Transitional Living. Contractor shall operate a transitional living program at a minimum of the following guidelines:
Transitional Living defined as a multi-family or single room residency program with intensive support services for homeless individuals and/or families, for a period of 6 months up to 2 years. Intensive support services shall include case management services and other activities provided to assist Clients in gaining self-sufficiency and moving into permanent housing.
Transitional Living. 6.75 High intensity residential care, including American Society of Addiction Medicine (ASAM) Criteria, for Covered Persons with substance-related and addictive disorders who are unable to participate in their care due to significant cognitive impairment Pharmacy Specific Exclusions
Transitional Living. 7.66 Medical and surgical treatment of excessive sweating (hyperhidrosis).
Transitional Living. □ Medication Error Waiver Agreement • Found on Pages 4 and 5 of the SFN 1606 – Agency Request to be a Qualified Service Provider application form. • Agreement to this service statement is required at initial enrollment and revalidation. □ Care Plan process • Provide a description of the process used to develop a care plan. • Describe your person-centered care planning process and the development of client goals to achieve or maintain independence. □ Staff Experience • Describe staff expertise and experience that will assist in fostering client independence in ADL’s, IADL’s, and social, behavioral, and adaptive skills. • List staff experience with supervision, training, or assistance with the self-care of individuals who have cognitive impairment or a traumatic brain injury (TBI). □ SFN 750/CNA/RN/LPN/DD • Complete this form for each individual staff member providing this service. ▪ Refer to Pages 13 – 14 of the Agency Handbook for proper procedures completing form. ▪ Employees are required to carry the Cognitive/Supervision global endorsement. • Licensed DD providers are exempt from this requirement. □ Staff Training • List the type of education and training you provide to your employees who work with individuals with cognitive impairment or a TBI. □ Quality Improvement Program • Refer to appendix for additional information FOR OFFICE USE ONLY Date Approved Approved By Change/Add New Renew Reapply ID Date Closed AGENCY REQUEST TO BE A QUALIFIED SERVICE PROVIDER DEPARTMENT OF HEALTH AND HUMAN SERVICES MEDICAL SERVICES DIVISION SFN 1606 (3-2023) This application is for a group or a sole proprietorship with an Employer Identification Number (EIN). If you are an individual or a sole proprietorship that does not have an Employer Identification Number, then you must complete the Individual Enrollment Application form. Clear Fields IDENTIFYING INFORMATION Group Information Group Organization Name (DBA) (Must match line 2 of W-9) Years Doing Business Under This Name Have you ever used a different Doing Business As (DBA) name? Yes No Former DBA Name IMPORTANT: Your EIN will be linked to your ND provider number. All claims paid to your ND provider number will be submitted as income under your EIN to the Internal Revenue Service (IRS).The EIN must be for the group whose information was given.
Transitional Living. Daily Rate (Includes at minimum two random UA tests per month) $21.00 per day plus a $100.00 refundable deposit
