS
P+ P for Billing
Quality Assurance and Assessing Consumer Satisfaction (at least annually)
Results/Findinds of Satisfaction Surveys, Incidents Review, etc.

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