D-U-N-S Number: __________________________________ N/A A D-U-N-S number can be obtained by visiting http://fedgov.dnb.com/webform and clicking on the link entitled “Click here to request your number via the Web.” is also a toll-free number: 1-866-705-5711 This question is applicable for Residential and Transportation providers only. All other providers may indicate N/A. Submit documentation received which shows organization has registered for the D-U-N-S number. 3) Question: In Administrative Entities (AE) does your organization intend to provide services? AE Name(s): __________________________________ __________________________________ Please list all AEs (Counties) in which your organization intends to provide service. 4) Question: What is the provider organization's Administrative Entity? (This is the AE from which the provider supports the most number of waiver participants or, for providers with no current authorizations, the AE within which your organization intends to serve the most waiver participants. This will also be the AE that processes your qualification application). AE Name: __________________________________ Please use the drop down to select the appropriate AE. Providers will be notified of their sample by their AE. The AE is identified in the spreadsheet received by AEs that identifies the provider’s sample of individuals. AEs will be receiving this in the first quarter of the new fiscal year. 5) Question: In which region is the AE located? Please use the drop down to select the appropriate region for your AE.
Central Northeast Southeast West 6) Question: What is the provider organization's contact information (for Provider Qualification)? Contact Name (first and last name): _________________________________ Contact Phone Number: _________________________________ Contact E-mail Address: _________________________________ Reviewers will enter the contact information for the primary contact person for the organization who is responsible for Provider Qualifications. This should be the person who is responsible for qualifications for the provider. 7) Question: Does the provider intend to operate as an Agency With Choice (AWC) or an Organized Health Care Delivery System (OHCDS)? AWC: Yes No OHCDS: Yes No Source Document(s): Please choose “Yes” “AWC” if the organization intends to operate as an Agency with Choice provider and “No” if they do not. Please choose “YES” under “OHCDS” if the organization intends to operate as an Organized Healthcare Delivery System and “No” if they do not. Agencies that are qualified as a waiver provider, and render at least one direct waiver service and are enrolled in HCSIS and PROMISeTM as a Provider Type 55, may function as an Organized Health Care Delivery System (OHCDS). Remediation: If the provider selects “Yes” but is not on the list, the reviewer should notify the provider and provide assistance as needed.
Question: Does the provider have a documented Emergency Disaster Response plan that addresses individual’s safety and protection, communications and/or operational procedures? Yes No N/A Remediation: Provider will develop/modify an emergency disaster response plan addressing individual safety and protection, communications and/or operational procedures. 18) Oversight area: Contingency planning Compliance Standard: Provider has procedures on how to respond to individual health and behavioral emergencies and crises. Question: Are policies and procedures on how to respond in cases of individual health and behavioral emergencies and crises? Yes No Source Document(s): Waiver Assurances Appendix G-3, (relating to Participant Safeguards) Reviewers will review policy and procedures for information on how to respond to health and behavioral emergencies and crises. This policy should include guidance on when it is appropriate to call 911. Submit Crisis (health, behavioral emergency and crises) Policy Remediation: Provider will develop policies/procedures on responding to individual health and behavioral emergencies and crises. 19) Oversight area: Grievances Compliance Standard: A provider shall develop grievance procedures to document, respond and resolve grievances. Source Document(s): 55 Pa. Code Chapter 51 Sections , Waiver Assurance on Health and Welfare (Appendix G) Reviewers will review the provider’s grievance procedures. The procedures should include the following: Processes to resolve a grievance within 21 days. Instructions for individuals and their families regarding grievance procedures, including how to seek help in filing a grievance.
Question: Does the provider have grievance procedures to document, respond and resolve grievances in accordance with 55 Pa. Code Chapter 51 regulations? Yes No Process to review, document and resolve each grievance including name, nature, date, actions to resolve resolution and date resolved. Process to review procedures annually to determine number of grievances and their disposition. Compliance is indicated when a provider has grievance procedures that meet all criteria above. Submit Grievance Procedures Remediation: Provider will develop grievance procedures in accordance with regulations. 20) Oversight area: Training Compliance Standard: A provider shall implement a training curriculum in compliance with 55 Pa. Code Chapter 51 regulations. Question: Does the provider have an annual training curriculum in accordance with 55 Pa. Code Chapter 51 regulations? Yes No N/A Source Document(s): 55 Pa. Code Chapter 51 Sections , Reviewers will review the provider’s training curriculum for that provides direct service to individuals. The curriculum must contain at least the following: Department policy on intellectual disability principles and values. Training to meet the needs of an individual as identified in the ISP. QM Plan. Identification and prevention of neglect and exploitation of an individual. Recognizing, reporting and investigating an incident. Grievance procedures. Department issued policies and procedures. Accurate billing and documentation of service delivery.