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Colorado Nursing Facilities Pay for Performance (P4P) Application
Facility Name: |  |  |  |  |  |  |  | Provider #:
Address:
Phone: |  |  |  | Fax#: |  |  |  | Applying for Year:
Name of Person Completing this Application:
Position: |  |  |  |  |  |  |  | Phone#:
[NAME]:
For Official Purposes Only:    Date Received: |  |  |  |  |  |  |  | Time Stamp:
Pre-Requisites For Participation
CDPHE Survey |  |  |  |  | Resident/Family Satisfaction Survey
No facility with substandard deficiencies, as defined in State Operations Manual, during the previous calendar year will be considered for the current P4P application.  See Appendix 1 for definition.  Please initial below to  indicate that the CDPHE Survey is attached. |  |  |  |  | Survey must be developed, recognized, and standardized by an entity external to the facility.  Must be administered on an annual basis with results tabulated by an agency external to the facility.  Please initial below to  indicate that the Satisfaction Survey is attached.
Acceptable Verification of Pre-Requisite Requirement |  |  |  |  | Acceptable Verification of Pre-Requisite Requirement
This prerequisite will be obtained and verified with Colorado Department of Public Health and Environment. |  |  |  |  | *Resident/family satisfaction surveys must have been conducted and tabulated between January 1 and December 31 of the previous year. *A Summary Report, identifying vendor completing, must be attached to this application and made available to the public along with the facility's State Survey Results.
STOP HERE IF YOU DO NOT MEET THE ABOVE PRE-REQUISITES: YOU CANNOT APPLY AT THIS TIME
Application deadline is February 28, 2014
Applications for inclusion into the Pay for Performance Program will be accepted on an annual basis only.  If you wish to apply,
you must have the requirements for each Domain/category in place at the time of submission of application.
Please note the following facts before continuing this form:
• There will be no partial points for subcategories.   • You must have 100% of the minimum requirements in place and submit documented evidence of programming.     • A written, detailed narrative must be submitted for every Quality of Life category you wish to have considered.  This narrative  should describe the process used to achieve and sustain each measure.   • Photos may be included as supporting documentation.   • All documents must accompany the application in order to qualify for inclusion.     • It is strongly encouraged that the application and all supporting documentation be submitted digitally on a CD.   • There may be a formal on-site evaluation prior to approval for participation in the P4P Program.
DOMAIN:  QUALITY OF LIFE:  The Quality of Life Program must be in place at time of P4P application
For evaluator use only
Points Achieved | Resident Directed Care |  | Definition/Minimum Requirement(s)/Required Documentation |  |  |  |  |  |  | Points Available | Self Scoring
 | Enhanced Dining |  | Menus that include numerous options, menus developed with resident input. The dining atmosphere reflects the community.  Residents have access to food 24 hours/day, and staff are empowered to provide food when resident desires it.  Dining atmosphere is defined as the table settings, table cloths, lighting, music, servers and dining style (restaurant, salad bar, menu, buffet) |  |  |  |  |  |  | 3
 | Minimum requirement(s) with supporting documentation
 |  | Include a detailed narrative describing your enhanced dining program
 |  | Evidence that menu options are more than the entree and alternate selection
 |  | Evidence that these options included input from a resident/family advisory group such as resident council or a dining advisory committee
 |  | Evidence that the residents have had input into the appearance of the dining atmosphere
 |  | Evidence that the residents have access to food at any time and staff are empowered to provide it
 |  | Supporting documentation can be resident signed testimonials, resident council minutes, minutes from another advisory group or a narrative and photographs of changes in the dining atmosphere
 | Flexible and Enhanced Bathing |  | Bath schedules are flexible to meet the residents' desires and choices.  Options for bathing are provided, and the physical bathing environment is enhanced and provides dignity for the resident. |  |  |  |  |  |  | 3
 | Minimum requirement(s) with supporting documentation
 |  | Include a detailed narrative describing your flexible enhanced bathing
 |  | Evidence residents are interviewed about choices, regarding time, choice of caregiver, and type of bath
 |  | Evidence that Bathing Without A Battle education is completed.  This education may be adapted according to your resident population.  Video available: [NAME]
 |  | Evidence that the bathing atmosphere includes home décor
 |  | Documentation may include photographs of the decor, receipts associated with the enhancements, in-service logs or certificates of education on enhanced bathing experiences for residents including choice in type of bath, schedule and caregiver
 | Daily Schedules |  | Residents are assisted in determining their own daily schedules and participate in developing their care plans. |  |  |  |  |  |  | 3
 | Minimum requirement(s) with supporting documentation
 |  | Include  a detailed narrative of the process used to identify and include resident choices in the daily routine
 |  | Include 4 resident testimonials that prove implementation of the resident's choices, preferences and daily schedules
 |  | Documentation must reflect that residents if able, families if available, and/or direct care staff participate in developing an individual's care plan that documents the resident choices with resident or family signatures on the care plan
 |  | The same 4 resident care plans and testimonials must be submitted with the application
 |  | Documentation includes photographs of the decor, receipts associated with the enhancements, in-service logs or certificates of education on enhanced bathing experiences for residents including choice in type of bath, schedule and caregiver.
 | End Of Life Program |  | The facility has developed a program advocating for residents' participation in their own end-of-life care, providing regular opportunities for re-evaluation of these wishes, and respecting these wishes when end of life is imminent.  A program includes: an individual's preferences, wishes, expectations, a plan for honoring those that have died, and a process to inform the community of such death. |  |  |  |  |  |  | 2
 | Minimum requirement(s) with supporting documentation
 |  | Include a detailed narrative of your end of life program that identifies individual preferences, wishes, and expectations, a plan for honoring those that have died and a process to inform the community of such death.
 |  | Provide documentation of 4 residents of his/her individual wishes as selected.
Points Achieved | Home Environment |  | Definition/Minimum Requirement(s)/Required Documentation |  |  |  |  |  |  | Points Available | Self Scoring
 | Public and Outdoor Space |  | Available public and outdoor spaces are designed for stimulation, ease of access, and activity.  Public spaces that allow for residents to remain as independent as possible such as laundry and cooking pantry areas.  These spaces should be comfortable and accommodating without clutter and free of visible medical equipment storage.  Overhead paging has been turned off and used only in emergencies |  |  |  |  |  |  | 3
 | Minimum requirement(s) with supporting documentation
 |  | Documentation should include a narrative of the process used for the de-institutionalization of  public and outdoor spaces
 |  | Documentation should include photographs of public spaces, indoor and outdoor, that provide the opportunity for residents to remain independent or enjoy normalcy such as personal laundry, cooking/pantry areas, small areas for socialization
 |  | Provide photographs to support ease of access to outdoor areas that include areas of socialization, gardening, or exercising
 |  | Documentation of uncluttered areas and lack of visible medical equipment should include photos of hallways, nurse's stations/areas and common areas
 |  | Ensure all photographs are captioned to identify the area and provide examples of how the space is used by residents and staff
 |  | Include your policy that overhead paging is limited to emergency use only
 |  | Testimonials of at least two non-management employees and two residents or family members that overhead paging is limited only to emergency use
 | Communities |  | Decisions around daily life are determined through a group process which includes residents, families and hands-on staff.  These decisions typically involve aspects of life such as special celebrations, decor, parties, group activities, or food choices for the neighborhood, household or home pantry. |  |  |  |  |  |  | 5
 | Minimum requirement(s) with supporting documentation
 |  | Provide 3 examples of shared decision-making, such as neighborhood meeting, learning circles and other spontaneous group decision-making.
 |  | Include testimony from at least 4 residents or family members and 2 non-management employees that explicitly discusses aspects of life and shared decisions made as a member of the community.
 |  | Evidence of a home like environment as directed by the residents' and staff, such as the removal or transformation of the nurses’ station to create community space, the capturing of space for promoting social interaction, the addition of resident chosen décor that reflects the people who live and work there.  Provide captioned photographs that show these changes.
Points Achieved | Relationships with Staff, Family, Resident and Community |  | Definition |  |  |  |  |  |  | Points Available | Self Scoring
 | Consistent Assignments |  | Consistent assignment is measured during the fourth quarter of 2013.  Please use the Advancing Excellence measurement tool found at the following website:  http://www.nhqualitycampaign.org/star_index.aspx?controls=consistentassignmentidentifybaseline |  |  |  |  |  |  | 6
 | Minimum requirement(s) with supporting documentation
 |  | Submit the completed worksheet to the Advancing Excellence website.
 |  | Print and attach the completed summary page for the community for each month during the fourth quarter of 2013.
 |  | Note: For Calendar Year 2014 (that will be submitted in 2015) this application will require a documented improvement in consistent assignments.
 | Daily Living Environment |  | Opportunity exists, as chosen by the resident for connection with the world including but not limited to nature, gardens, animals, children, crafts, music, art and technology as indicated by residents' majority/individual preferences.  Technology may include access to computers, tablets and other multimedia devices.  These opportunities should exist as a part of day to day life and should not be represented solely through special events. |  |  |  |  |  |  | 2
 | Minimum requirement(s) with supporting documentation
 |  | Documentation includes a narrative describing at least three opportunities as listed above
 |  | Include testimonials from 4 residents describing their involvement or enjoyment of these opportunities
 |  | Clearly labeled photographs identifying the living environment
 | Volunteer Program |  | A formalized volunteer program exists to allow for the provision of resident-specific activities and visits. |  |  |  |  |  |  | 2
 | Minimum requirement(s) with supporting documentation
 |  | Written volunteer policy
 |  | Documentation of hours of visits, these visits may be proven with samples of sign-in/sign-out sheets
Points Achieved | Staff Empowerment |  | Definition/Minimum Requirement(s)/Required Documentation |  |  |  |  |  |  | Points Available | Self Scoring
 | Care Planning |  | Certified Nursing Assistant(s) is involved in care planning and care conferences.  (No Narrative Required) |  |  |  |  |  |  | 6
 | Minimum requirement(s) with supporting documentation
 |  | Include both ten initial and ten quarterly care plan attendance forms with clearly identified CNA participation in care plan meeting including signatures of CNA's.  The care plan attendance forms should represent a total of 20 different residents.  If your facility has fewer than 10 admissions per year, please include all initial care plan attendance forms.
 |  | Attendance forms must be clearly labeled to identify initial/quarterly meetings
 | Career Ladders/Career Paths |  | Facility has systems in place to promote and support staff advancement. |  |  |  |  |  |  | 2
 |  | Include Written program or policy and procedures that include staff advancement, tuition reimbursement, internal promotion, and posting of open positions
 | Person-Directed Care |  | Facility supports and has systems in place to provide formal training on person-directed care to all staff.  This training should be based on current resident needs/requests and can be offered both internally and externally. Person-directed care is defined as facilities or portions of facilities in which the provision of care or services promotes decision making and choices by the residents, enhances the primary caregiver’s capacity to respond to each resident’s needs, and promotes a homelike environment. |  |  |  |  |  |  | 4
 | Minimum requirement(s) with supporting documentation
 |  | Submit annual training objectives for your person-directed care curriculum
 |  | Include Mission and Vision statement regarding person-directed care
 |  | Provide a list of person-directed care trainings and any other pertinent documentation that supports person-directed care
 |  | If your facility is Eden Registered, a Planetree Designated Facility, or CARF Person-Centered Care Accredited you only need to submit verification of that association from the accrediting organization.
 | Hand in Hand Training |  | Complete all 6 modules of Hand in Hand training.  All communities received Hand in Hand training from CMS.  If you are unable to locate your training information, please access the CHCA website at www.cohca.org or contact CFMC at [PHONE], ext. 3023.
 | Minimum requirement(s) with supporting documentation
 | Hand in Hand Training |  | 50% of all Staff Members (www.cms-handinhandtoolkit.info) |  |  |  |  |  |  | 7
 | New Staff Program |  | A formalized new staff program exists to allow for the provision of peer mentoring and support to promote staff retention. This program may include a buddy system as well as exposure to community expectations and values. |  |  |  |  |  |  | 2
 | Minimum requirement(s) with supporting documentation
 |  | A written narrative of a program that includes staff mentoring and/or buddy system for new employees
 |  | Documentation may also include an outline or policy for buddy system and mentoring program(s)
 |  | Testimonials from 4 staff about their involvement in new staff programs
 | Total Points Awarded for Domain Quality Of Life |  | Total Points available for Domain Quality of Life |  |  |  |  |  |  | 50
DOMAIN:  QUALITY OF CARE:  The Quality of Care Program must be in place at time of P4P application
For evaluator use only
Points Achieved | Quality Of Care |  | Definition/Minimum Requirement(s)/Required Documentation |  |  |  |  |  |  | Points Available | Self Scoring
 | +2 Continuing Education |  | 12 hours on average caregiver/ staff person (Social Services/Activities/RN's/LPN's/C.N.A's) Continuing Education per year |  |  |  |  |  |  | 2
OR
 | +4 Continuing Education |  | 14 hours on average caregiver/staff person (Social Services/Activities/RN's/LPN's/C.N.A's) Continuing Education per year |  |  |  |  |  |  | 4
OR
 | +6 Continuing Education |  | 16 hours on average caregiver/staff person (Social Services/Activities/RN's/LPN's/C.N.A's) Continuing Education per year |  |  |  |  |  |  | 6
 | Minimum requirement(s) with supporting documentation
 |  | See Appendix 3 continuing education for job categories:  Social Services, Activities, RN, LPN, CNA's
 |  | Submit individual continuing education tracking forms, [NAME], for 20% of individual employees in each job category
 |  | Submit list of continuing education provided in-house in previous calendar year
 | Quality Program Participation |  | Participation in Advancing Excellence in America's Nursing Homes or a successor quality program |  |  |  |  |  |  | 1
 | Minimum requirement(s) with supporting documentation
 |  | List of goals that the facility is actively participating in, printing from the Advancing Excellence Website.  This should be the one page titled Goal Selection.
Nationally Reported Quality Measures Scores: |  | For assistance in accessing Quality Measure Reports please contact CFMC at [PHONE].  Print and include with the application Quarter 3 and Quarter 4 from 2013 for the 5 Quality Measures noted on the application and score accordingly |  |  |  |  |  |  |  |  | Self Scoring
 | Quality Measure |  | Measure ID |  | Percentiles
 | Falls with Major Injury |  | 13.01 |  | Score of 2.2 or less |  |  |  |  | 5
 | Falls with Major Injury |  |  |  | Score >2.2 but <= 3.1 |  |  |  |  | 3
 | Moderate/Severe Pain(L) |  | 14.01 |  | Score of 6.3 or less |  |  |  |  | 5
 | Moderate/Severe Pain(L) |  |  |  | Score of >6.3 but <= 9.9 |  |  |  |  | 3
 | High Risk Resident with Pressure Ulcers(L) |  | 15.01 |  | Score of 2.8 or less |  |  |  |  | 5
 | High Risk Resident with Pressure Ulcers(L) |  |  |  | Score of >2.8 but <= 4.3 |  |  |  |  | 3
 | UTI |  | 24.01 |  | Score of 3.6 or less |  |  |  |  | 5
 | UTI |  |  |  | Score >3.6 but <= 5.7 |  |  |  |  | 3
 | Antipsychotics |  | 31.02 |  | Score of 8.7 or less |  |  |  |  | 5
 | Antipsychotics |  |  |  | Score >8.7 but <= 11.3 |  |  |  |  | 3
 | Reducing Rehospitalizations |  | Note: For Calendar Year 2014 (that will be submitted in 2015) this application will require a documented improvement in re-hospitalization rates. |  |  |  |  |  |  | 3
 | Minimum requirement(s) with supporting documentation
 |  | Submit a Policy for initiation of the Interact Program (or like program) that includes tracking hospitalizations and a Quality Assurance Process for reviewing hospitalization data.
 |  | Submit your re-hospitalization data for calendar year 2013.
 |  | Submit evidence of quarterly review of the discussion of advance directives for 10 residents.  For 2013 the 3rd and 4th quarter for the same 10 residents must be submitted.
Points Achieved | Facility Management |  | Definition/Minimum Requirement(s)/Required Documentation |  |  |  |  |  |  | Points Available | Self Scoring
Medicaid Occupancy Average |  |  | In order to qualify, a facility must be the designated percentage points above the statewide average of 66.6%
 | 10% Medicaid |  | Medicaid occupancy of 10% (73.26%) or more above statewide average |  |  |  |  |  |  | 5
OR
 | 5% Medicaid |  | Medicaid occupancy of 5%(69.93%) to <10%(73.25%) above statewide average |  |  |  |  |  |  | 3
 | Minimum requirement(s) with supporting documentation
 |  | Submit copy of most recent data available
Points Achieved | Staff Stability |  | Definition/Minimum Requirement(s)/Required Documentation |  |  |  |  |  |  | Points Available | Self Scoring
 | Staff [NAME] |  | Staff retention rate (excluding NHA and DON) at or above 60%. |  |  |  |  |  |  | 3
OR
 | Staff [NAME] |  | A 5% improvement on the staff retention rate per year for facilities with less than a 55% retention rate. Facilities with 60% retention rate or greater must remain consistent from year to year |  |  |  |  |  |  | 3
 | Minimum requirement(s) with supporting documentation
 |  | [NAME] Retention OR Staff Retention Improvement Form and attach
 |  | Submit December 31 payroll roster listing names of all employees AND dates of hire, with employees hired on or before January 1 highlighted.
 | [NAME] |  | DON retention rate of three years or more. |  |  |  |  |  |  | 2
 | Minimum requirement(s) with supporting documentation
 |  | Name and hire date including date started in DON position
 | NHA Retention |  | NHA retention rate of three years or more. |  |  |  |  |  |  | 2
 | Minimum requirement(s) with supporting documentation
 |  | Name and hire date including date started in NHA position
 | Employee Satisfaction Survey Response Rate |  | Externally developed, recognized, and standardized employee satisfaction survey conducted on an annual basis with a response rate of 60%. |  |  |  |  |  |  | 3
OR
 | Employee Satisfaction Survey Response Rate |  | Externally developed, recognized, and standardized employee satisfaction survey conducted on an annual basis with a response rate of 50%. |  |  |  |  |  |  | 2
 | Minimum requirement(s) with supporting documentation
 |  | Survey summary page with clearly identified response rate
 | Total Points Awarded for Domain QOC |  | Total Points available for Domain Quality of Care |  |  |  |  |  |  | 50
 | Total Points Awarded for Domain Quality Of Life |  | Total Points available for Domain Quality of Life |  |  |  |  |  |  | 50
 |  |  |  |  |  |  |  |  |  |  | Self-Score Grand Total
 | Total Points Awarded for Domains Quality of Life and Quality of Care |  | Total Points available for Domains Quality of Life and Quality of Care |  |  |  |  |  |  | 100
Please sign and date below as an indication that all the information above is complete and accurate.
 | Signature |  |  |  |  |  | Date
 | Check the box to the left to indicate that CDPHE survey is attached to this application (required).
 | Check the box to the left to indicate that Resident/Family Satisfaction survey is attached to this application (required).
Revised 7/10/2013
Appendix 1
 | DETERMINATION OF SUBSTANDARD QUALITY OF CARE (per SOM,chapter 7)
 | "Substandard quality of care means one or more deficiencies related to participation requirements under 42 CFR 483.13, resident behavior and facility practices, 42 CFR 483.15, quality of life, or 42 CFR 483.25, quality of care, that constitute either immediate jeopardy to resident health or safety (level J, K, or L); a pattern of or widespread actual harm that is not immediate jeopardy (level H or I); or a widespread potential for more than minimal harm, but less than immediate jeopardy, with no actual harm (level F)."
 | Severity of Deficiency | Scope of Deficiency
 |  |  |  | Isolated |  | Pattern |  |  | Widespread
 |  | Immediate jeopardy to resident health or safety |  | J |  | K |  |  | L
 |  | Actual harm that is not immediate jeopardy |  | G |  | H |  |  | I
 |  | No actual harm with potential for more than minimal harm that is not immediate jeopardy |  | D |  | E |  |  | F
 |  | No actual harm with potential for minimal harm |  | A |  | B |  |  | C
 | * Shading indicates the ratings classified as substandard quality of care.
Appendix 2
CONTINUING EDUCATION INSTRUCTIONS
Documentation to be provided:
(1) | Complete attached Continuing Education Form for 20% all Employees in previous calendar year for the following job categories:
 |  | Social Services
 |  | Activities
 |  | Registered Nurses
 |  | Licensed Practical Nurses
 |  | Certified Nursing Assistants
(2)   Individual Continuing Education Tracking Forms for 20% of individual employees in each job category
(3)   List of Continuing Education Provided in-house in previous calendar year
Definition of Continuing Education:
 |  | Any education provided internally or externally that enhances the Quality of Care or Quality of Life of the resident, clinical training, leadership/management training or safety training.  Included in Continuing Education would be In-Service Education, seminars, workshops and conferences.  General [NAME] not related to resident care or meetings related to general facility information would not be considered. Nursing department licensure/certificate or degree based college credits will not be considered as Continuing Education for this purpose.
 |  | Required Hours:  10 hours of mandatory education are required for each employee on an annual basis.  When an employee works the full calendar, 10 hours should be subtracted on the attached form as required hours.  When an employee works less than a full calendar year 1 hour for each month of employment should be subtracted as required hours.
 |  | Job Category |  |  | Number of Staff in Calendar Year
 |  |  | Social Services |  |  | __________________
 |  |  | Activities |  |  | __________________
 |  |  | Registered Nurses |  |  | __________________
 |  |  | Licensed Practical Nurses |  |  | __________________
 |  |  | C.N.A. |  |  | __________________
 |  | Choose 20% from each Job Category and submit Individual Continuing Education Tracking Forms
Appendix 3
CONTINUING EDUCATION FORM
Employee Name |  |  | Job Category |  | # Months Worked | Total Hours of Training |  | Subtract Required Hours of Training |  | Additional Hours
Definition of Continuing Education: any education provided internally or externally that enhances the Quality of Care or Quality of Life of the resident, clinical training, leadership/management training or safety training. Included in Continuing Education would be In-service Education, seminars, workshops and conferences. General [NAME] not related to resident care or meetings related to general facility information would not be considered.
Appendix 4
STAFF STABILITY
A facility may qualify for P4P points in EITHER Staff Retention
OR
Staff [NAME].
NEITHER  the Director of Nursing NOR the Nursing Home Administrator are included in calculations
STAFF RETENTION
Supporting documentation to include the following:
December 31 payroll roster listing names of all employees (except [NAME] and NHA) AND dates of hire, with employees hired on or before January 1 highlighted
 | Purpose:  To calculate the percentage of total employees (NOT FTE’s) who were employed at the start of the measurement period that remain with the facility at the end of that period.
 | (a)    Total number of individual employees on payroll roster on January 1: _______
 | (b)   Total number of employees identified in (a) above who remain on payroll roster on December 31:  _____(this number must be verifiable thru submitted supporting documentation – (1) or (2) above)
Retention percentage:  (b) divided by (a) times 100 = _____% (this number must be 55% or greater)
EXAMPLE:
A home has 100 total employees (not FTE’s) on payroll on January 1.  (a) = 100
Of those 100 employees at the start of the year, 75 remain employed and on payroll as of December 31.  (b) = 75
Retention percentage = (b) 75/(a) 100 x 100 = 75% retention.
Appendix 4
STAFF STABILITY (CONTINUED)
 | Purpose:  To calculate the staff improvement percentage rate for those facilities with a retention rate between 40-60%.  If a retention rate for the P4P qualifying year(regardless of percent improvement) is LESS than 40%, a facility cannot apply for P4P points in Staff Stability.
 | (Δ)  Staff retention rate – in percentage – calculated from January 1 to December 31 for P4P application qualifying year:  _____ (Must be ≥ 40%)
 | (β)  Staff retention – in percentage – calculated from January 1 to December 31 for calendar year PRIOR to year used in (Δ) above: _____
 | Percent improvement:  (Δ) minus (β): _____%
 | (this number must be positive, and greater than or equal to 5%)
 | STAFF RETENTION IMPROVEMENT EXAMPLE :
 | A home is applying for P4P on January 31, 2014.
 | Its retention rate for calendar year 2013 (P4P qualifying year), based on evaluation of year end payroll and determining  which employees started on or prior to January 1, 2013 (Supporting Documentation Data set (2), is 60% (Δ)
 | Its retention rate for calendar year 2012, based on evaluation of year end payroll and determining which employees started on or prior to January 1 2012, is 40% (β)
 | Retention improvement rate = (Δ) 60% - (β) 40% = 20% improvement