Colorado Nursing Facilities Application for Supplemental Programs
         Facility Name:  
         Address:
         Phone:                                                                  Fax#:
         Alt Fax#:                                                             Provider#:
         Name of Person Completing this Application:
         Position:
         Email Address:
         Submission of this application with the documented evidence identified in 
          the application must be submitted by March 31, 2021 for reimbursement 
               starting fiscal year July 01, 2021-June 30, 2022.  All submitted 
                       documentation must be for calendar year 2020.
             Due to COVID-19, facilities may submit modified evidence for items 
          highlighted in yellow: Modified evidence must document how the facility 
           was compliant prior to implmenting COVID-19 procedures, or how the 
         facility would have been compliant if not for implementation of COVID-19 
             procedures.  Existing policies, drafted policies, historical or partial 
          training schedules, and narratived on implementation will be accepted.  
          Specialty Program Identification:  Must have both components in place to apply
                   Item                  Description        Documented Evidence
         Mission                  Definition of program and  Submit Mission and Vision 
                                  mission statement         Statements
         Policies and Procedures  Written Policy &          A Table of Contents listing 
                                  Procedure Manual          all Policies and Procedures 
                                  covering all key          related to your current 
                                  components listed below   Behavioral Health 
                                                            Programming
                Staffing and Education:  Must have all components in place to apply
                   Item                  Description        Documented Evidence
          Program must be under  Program Director must             Submit Program Director 
          the direct supervision of  have experience within 5  resume and job description
          a Program Director         years managing behavioral 
                                     populations and dealing 
                                     with behavioral issues
          Enhanced staffing in       Minimum staffing in           Submit list of Social 
          Social Services and        combined Social Services  Services and Activities staff 
          Activities                 and Activities is 1 FTE per (including % of FTE) and 
                                     15 residents served in the  number of residents served 
                                     program                       in program.
          Crisis Intervention        Training required for all     Training Schedule with staff 
          Training                   staff who routinely           sign in.  Completion 
                                     interact with residents       Certification, Training 
                                     served in the program         hours, Trainer 
                                                                   Qualificaitons.
          Behavior Management        General training specific     Brief description of training 
          Training                   to targeted behavioral        offered in previous calendar 
                                     populations                   year.  Sign-in sheets, 
                                                                   curriculum sample, and 
                                                                   training hours per topic.
          Population Specific        Training specific to facility List of education provided in 
          Training                   resident's needs. (i.e.       house annually and how it 
                                     Mental Illness,               realtes to your facilities 
                                     Neurological Disorders,       population.  Sign-in sheets, 
                                     Dementia, Drug & Alcohol, curriculum sample, and 
                                     27-65 Regulations,            training hours per topic
                                     Emergency Management 
                                     and Suicide Prevention)
              Staffing and Education Con't:  Must have all components in place to apply
                     Item                     Description          Documented Evidence
               Psychotropic Medication  Training required for all                                    Brief description of training 
               Training                                  staff who routinely                         related to psychotropic 
                                                         interact with the residents medication (and reduction) 
                                                         served in the  program.  To offered in previous calendar 
               Staff Support Program                     Examples include:  Stress  Brief description of 
                                                         include: potential side                     year with sign in sheets, 
                                                         Management Training,                        programs offered in 
                                                         effects, preceautions for                   curriculum sample, training 
                                                         Post Crisis Support, EAP                    previous calendar year
                                                         proper administration and  hours. 
                                                         other possible adverse 
                                                         reactions.
               Memo of Understanding Completed agreement                                             Submit most recent copy of 
                                                         between the facility and                    Memorandum of 
                                                         the mental health center                    Understanding
                                                         providing treatment
                      Psycho-Social Programming:  Must have all components in place to apply
                                Item                                 Description                     Documented Evidence
               Therapeutic groups in                     Groups must be age                          Submit one quarter of 
               addition to regulatory                    appropriate & population  activity calendars clearly 
               requirements under                        specific.  Examples                         identifying 2 therapeutic 
               F248.                                 include:  Healthy                               groups daily.  Narrative on 
                                                         Lifestyles, Goal Setting,                   why these activities were 
                                                         Effective Communication,  chosen. 
                                                         Social Skills, Problem 
                                                         Solving, Hygeine, Conflict 
               Therapeutic Work                          Program must include:                       Brief description on the 
                                                         and Anger Management, 
               Programs                                  Application/Contract, Time facliity work program and 
                                                         Drumming, Art Therapy, 
                                                         Recording System, Reward narrative on 
                                                         Tai Chi, Meditation, Yoga, 
                                                         System.                                     successes/struggles.  
                                                         AA, NA
                                                                                                     Sample job description, 
                                                                                                     timesheet, participant list.
          Community                  Components Include:  Pass Submit Pass Program Policy 
          Reintegration              Program with community  and Procedures including 
                                     safety training, resident     community safety training 
                                     specific life skills training,  resident reintegration 
                                     community outings             training.  Give 10 examples 
                                                                   of community outings in the 
                                                                   previous calendar year that 
                                                                   promote community 
                                                                   reintegration and life skills 
          Plans of Care for          Resident specific written     Provide plans of care for 
                                                                   training.  These examples 
          Behavior Management        plans of care and positive  Behavior Management for 
                                                                   should cover 10 months and 
                                     reinforcement                 10% of your population 
                                                                   include a narrative 
                                                                   served in this program.  
                                                                   description of how 
                                                                   This may be formal 
                                                                   reintegration training 
                                                                   Behavior Management 
                                                                   directs the planning of 
                                                                   Plans or Behavior Care 
                                                                   outings, and how the 
                                                                   Plans that show inclusion of 
                                                                   interaction(s) fits the 
                                                                   positive reinforcement
                                                                   therapuetic goals of the 
                                    Psychotropic Medication Review
                                                                   resident(s).
                     Item                     Description          Documented Evidence
          Clinical Behavior Review Quarterly review to             Submit one quarter of 
          with Medication            include:  Social Services,    monthly sign in sheets with 
          Management                 Nursing, Pharmacist,          title of individuals clearly 
                                     Mental Health Agency          identified  
                                     Professional