Nursing Home and Assisted Living Facilities

Submission Requirements

Independent, Personal, Assisted, Intermediate, Skilled and Sub-Acute

        Appropriate application and supplements

        All applicable Acord Applications

      State Inspection Reports for the last 2 years. Including all statements of deficiencies & plans of correction

      Five years of current valued loss reports

        Current audited financial statement (income, balance sheet, profit & loss) with management notes

       Quality Indicator Report (one report for the past 6-month period)

        Substantiated Complaint Survey if substantiated complaint is within last 2 years

        Signed Statement of Values

        Brochures and/or advertising materials, web address

        Facility diagram/plot plan

        LTC Business Interruption Worksheet (if applicable)

        Resumes for administrator & director of nursing

        Facility license

        Admission/Resident agreement.

Additonal requirements for Intermediate, Skilled and Sub-Acute

      Current HCFA Forms: 671 Facility Staffing & 672 Resident Census

    Skin/Wound Protocol