State Veterans Homes Program
rightbottom1000000left3286125State Veterans Homes ProgramNorth Carolina Department of Military and Veterans Affairs2018-201900State Veterans Homes ProgramNorth Carolina Department of Military and Veterans Affairs2018-2019Table of Contents TOC \o "1-3" \h \z \u List of Acronyms PAGEREF _Toc21442794 \h 3Overview PAGEREF _Toc21442795 \h 5Historical Prospective PAGEREF _Toc21442796 \h 5Location of Homes PAGEREF _Toc21442797 \h 6Mission Statement of the NCSVH Program PAGEREF _Toc21442798 \h 7Construction PAGEREF _Toc21442799 \h 8Application for License to Operate PAGEREF _Toc21442800 \h 8Design PAGEREF _Toc21442801 \h 9Construction Event Timeline PAGEREF _Toc21442802 \h 10Groundbreaking PAGEREF _Toc21442803 \h 11Establishment of Fiscal Accounting PAGEREF _Toc21442804 \h 12Establish Veteran’s Home PAGEREF _Toc21442805 \h 14Register for NPI Standard PAGEREF _Toc21442806 \h 14Application for Medicare (CMS Form 855B) PAGEREF _Toc21442807 \h 16Application for Medicaid (CMS Form 855R) PAGEREF _Toc21442808 \h 19Facility Management PAGEREF _Toc21442809 \h 21Description of Service Providing Agency PAGEREF _Toc21442810 \h 21Key Control PAGEREF _Toc21442811 \h 22Inventory PAGEREF _Toc21442812 \h 23Vehicle Operator Selection and Validation PAGEREF _Toc21442813 \h 25Invoicing PAGEREF _Toc21442814 \h 29Invoice Policy PAGEREF _Toc21442815 \h 29Receipt of Goods PAGEREF _Toc21442816 \h 31Residence Administration PAGEREF _Toc21442817 \h 32Admissions PAGEREF _Toc21442818 \h 32Collection of Funds PAGEREF _Toc21442819 \h 39Bed Hold PAGEREF _Toc21442820 \h 41Grooming Standards PAGEREF _Toc21442821 \h 42Points of Contact PAGEREF _Toc21442822 \h 44Reports Schedule PAGEREF _Toc21442823 \h 45Appendices PAGEREF _Toc21442824 \h 46List of AcronymsAdministrative DirectorADCenter for Medicare and Medicaid Services CMSCombined Federal RegulationCFRElectronic File Interchange Organization?EFIOGain and LossG&LHealth Insurance Portability and Accountability Act HIPAAMaintenance DirectorMDMedicare Administrative Contractor MACNorth Carolina Department of Military and Veterans AffairsNCDMVANorth Carolina Division of Motor VehiclesNCDMVNorth Carolina State Veterans HomeNCSVHNorth Carolina State Veterans Home Trust FundNCSVHTFNursing Home Management CompanyNHMCNational Plan and Provider Enumeration System NPPESNational Provider Identifier NPIOffice of State Budget ManagementOSBMPower of AttorneyPOAProgram ManagerPMProvider Enrollment, Chain and Ownership System PECOSProvider Transaction Access Number PTANRequest for ProposalRFPState Construction OfficeSCOStandard Operating ProceduresSOPState of North CarolinaNCUnited States Department of Veterans AffairsUSDVAVeterans Administration Medical CenterVAMCVeterans Affairs CommissionVACVeterans Integrated Service NetworkVISNVeteran Services OfficerVSOOverviewHistorical ProspectiveThe NC Division of Veterans Affairs was first established by NC Session Laws 1925, chapter 288 as a part of the NC Commission of Labor.NC Session Laws 1945, chapter 723 created the separate agency named the NC State Veterans Affairs Commission.NC Session Laws 1967, chapter 1060 re-designated the organization as the NC Department of Veterans Affairs.In the Executive Organization Act of 1971, the NC Department of Administration was created as part of the governmental reorganization defined by this document, with a subordinate branch known as the NC Division of Veterans Affairs, thus inactivating the NC Department of Veterans Affairs.NC Session Laws 1973, chapter 620 re-created the NC Department of Military and Veterans Affairs and assigned the NC Division of Veterans Affairs to it.NC Session Laws 1977, chapter 70 restructured and renamed the NC Department of Military and Veterans Affairs as the NC Department of Crime Control and Public Safety, and the NC Division of Veterans Affairs was reassigned by the governor to the NC Department of Administration.NC Session Laws 2015, chapter 143B once again recreated NC Department of Military and Veterans Affairs by inactivating the NC Division of Veterans Affairs within the NC Department of Administration.The NCSVH program was established as part of the NC Division of Veterans Affairs by NC Session Law 1995, chapter 346. It has remained in this capacity through today.Location of HomesNCSVH serve all qualified North Carolina veterans. The rate of payment is based on a daily per diem rate established by the NC VAC. There are currently four (4) existing homes, and two (2) more projected to be completed in 2020.The physical location of the existing homes is:Fayetteville State Veteran’s Home (Cumberland County) (#3)214 Cochran Avenue, Fayetteville NC 28301Phone (910) 822-7231150 BedsSalisbury State Veteran’s Home (Rowan County) (#2)1601 Brenner Ave Bldg 10, Salisbury NC 28144Phone (704) 638-4200 ext 230499 BedsKinston State Veteran’s Home (Lenoir County) (#4)2150 Hull Road, Kinston NC 28504Phone (252) 939-8002100 Beds Black Mountain State Veteran’s Home (Buncombe County) (#1)62 Lake Eden Road, Black Mountain NC 28711Phone (828) 257-6818100 Beds The physical location of the new home is:Kernersville State Veteran’s Home (Forsyth Country) (#5)Kernersville, NC (Address TBD)Phone (TBD)120 Beds (Projected)Mission Statement of the NCSVH ProgramTo provide quality health care services in a professional and ethical manner, ensuring the trust, confidence and respect of our veteran residents, their families, and the communities we serve.ConstructionApplication for License to OperateThe NC VAC promulgates rules and regulations concerning the operations of the NCSVH, including authorizing expenditures from the NCSVHTF.DesignAll NCSVH projects are required to be completed as public agency construction. As such, authority to manage the process of selecting the commercial designer and general contractor resides in the NC SCO.The NCSVH will provide funding (either in the form of a grant or from the NCSVHTF) to support the entire construction project.The NCSVH will work with the NC SCO to determine size and/or scope (number of bed spaces, etc) of new construction projects. NCSVH will submit appropriate requests for grants to the VA in support of the new construction projects.NC SCO will manage all new construction projects through completion. NCSVH will assume ownership of project once NC SCO certifies 100% complete.If new furnishings are required, NCSVH will manage the entire purchasing and installation process.Construction Event TimelineThe construction event starts with the intent to execute a construction project. Once that intent exists, the following steps occur:1. Establish an initial cost estimate to complete the project. 2. Determine if a request will be made to USDVA for a grant to support this project.3. Determine if matching funding is available per USDVA grant guidance.4. If step 3 and 4 above are both “YES”, then initiate a grant request to USDVA.Once the grant request is forwarded to USDVA, NCSVH will wait until USDVA funds the grant request to move forward. Upon approval, the following steps occur:1. Project is referred to SCO for further action.2. SCO establishes project design, with input from NCSVH.3. SCO identifies general contractor, with input from NCSVH.4. General contractor establishes bid timeline based on guidance from NCSVH, and provides completed bid tabulation to SCO and NCSVH.5. NCSVH updates USDVA grant request to provide additional required information in order to facilitate approval to execute funds for construction.6. General contractor manages construction process until project complete, with input from SCO and NCSVH.7. General contractor will provide monthly fiscal data to facilitate NCSVH transferring funds to support payment of monthly requirements (NCSVH insures appropriate paperwork is completed to update USDVA on progress).Once construction is complete, NCSVH will coordinate for issue of license to operate and receipt of certificate of occupancy (if applicable), and finalize hiring of NHMC (if applicable).The final step is to close out the USDVA grant.GroundbreakingNCSVH will coordinate groundbreaking event for new construction.Establishment of Fiscal AccountingThere is a multi-faceted process involved in order to move a capital improvement project from an idea to a completed state-owned facility. 1. Step 1: Procure an appropriate piece of real estate to support the construction of a facility. This can be done by outright purchase of property, or transfer title from one government agency to another, or designate already titled property for the project.2. Step 2: Develop the idea to a point where a federal grant can be requested to support completion of the project (this step will be covered in detail in another SOP). 3. Step 3: Once the grant request has been initiated, the following activities can begin:a. The design phase can begin. The architect will work with the SCO and the designer to move this phase forward. The completion of this phase will generate a product to apply to the federal grant request that is pending at USDVA level.b. The Business Director will coordinate with OSBM to get legislation approved to appropriate funds from the NCSVHTF to create the budget for the capital improvement project, based on the requirements contained in the federal grant request. c. The Business Director will coordinate with the DOA Fiscal Management Branch to create the capital improvement project so that approved funding can be applied and tracked.4. Step 4. Approval of the Federal Grant Requesta. The USDVA will provide the department the original Memorandum of Agreement between the USDVA and the department to provide federal funds to the support the construction of the new facility.b. A copy of the MOA will be provided to OSBM to attach to the approved legislation. c. OSBM will publish a memorandum for the SCO authorizing award of the letter to proceed to start the construction phase of the project. NOTE: OSBM will provide a copy of this memorandum to the department for informational purposes, as well as DOA Fiscal Management as a support document for the budget creation.d. A copy of the MOA will be provided to DOA Fiscal Management to support the creation of the approved budget for the previously approved capital improvement project. e. A copy of the MOA will be provided to SCO to support the contract award letter to the general contractor.5. Step 5. Construction Phasea. The general contractor will invoice the department as required for construction.b. The department will certify the invoice and rout as appropriate through the fiscal process for payment and tracking.c. The architect will conduct primary liaison between the department, SCO, the designer, and the general contractor. 6. Step 6. Equipping the Facilitya. The designer will coordinate with NCDMVA to orchestrate the purchase of furnishing for the facility.b. NCDMVA will execute purchase of furnishings per NC DOA fiscal guidance.c. NCDMVA will coordinate to have furnishings delivered to the facility based on the designer timeline.d. NCDMVA will ensure proper inventory of furnishings upon delivery and establish inventory control as required by NCDOA State Property Accountability guidelines.6. Step 7. Occupation Phasea. The designer will coordinate with the construction company to complete appropriate inspections as required.b. NCDMVA will award contract for facilities operations not later than 4 months prior to projected beneficial occupancy date.c. The designer will notify NCDMVA of projected award of beneficial occupancy.d. Once the certificate of beneficial occupancy is awarded, NCDMVA will instruct NHMC to begin to admit residents.e. The construction company will be responsible for “punch list” items until fully completed and approved by NCDMVA in accordance with construction contract.Establish Veteran’s HomeRegister for NPI StandardREFERENCE. 45 CFR Part 162 HIPAA Administrative Simplification: Standard Unique Health Identifier for Health Care Providers; Final Rule.OVERVIEW. The NPI is a HIPAA Administrative Simplification Standard. The NPI is a unique identification number for covered health care providers. Covered health care providers and all health plans and health care clearinghouses must use the NPIs in the administrative and financial transactions adopted under HIPAA. The NPI is a 10-position, intelligence-free numeric identifier (10-digit number). This means that the numbers do not carry other information about healthcare providers, such as the state in which they live or their medical specialty. The NPI must be used in lieu of legacy provider identifiers in the HIPAA standards transactions.As outlined in the CFR, The HIPAA Act of 1996 (HIPAA), covered providers must also share their NPI with other providers, health plans, clearinghouses, and any entity that may need it for billing purposes.HOW TO APPLY. The NPI Application/Update Form (CMS-10114) has been revised to provide additional guidance on how to accurately complete the form. The revised form was recently approved by the OMB. The revised version of the form is currently available to view and download from the CMS Forms website at .? A link to the downloadable form can also be found below under ‘Downloads’.?Providers should send the form to the NPI Enumerator.Health care providers can apply for NPIs in one of three ways:1. For the most efficient application processing and the fastest receipt of?NPIs,?use the web-based?application process.? Simply?log onto the NPPES?and apply on line (see ‘Apply Now’ link under the Related Links section below).2. Health care providers can agree to?have an EFIO submit?application data on their behalf (i.e., through a bulk enumeration process) if an EFIO requests their permission to do so (See ‘EFI’ link on left hand column for more information regarding this process).3. Health care providers may wish to obtain?a copy of the paper?NPI Application/Update Form (CMS-10114) and mail the completed, signed application to the NPI Enumerator located in Fargo, ND, whereby staff at the NPI Enumerator will enter the application data into NPPES.? This form is now available for download from the CMS website (see link to the form under Downloads below).? Health care providers who require assistance with?this form from the NPI Enumerator may contact the enumerator in any of these ways: a. Phone:? 1-800-465-3203 or TTY 1-800-692-2326b. E-mail:? customerservice@c. Mail:NPI EnumeratorP.O. Box 6059Fargo, ND? 58108-6059Application for Medicare (CMS Form 855B)OVERVIEW. Clinics and group practices can apply for enrollment in the Medicare program or make a change in their enrollment information using either:1. The Internet-based PECOS2. The paper enrollment application process (e.g., CMS 855B).For additional information regarding the Medicare enrollment process, including Internet-based PECOS, go to . WHO SHOULD APPLY. Clinics and group practices who are enrolled in the Medicare program, but have not submitted the CMS 855B since 2003, are required to submit a Medicare enrollment application (i.e., Internet-based PECOS or the CMS 855B) as an initial application when reporting a change for the first time. The following suppliers must complete this application to initiate the enrollment process:1. Ambulance Service Supplier2. Mammography Center3. Ambulatory Surgical Center4. Mass Immunization (Roster Biller Only)5. Clinic/Group Practice6. Part B Drug Vendor7. Independent Clinical Laboratory8. Portable X-ray Supplier9. Independent Diagnostic Testing Facility (IDTF)10. Radiation Therapy Center11. Intensive Cardiac Rehabilitation SupplierIf your supplier type is not listed above, contact your designated fee-for-service contractor before yousubmit this plete and submit this application if you are an organization/group that plans to bill Medicare and you are:1. A medical practice or clinic that will bill for Medicare Part B services (e.g., group practices, clinics, independent laboratories, portable x-ray suppliers).2. A hospital or other medical practice or clinic that may bill for Medicare Part A services but will also bill for Medicare Part B practitioner services or provide purchased laboratory tests to other entities that bill Medicare Part B.3. Currently enrolled with a Medicare fee-for-service contractor but need to enroll in another fee-for-service contractor’s jurisdiction (e.g., you have opened a practice location in a geographic territory serviced by another Medicare fee-for-service contractor).4. Currently enrolled in Medicare and need to make changes to your enrollment data (e.g., you have added or changed a practice location). Changes must be reported in accordance with the timeframes established in 42 C.F.R. § 424.516(d). (IDTF changes of information must be reported in accordance with42 C.F.R. § 410.33.)BILLING NUMBER INFORMATION. The NPI is the standard unique health identifier for health care providers and is assigned by the NPPES. As a Medicare health supplier, you must obtain an NPI prior to enrolling in Medicare or before submitting a change for your existing Medicare enrollment information.Applying for an NPI is a process separate from Medicare enrollment (see guidance previous section).As a supplier, it is your responsibility to determine if you have “subparts.” A subpart is a component of an organization (supplier) that furnishes healthcare and is not itself a legal entity. If you do have subparts, you must determine if they should obtain their own unique NPIs. Before you complete this enrollment application, you need to make those determinations and obtain NPI(s) accordingly. For NPI purposes, sole proprietors and sole proprietorships are considered to be “Type1” providers. Organizations (e.g., corporations, partnerships) are treated as “Type 2” entities. When reporting the NPI of a sole proprietor on this application, therefore, the individual’s Type 1 NPI should be reported; for organizations, the Type 2 NPI should be furnished. The Medicare Identification Number, often referred to as a PTAN or Medicare “legacy” number, is a generic term for any number other than the NPI that is used to identify a Medicare supplier. APPLICATION PROCESS.Type or print all information so that it is legible. Do not use pencil. Report additional information within a section by copying and completing that section for each additional entry. Attach all required supporting documentation. Keep a copy of your completed Medicare enrollment package for your records. Send the completed application with original signatures and all required documentation to your designated Medicare fee-for-service contractor. AVOID ENROLLMENT DELAYSTo avoid delays in the enrollment process, you should:1. Complete all required sections. 2. Ensure that the legal business name shown in Section 2 matches the name on the tax documents. 3. Ensure that the correspondence address shown in Section 2 is the supplier’s address. 4. Enter your NPI in the applicable sections. 5. Enter all applicable dates. 6. Ensure that the correct person signs the application. 7. Send your application and all supporting documentation to the designated fee-for-service contractor. ADDITIONAL INFORMATION. For additional information regarding the Medicare enrollment process, visit MedicareProviderSupEnroll. The fee-for-service contractor may request, at any time during the enrollment process, documentation to support and validate information reported on the application. You are responsible for providing this documentation in a timely manner. Certain information you provide on this application is considered to be protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application for the Privacy Act Statement. MAIL YOUR APPLICATION. The Medicare fee-for-service contractor (also referred to as a carrier or a Medicare administrative contractor) that services your State is responsible for processing your enrollment application. To locate the mailing address for your fee-for-service contractor, go to MedicareProviderSupEnroll.Application for Medicaid (CMS Form 855R)OVERVIEW. Complete this application if you are reassigning your right to bill the Medicare program and receive Medicare payments for some or all of the services you render to Medicare beneficiaries, or are terminating a currently established reassignment of benefits. Reassigning your Medicare benefits allows an eligible organization/group to submit claims and receive payment for Medicare Part B services that you have provided as a member of the organization/group. Such an eligible organization/group may be an individual, a clinic/group practice or other health care organization. Both the individual practitioner and the eligible organization/group must be currently enrolled (or concurrently enrolling via submission of the CMS-855B for the eligible organization/group and the CMS-855I for the individual practitioner) in the Medicare program before the reassignment can take effect.Generally, this application is completed by the organization/group, signed by the Delegated/Authorized Official of the organization/group and the individual practitioner, and submitted by the organization/group. When terminating a current reassignment, either the organization/group or the individual practitioner may submit this application with the appropriate sections completed and signed. NOTE: A separate CMS-855R must be submitted for each organization/group where a reassignment is being established or terminated. The individual or delegated/authorized official, by his/her signature, agrees to notify the MAC of any future changes to this reassignment in accordance with 42 CFR § 424.516(d)(2). NOTE: An individual does not need to reassign their benefits to a corporation, limited liability company, professional association, etc., when he/she is the sole owner. See the CMS-855I Application for Physicians and Non- Physician Practitioners for more information. NOTE: Physician Assistants: This application should not be used to report employment arrangements. Employment arrangements must be reported using the CMS-855I application. Physicians and non-physician practitioners, other than physician assistants, can reassign Medicare benefits or terminate a reassignment of Medicare benefits after enrollment in the Medicare program or make a change in their reassignment of Medicare benefit information using either: 1. The Internet-based PECOS 2. The paper CMS-855R application. Be sure you are using the most current version. For additional information regarding the Medicare enrollment and reassignment process, including Internet-based PECOS and to get the current version of the CMS-855R, go to . INSTRUCTIONS FOR COMPLETING THIS APPLICATION. 1. Type or print all information so that it is legible. Do not use pencil. Blue ink is preferred. 2. Sign and date the certification statement(s) as appropriate. 3. Enter all NPIs in the applicable sections. 4. Keep a copy of your completed Medicare reassignment package for your own records. ADDITIONAL INFORMATION. When establishing a new reassignment, Section 6A must be signed by the individual practitioner and Section 6B must be signed by a delegated or authorized official of the organization/group. If the reassignment is to an individual, that person must sign Section 6B. When terminating a reassignment, either Section 6A or Section 6B can be completed. Reassigned claims for services rendered by the individual will no longer be paid to the organization/group after the effective date of the termination. The MAC may request additional documentation to support and validate information reported on this application. You are responsible for providing this documentation in a timely manner, usually within 30 days of the request. The information you provide on this form is protected under 5 U.S.C. Section 552(b)(4) and/or (b)(6), respectively. For more information, see the last page of this application to read the Privacy Act Statement. WHERE TO MAIL YOUR APPLICATION. Send the completed application with original signatures to your designated MAC. The MAC that processed your initial enrollment application is responsible for processing your reassignment application. To locate the mailing address for your designated MAC, go to MedicareProviderSupEnroll. Facility ManagementDescription of Service Providing AgencyNC will contract with a NHMC to provide full spectrum facility management at each NCSVH, to include the following:1. Provide administrative management of facility2. Provide clinical management of facility.3. Provide routine facility maintenance.4. Conduct internal audit of procedures as required.5. Interact with Medicare as required.6. Provide monthly status report to NCDMVA Program Manager.7. Provide Food Service and Laundry Service to facility residents.Key ControlPURPOSE: The NCDMVA and the NCSVH are responsible for the security and safety for all their residents, staff, and guests. This policy is designed to control access to and within the facility from unauthorized personnel, promote accountability, prevent loss of property, and to maintain security as a priority. Key(s) should be issued to supervisors. POLICY: To create a policy to ensure the safety of the residents, staff and visitors.The following are guidelines and regulations for issuing facility keys and limiting access to areas located that are not noted as public access areas: ACCESS: 1. The main facility may be accessed for staff during work hours. During non-work hours the staff must sign-in at the receptionist desk. 2. All visitors and guests must sign-in at the reception desk upon arrival at the facility from 8:00 a.m. to 8:00 pm. 3. The staff will at no time disclose the access code/codes to the electronic access system devices to a visitor, guest, external vendors, and former employees. Any exception must be approved by AD and accompanied by a written consent. 4. Doors shall never be propped open. 5. The staff is not allowed to duplicate any key(s). It is unlawful to duplicate keys belonging to the NCSVH. Violators will be terminated. KEY ISSUANCE: The staff must sign a Key Receipt for all key(s) that are issued and sign an agreement. The form obtained from the MD; however, approval is issued from the AD. KEY INVENTORY: 1. A current key inventory containing all locks in the facility shall be maintained in a log book in the MD office with a copy being submitted to the AD and NCDMVA when changes are made within the facility. 2. All spare keys shall be locked in a secure key box in the MD office. KEY AUDIT: A key audit shall be conducted by the MD at the beginning of each quarter to verify information contained in the key log. A report will be completed and submitted to the NCSVH PM by the 5th of each month. InventoryPURPOSE: To establish procedures and requirements for the maintaining records of all goods/equipment purchased by NC (directly or indirectly) otherwise known as an inventory at each NCSVH. The term “directly” references purchases made through the NC State e-procurement system. “Indirectly” would reference purchases through the management company, in which NCDMVA reimburses for all expenses for the operation of the home. State property is both direct/indirect purchases.POLICY: Guidelines for recording and maintaining an inventory of all equipment purchased for the NCSVH. VSO DUTIES: The VSO in each NCSVH will be responsible for maintaining a complete and comprehensive inventory in each respective facility. To include transfers (to and from), surplus items, etc… A electronic inventory spreadsheet for each NCSVH will include any and all information related to the inventoried item; i.e. Manufacturer, State Asset Tag Number (see NC State Asset Assignment 2:00), Model Number, Serial Number, Date Purchased, Warranties, State Purchase Order Number, Invoice Number, Description of Item, Date of Surplus, Date of Transfer to NCDMVA, Date of Transfer from NCDMVA, Cost of Item, etc… NC STATE ASSET ASSIGNMENT: NC State Asset Tags are assigned through the NCDMVA Raleigh office. When equipment purchases are made (serial numbers are sent to NCDMVA) and determined to meet the fixed asset requirements, a NC State Asset Tag is assigned. A copy of the XXXXXXXX form and NC State Asset Tag is sent to the VSO for recordkeeping purposes and to be affixed to the item (equipment). EQUIPMENT INFORMATION: State equipment information will be compiled from copies of State Purchase orders, State Veterans Homes Invoices and Asset Inventory Sheets. Items are sent to the VSO. NCSVH equipment information will be compiled from copies of weekly invoices processed to you from the NCSVH staff. NCDMVA INVENTORY REVIEW: Yearly, the VSO will conduct an inventory of items with State assigned asset tags. The Asset Tag Inventory forms will be sent to the VSO from the NCDMVA. After verification of the equipment, the forms will be sent back to the NCDMVA. INVENTORY REPORT: It is the responsibility of the VSO to submit a monthly Inventory Report of all inventoried items to the NCSVH PM. In addition, the VSO should report to the NCSVH PM immediately in writing any and all damaged, broken, lost, etc… items at each respective facility. Vehicle Operator Selection and ValidationPURPOSE: The NCDMVA and the NCSVH are responsible for the security and safety for all their residents, staff, and guests. This policy is designed to ensure that personnel that operate vehicles at the NCSVHs that transport residents meet appropriate safety and motor vehicle operation standards; and are properly vetted to meet insurance requirements. POLICY: Maintain a roster of personnel authorized to operate vehicles owned by NCSVH.The following are guidelines to support this requirement.DRIVER REQUIREMENTS1. 21 years of age of older2. Be issued a valid North Carolina State Driver’s License3. Meet selection criteria listed below based on Motor Vehicle Driving Record4. Complete the Driver History Form (attached) and provide to NHMC Administrator5. Complete the Van Transportation Certification ProgramPROCEDURES1. Upon identification of potential driver, the NHMC Administrator will forward a request to NCDMVA to produce the Motor Vehicle Driving Record from NCDMV.2. NCDMVA will provide the NHMC Administrator a copy of the driving record for evaluation by the NHMC Risk Management personnel for suitability to be a vehicle operator3. NHMC Risk Management will provide written evaluation of the candidate’s driving record to NHMC Administrator and to NCDMVA Program Manager.4. NHMC Administrator will also provide copies of driver candidate driver’s license and Driver History Form to NCDMVA Program Manager.5. NHMC Administrator will review all authorized drivers driving records annually.6. NHMC Administrator will complete a Driver Authorization Vehicle Checklist on each approved vehicle operator and maintain in the driver permanent record.EVALUATION CRITERIA FOR CLASSIFICATION OF DRIVERS1. Items documented on the Motor Vehicle Driving Record will be categorized as follows:a. Minor: Any moving vehicle violation during the preceding 3 years that is not listed in either the “Major” or “Unacceptable” criterium below; and does not result in an “at fault” accident. Examples include (but are not limited to):Speeding 14 miles per hour or less over the posted speed limit.Impeding trafficDisobeying posted traffic signsMaking improper turnsb. Major: A citation issued during the preceding 5 years for a serious traffic violation that involves:An “at fault” accidentSpeeding between 15 and 20 miles per hour of the posted speed limitPossession of an open container of alcoholPossession of illegal drugsAny failure to adhere to appropriate traffic lawsFailure to stop and report an accident in which you were involved, regardless of faultSpeeding that results in an accident or property damage.c. Unacceptable: Citations for any of the following violations:Driving while intoxicated (DWI)Driving under the influence (DUI)Speeding in excess of 20 miles per hour over the posted speed limitVehicular Manslaughter or Vehicle HomicideDriving with a suspended or revoked driver’s licenseAggravated assault with a vehicleOperating a vehicle without the owner’s permission (THEFT)Hit and runReckless driving, drag racing, or attempting to elude an officer of the law2. Evaluation Criteriaa. Points will be applied to a driver’s record as follows:Minor Infraction1 pointMajor Infraction (more than 5 years)3 pointsMajor Infraction (between 3 & 5 years)6 pointsUnacceptable Infraction7 pointsb. Additional points will be applied to a driver’s record for the following circumstances:2 Incidents in the last 18 months (all types)1 point3 Incidents in the last 18 months (all types)2 pointsc. Application of Evaluation (as documented annually in the Administrator’s review):2 points or lessNo action3 pointsSix months driving probation4 to 6 points12 months driving probation7 or more pointsDriving suspendedd. As soon as points drop off a driving record, the driver’s status will be reevaluated. 3. High Risk Driversa. Any driver that their Motor Vehicle Record Check indicates any of the following:Convicted for an alcohol or drug related driving offenseRefusal to submit to a Blood Alcohol Content (BAC) testConviction of speeding in excess of 25 miles per hourAny criminal convictionAny combination of 3 or more moving violations, regardless of “at fault”, within 3 yearsDriving with suspended, revoked, or an administrative suspended licenseLeaving the scene of an accidentReckless drivingb. If classified as a “High Risk” Driver, the NHMC Administrator will exercise, at his/her discretion, option 1 or option 2, below (and notify NCDMVA Program Manager):Option 1: Probation – Do all of the following:Place driver on probation for 2 years from the date of most recent violationRequest Motor Vehicle Record check every 6 months for progressImmediately suspend driving privilege if a repeat violationImmediately suspend driving privilege if involved in an “at fault” accidentImmediately suspend driving privilege if probation is violatedCoordinate with NHMC Risk Management for additional stipulationsProvide terms of probation in writing to driver and have driver acknowledge receiptNotify NHMC Risk Management and NCDMVA Program Manager when probation endsOption 2: Suspension - Do all of the following:Insure driver does not operate vehicle for any company businessCan result in transfer to non-driving positionCan result in dismissalDriver can reapply for position after one-year suspensionIf approved, driver will be placed in probation statusOTHER PROVISIONS1. Unauthorized use of NCSVH owned vehicle: It the event an unauthorized person operates the NCSVH vehicle, disciplinary action will be taken, up to and including suspension, against the person that allowed the unauthorized operation to happen. Action can also include repayment of damages, in the event of an accident2. InsuranceAll NCSVH vehicles are insured against accident, loss, and damageInsurance information is maintained at NCDMVA and NHMC AdministratorKeep the Vehicle Insurance Identification Card in the vehicle at all timesKeep the “If you are injured on the job” brochure in the vehicle at all times InvoicingInvoice PolicyPURPOSE: To establish a standard to NHMC operates under a centralized system and therefore, all invoices are not reviewed by the accounts payable clerk at each facility. POLICY: A process in which invoices for goods and services submitted for payment can be reviewed. In addition, costs will be researched per RFP #200900594 – Management & Operation of Licensed Nursing Facility, IV. Payments, 4.01 General Provisions: B. The activity of the related party shall be identified before each invoice is submitted each month and the lower of actual cost or market value will be substituted for operational expenses to NCDMVA. QUARTERLY REQUESTS: 1. NCDMVA will receive a quarterly complete detailed Gain and Loss (G&L) statement from the NHMC by the 10th of the following month for the preceding quarter for any NCSVH they manage. The G&L will be reviewed and invoices will be selected at random to validate. 2. Quarterly requests will be submitted to each the NHMC for any NCSVH for invoices and documentation of request and payment by the 20th of the month. 3. Quarterly terms are as follows: January 1 – March 31April 1 – June 30July 1 – September 30October 1 – December 31SELECTION OF INVOICES: 1. Requested invoices will be selected randomly. 2. Selection of Invoices: a. Number sequence for each vendorb. Invoices ending with a certain numberc. All invoices for one vendord. However, not limited to the selection process aboveINVOICES AND DOCUMENTATION TO BE SUBMITTED: 1. Itemized invoices per quarterly request 2. Documentation: a. Request for purchase from the nursing home management company of any NCSVHb. Original invoice from vendor (in the case of related parties)c. Original invoice from vendor PROCEDURE FOR THE REQUEST OF INVOICES: 1. An e-mail request with the randomly selection invoices will be submitted to the NHMC of any NCSVH per the following schedule:a. April 20thb. July 20thc. October 20thd. January 20th2. Invoices and documentation information per the request will be submitted to the NCSVH Program Manager per the following schedule: a. April 30thb. July 31st c. October 31st d. January 31st 3. Copies of the documentation may be forwarded to each respective NCSVH as well for their review. REVIEW OF INVOICES: 1. Information will be reviewed for accuracy in billing by the NCSVH. 2. Random research on prices of goods and services will be conducted to verify actual costs/market value whichever is lower. 3. A quarterly report will be prepared for the NCSVH PM for each facility noting the findings.Receipt of GoodsPURPOSE: To establish procedures and requirements for the proper processing of paperwork for the receipt of goods and services ordered or paid by NC.POLICY: Outline procedures for processing paperwork, recording information on the Inventory spreadsheet, and notifying Raleigh of the receipt of goods/services. VSO RESPONSIBILITY: The VSO in each NCSVH will be responsible for acknowledging receipt of goods/services ordered by NC through the e-procurement system. 1. When a State Purchase Order is issued for Goods/Services. An e-mail will be sent to each respective NCSVH. 2. The VSO should post the information received with the product received or Asset Tag Form to the Inventory spreadsheet. 3. An approximate date of when the goods/services will be received at the home will be e-mailed to the facility. If the items are not received within a week, notify NCDMVA via e-mail. 4. As soon as the goods/services are received at the NCSVH, the VSO is responsible for checking the items received to ensure that all items are received. 5. The VSO is responsible for verifying that all items received are operating properly and received in acceptable condition. 6. The packing slip/invoice with serial number is courier mailed to NCDMVA, ATTN: NCSVH immediately. Serial number is noted on the Inventory spreadsheet.Residence AdministrationAdmissionsPURPOSE: North Carolina General Statute §143-52 states that the VAC shall have the authority to determine administrative standards for admission and dismissal, as well as medical conditions, of all persons admitted to and dismissed from the NCSVH, and to issue any necessary rules, subject to the requirements set out in G.S. §143-53, Eligibility and Priorities. POLICY: The SOP for Admissions into a NCSVH is to be strictly adhered to and followed when veterans apply for residency at a NCSVH. The information obtained must be complete and in compliance with State and Federal Law. A veteran must meet criteria as stated in this policy to be placed in a NCSVH.NCDMVA GENERAL ADMISSION REQUIREMENTS: The NCSVH may refuse to place a veteran in the NCSVH if a veteran fails to meet the either the medical or non-medical Admission Requirements (see below). The AD will notify the NCSVH PM immediately of veteran’s failure to meet requirements. The AD is responsible for contacting the appropriate party of the refusal. Bed offers are only made through the AD. Non-medical Admission Requirements: 1. The veteran must have served on active duty in the Armed Forces of the United States for other than training purposes. 2. Veteran must have been discharged from the Armed Forces under honorable conditions (applicant must supply DD-214 or equivalent Report of Separation from Service). 3. Veteran must be a bona fide resident of NC twenty-four (24) months immediately prior to date of application. 4. A licensed physician must refer the veteran. 5. Veteran must be disabled by reason of age, disease, or other reasons determined through a physical examination. The medical staff will review the FL-2 and History and Physical to confirm that the NCSVH can meet the need of the veteran/resident. 6. Additionally, per Public Law 109-461, Attachment 19426 Federal Register effective May 29. 2009, a veteran that has at least a 70% service connected disability rating; or requires nursing home care due to a service connected disability is also eligible. Medical Admission Requirements: 1. Must not be a carrier or suspected of having any infectious, communicable disease. 2. Must not have a condition which, in the opinion of the attending physician, is such that there is a probability of their being unduly disruptive to other residents, staff or visitors, or committing physical harm to themselves or others. 3. Must not be chemically dependent on drugs or alcohol. If previously dependent, must have successfully completed a structured rehabilitative program prior to admission. 4. Not acutely ill or require medical, surgical, and nursing care beyond the capabilities of the facility. Admission Priority: Eligible veterans will be admitted into a NCSVH or placed on a waiting list for admission into a home according to the following priorities: 1. Eligible wartime veterans with equal care requirements will be ranked in chronological order based on the earliest date of receipt of the veteran’s application for care. If more than one application is received on the same date, the VSO / AD will determine their sequential order on the list according to medical need.2. All other eligible veterans will be ranked in chronological order based on the earliest date of receipt of the veteran’s application for care. If more than one application is received on the same date, the VSO / AD will determine their sequential order on the list according to medical need.3. Occupancy is limited to 5% of total capacity of the facility (see below) for veterans that have at least a 70% service connected disability rating; or require nursing home care for a service connected disability. Occupancy levels are as follows:a. Salisbury – 5 personnelb. Fayetteville – 7 personnelc. Kinston – 5 personneld. Black Mountain – 5 personnele. Raleigh – 6 personnel (to be validated)f. Kernersville – 6 personnel (to be validated) 4. Any non-veterans. A non-veteran may occupy no more than twenty-five percent (25%) of the total beds in a NCSVH and may not be admitted unless the census is at 90% or lower. When any space is available for non-veterans, priority will be as follows: a. Spouseb. Widow or widower whose spouse, if living, would be an eligible veteran. c. Gold Star parents, defined as the mother or father of a veteran who died an honorable death while in active service to the United States during time of war or emergency. MEDICAL CRITERIA DETERMINING LEVEL OF CARE: Must have a current physical within thirty-days (30) of admission verifying that the individual needs assistance with most activities of daily living and has a medical and/or nursing supervision need. Must have current chest x-ray within thirty-days (30) of admission verifying that the individual is free of tuberculosis (if available). A veteran who has been preliminarily qualified for admission may be required to furnish additional information including but not limited to: 1. Current Medical Findings - diagnosis and prognosis. 2. Medical Rehabilitation Goals - summary of course of treatment followed in hospital or other health care facility. 3. Physician orders for transferring care. ADMISSION PACKET: Letter from the NCSVH PMInformation Sheet (List of Requirements/Documents) Brochure NCDMVA 31 - NCSVH Application (Copy maintained in resident’s file.) The AD maintains copies of the Admissions Packets. Information and instructions to applicants to the NCSVH complies A veteran or family member may obtain a copy of the Admissions Packet/Information prior to admission by requesting information in the following manner: 1. A copy of the Admissions Packet may be obtained by visiting the NCSVH – AD, District Service Office, or County Service Office). 2. A copy of the Admission Packet may be mailed to the veteran’s home for his/her convenience (NCSVH– AD). 3. Contact the AD at each respective home for information on admissions. The AD schedules all tours. COMPLETION OF APPLICATION PACKET (REQUIRED DOCUMENTS/FORMS/ INFORMATION): A completed application packet does not guarantee your acceptance and placement in the NCSVH. It is a means of determining eligibility and benefits available to you from USDVA. The admission packet can be completed at date of admission. If there is a problem completing the admission documents, contact the NCSVH Program Manager immediately. Assistance in Completing NCDMVA / USDVA Required Documents: 1. The VSO within the NCSVH assists in preparing and completing the required NCDMVA / USDVA forms for the veteran’s admission. 2. The VSO at the NCSVH may request VA benefit information on a potential resident from a District or County VSO. The admission process is separated by NCDMVA and Management Company required information. All forms, documents and information are required for veteran to be admitted into the NCSVH. The VSO will assist the veteran in obtaining the information and/or completing the documents. 1. NCDMVA Required Application Packet:a. Completed Form NC FL-2 (30 days current), Medicaid Program Long Term Care Services (must be signed and dated by physician), and recent history and physical (30 days current – 2 to 3 pages) completed by physician. These forms are forwarded to the NCDMVA office from the AD (Copy forwarded to VAMC and State Service Office/Copy maintained in resident’s file). b. Completed Form NCDMVA-31, Application for NCSVH (Copy maintained in resident’s file).c. Completed DVA Form 10-10EZ, Application for Medical Benefits and Financial Worksheet (Original forwarded to VAMC/Copy maintained in resident’s file). d. Completed 10-10EZA, DOB and Parental Information (Original forwarded to VAMC/Copy maintained in resident’s file). e. Completed 21-4138, “I wish to advise you that I am currently a nursing home patient . . . facility as provided for in P.L. 109-461, Sec 211.” (Original forwarded to VAMC/Copy maintained in resident’s file). f. Completed USDVA Release of Information (Original forwarded to the VAMC/Copy maintained in resident’s file). g. Completed DVA Form 21-526/527, Veteran’s Application for Compensation or Pension, if applicable (Original forwarded to State Service Office/Copy maintained in resident’s file). h. Completed DVA Form 21-22, Appointment of VSO as Claimant’s Representative (Original forwarded to State Service Office/Copy maintained in resident’s file). i. Completed “Notice of Responsibility for Medicaid Residents Form”2. Documents Needed to Support Application: a. A copy of military discharge, DD-214, or equivalent. (Copy may be forwarded to State Service Office/Copy maintained in resident’s file)b. Proof of Residency for past 2 years (example: voter registration, NC tax return, property tax records, NC driver’s license, employment records) (Copy maintained in resident’s file) c. A copy of Legal POA (if applicable) (May be forwarded to VAMC/Copy maintained in resident’s file) d. A copy of Health POA (if applicable) (Copy maintained in resident’s file) e. A copy of Guardianship (if applicable) (Copy maintained in resident’s file) f. A copy of Living Will (if applicable) (Copy maintained in resident’s file)g. A copy of Court-Appointed Conservatorship (if applicable) (Copy maintained in resident’s file) h. A copy of Marriage/Death/Divorce Paperwork (if applicable) (May be forwarded to State Service Office/Copy maintained in resident’s file) i. Income Information – Bank statements, any information regarding stocks and bonds, pension, social security, information on rental property, earned interest, property taxes, etc. (if applicable). (May be forwarded to State Service Office/Copy maintained in resident’s file) j. Veterans currently receiving pension/compensation – VA paperwork (if applicable) (Copy maintained in resident’s file) k. Social Security Card, Driver’s License (if applicable), Medicare Card/Medicaid Card (if applicable) and any other Health Insurance Cards (if applicable). (Copy maintained in resident’s file) 3. Contact Person, Address and Telephone Number (Must have POA or be able to make decisions on behalf of the veteran, without recourse or confusion). NOTICE OF AVAILABILITY: The veteran or veteran’s designated contact person will be contacted by telephone by the AD at the NCSVH to notify them of the room availability. ACCEPTANCE: After the Medical Requirements have been met, the AD will forward FL-2, History and Physical to the VSO. The VSO is responsible for obtaining a copy of the DD-214 and documentation of the residency requirement. If there is a problem or issue with this requirement, the NCSVH PM is notified immediately. Upon notification of room availability by the AD, an appointment will be set-up for the veteran to begin the admission process into the NCSVH. The AD will notify the VSO of the appointment; however, the VSO is responsible for re-scheduling an appointment if they are not available during the initial application admission process. The veteran and/or family member will meet with the VSO at the NCSVH, hospital or residence to ensure all State/Federal required forms and documents are completed. PRIVATE ROOMS: The policy and priority for private room assignment is as follows: 1. Contagious or infectious disease; 2. Oxygen or terminally ill; 3. Female admissions (where private room is available, and female is #1 on the waiting list and home occupancy would preclude admittance of the female); 4. First come, first served (any occupant of a private room, due strictly to the choosing of the resident will be charged an additional $30.00 per day). Private room occupants in categories 1, 2, and/or 3 will vacate the private room when the condition(s) and/or situations are resolved. Private room occupants from category 4 will be required to vacate the private room for category 1, 2, and 3, residents on a last in, first out basis (name would be placed back at the top of the first come, first served waiting list). CIVIL RIGHTS ACT: Residents shall recognize that the homes will be operated in full compliance with the Civil Rights Act without discrimination as to race, color, creed or religion. EXCEPTION TO COST FOR VETERANS WITH AT LEAST 70% SERVICE CONNECTED DISABILITY RATING, OR REQUIRE NURSING HOME CARE FOR A SERVICE CONNECTED DISABILITY:Per the previously mentioned Public Law, the NCDMVA receives a per diem rate from the Federal Government, however, transportation costs to and from a medical facility that exceed 25 miles are the responsibility of the veteran and/or his/her family. Collection of FundsPURPOSE: To establish procedure and requirements for the collection and deposit of funds into the NCSVHTF. ABSOLUTELY NO CHECKS WILL BE CASHED. All donated checks and monies (cash) collected will be receipted and turned into the NCDMVA for deposit into the NCSVHTF. POLICY: NC General Statutes §143-49. Funding states under (b) and (c): “(b) The NCDMVA may receive from any source any gift, contribution, bequest, or individual reimbursement, the receipt of which does not exclude any other source of revenue. (c) All funds received by the Department shall be deposited in the NCSVHTF, except for any funds deposited into special agency accounts established pursuant to G.S. 143-48(d)(3). The VAC shall authorize the expenditure of all funds from the NCSVHTF. The VAC may delegate authority to the Assistant Secretary for Veterans Affairs for the expenditure of funds from the NCSVHTF for operations of the NCSVH. (1995, c. 346, s. 1; 2001-117, s. 1.)” This policy outlines the responsibility for the collection of funds deposited into the “NCSVHTF Account”. COLLECTION OF FUNDS: Checks made payable to the NCSVH or NCSVHTF and monies collected must be receipted by person (NCSVH-AD or VSO) at the home receiving the funds. All funds collected on behalf of the NCSVHTF will be turned into the NCDMVA for deposit.A receipt is issued to the person/entity donating the funds (checks/cash). If there is a specific usage or purpose, in the memo section of the check, a note should be made to reflect the usage/purpose on receipt; THANK-YOU LETTER: An informal thank you letter should be sent by the NCSVH activity staff (NCSVH letterhead/or NCSVH Card). The VSO will send a formal thank you letter on State letterhead to the giver and if specific usage was noted; will send a second letter acknowledging receipt of gift(s) or accountability. In the case of memorial gifts, one letter will be sent to the giver and a second to the family as an acknowledgment itemizing the givers and amounts. A copy of the initial thank you letters by the VSO will be sent to NCDMVA with the funds collected. In the case of the second letter, a copy will be sent to NCDMVA when completed. DEPOSITS: When receipt, funds and thank you letter are received at the NCDMVA, a receipt will be issued and sent back from to the appropriate entity (NCSVH Activity Staff or VSO). The deposits are submitted to Department of Administration, Fiscal Management on the appropriate form for deposit into the NCSVHTF. RECEIPT BOOKS: Used Receipts books should be turned into the NCDMVA and kept on file as official record. GIFT AND DONATION LOG: The VSO will maintain a Gift and Donation Log (spreadsheet) of all monetary gifts or donations given to the NCSVH Program in each respective home. A copy of the updated log will be sent to the NCDMVA monthly. It is due on the first of the month. INVENTORY LOG:Equipment/Significant donations will be recorded on an Inventory Log (spreadsheet) maintained in each facility by the VSO. (See Inventory Policy). ABUSE OF STATE FUNDS: Abuse of State Funds may result in disciplinary action to include the loss of employment and criminal action. Bed HoldESTABLISHING RESIDENCY:Upon admission into the NCSVH a veteran resident must establish residency to be eligible for the new Bed hold Policy benefits. A veteran must be a resident of the NCSVH for 30 consecutive days (including overnight stays) and the facility must maintain an occupancy rate of 90% or greater for the 30 days. If the veteran resident does not meet the residency requirement above, and the facility does not meet the 90% or greater occupancy rate; for either medical or non-medical bed holds, the veteran resident will be charged the basic daily rate established by the VAC to hold their bed. BEDHOLD POLICY:Non-Medical Bed holds: A qualifying veteran resident will be permitted only 12 days in a calendar year (retroactive to January 1, 2009) for a leave of absence (LOA) from the NCSVH for non-medical reasons. No more than 10 consecutive days may be taken at any one time during a calendar year. If a veteran resident exceeds the 12 days of LOA per calendar year for non-medical reasons, he/she will be charged the basic daily rate established by the VAC to hold their bed. Medical Bed holds: A qualifying veteran resident will be permitted a bed hold for the first 10 consecutive days that they are admitted as a patient in a VA Medical Center or other hospital (this could occur more than once in a calendar year). After the first 10 consecutive days, the veteran resident will be charged the basic daily rate established by the VAC to hold their bed. The Medical Bed holds are per admission into a Medical Center and the resident is entitled to unlimited ten (10) day bed holds throughout the year. Grooming StandardsPURPOSE: Per regulations (§483.15 and §483.15a) required by the State Regulations, our resident’s must be properly groomed which makes these services mandatory at least once a month for male residents and one a month for female residents. POLICY: To allow each resident at no cost in the NCSVH one haircut/wash and set per month. This service will allow the NCDMVA and NCSVH to be in compliance with State regulations. STATE REGULATIONS: Regulation: §483.15 - A facility must care for its residents in a manner and in an environment that promotes maintenance or enhancement of each resident’s quality of life. The intention of the quality of life requirements is to specify the facility’s responsibilities toward creating and sustaining an environment that humanizes and individualizes each resident. Compliance decisions here are driven by the quality of life each resident’s experiences. Regulation: §483.15a - The facility must promote care for residents in a manner and in an environment that maintains or enhances each resident’s dignity and respect in full recognition of his or her individuality. “Dignity” means that in their interactions with residents, staff carries out activities that assist the resident to maintain and enhance his/her self-esteem and self-worth (ie: Grooming residents as they wish to be groomed (e.g., hair combed and styled, beards shaved/trimmed, nails clean and clipped))1. As per State regulations, each male resident will receive one haircut (no other services included) per month at no cost to the male resident.2. Additional haircuts and other services can be completed; however, the cost will be the responsibility of the resident. The NCDMVA or the NCSVH will assume no responsibility for these additional services and/or costs. 3. As per State regulations, each female resident will receive one wash and set (no other services included) per month at no cost to the resident. 4. Additional wash and sets, permanents, colors, haircuts, manicures, and any and all other services can be completed; however, the cost will be the responsibility to the resident. The NCDMVA or the NCSVH will assume no responsibility for these additional services and/or costs. RESPONSIBILITY OF STAFF OF THE NCSVH: The staff will verify that each resident desiring a haircut/wash and set receives one monthly at no cost to the resident. The responsible staff member will initial the billing sheet to confirm that these services have been completed. The staff will ensure that if additional haircuts/wash and sets or any and all other services will be at the cost of the resident; therefore, they will responsibly check to make sure that the residents have adequate funds to pay for the additional services and there is no double billing to the State of North Carolina. RESPONSIBILITY OF THE BARBER/BEAUTICIAN: To be licensed by NC and insured; with proof of insurance kept on file at the home. The barber/beautician will check to make sure that each resident does not receive more than one haircut/wash and set per month that will be billed to the NCDMVA or NCSVH. An invoice for the billable services to the NCDMVA or NCSVH will be turned in the first of each month following the month of service. A check will be issued through the monthly billing process within 45 days of submission. Services other than the one haircut/wash and set will be the responsibility of the Barber/Beautician to collect from the resident/business office. Points of ContactDEPARTMENTNAMEEMAILPHONEBerry Dunn ACCTLisa Trundy-Whittenltrundy@207-541-2263 207-590-1414DOA-InterscopeLee Anne Hahnelinterscope@doa.984-236-5429RNDVicky Shafervicki@919-490-1266DHHS-MedicaidDonna DeansDonna.deans@dhhs.919-527-6213InsuranceBarbra Abrahamsbabrahams@919-863-6529Wells FargoDonna SherillDonna.sherrill@NC DHHSQwonthafia JonesQwony.jones@dhhs.919-855-4536DOATheresa WatsonTheresa.k.watson@doa.919-807-2459DOIPat HowellPat.howell@919-647-0069PruittNina Garyngary@VA-DHSRBecky WertzBecky.wertz@dhhs.919-855-4580VA-Cemetery GrantsGeorge EisenbachGeorge.eisenbach@202-632-7369Friends of NCSVHTFLee Littikencoolheat@919-776-6958NC OSBMSusie EsealukaSusie.esealuka@osbm.919-807-4745USDVA SVH Cont.Mehvesh ShereefMehvesh.shereef@301-674-2331USDVA SVH PMAnna GaugAnna.gaug@202-815-9694USDVA SVH Rep.Lisa MooreLisa.moore6@202-746-7464USDVA SVH CMElizabeth YoElizabeth.Yo@202-632-5924USDVA SVH CMChristine ModovskyChristine.Modovsky@202-632-5352USDVA SVH CMJihaad DavenportJihaad.Davenport@USDVA SVH PMAnna GaugPersonal Cell Phone760-267-7336VA-GreenvilleYolanda SoneyYolanda.soney@252-830-2149VA-SalisburyTammy AhlersTammy.ahlers@ (x13338)704-683-9000VA-FayettevilleKeninthe DavisKeninthe.davis@PSC-HHSTheresa RittaTheresa.ritta@psc.LS3PLaura Millerlauramiller@910-409-1105Rodgers ConstructionNeil Stuckynstucky@704-971-8229Fayetteville SVH ADWhitney BellWRBell@910-822-7202Kinston SVH ADBonnie Ardbard@252-939-8006Salisbury SVH ADSally Davissfdavis@704-638-4200Black Mountain SVH ADSteve Sheetsssheets@828-257-6800Pruitt Health - RVPMelvin Mosesmmoses@404-405-3856Pruitt Health - RFMMichelle Santillimsantilli@843-260-6256Pruitt Health – RDONKathy CumminsKCummins@678-215-1870VA-TungstenKarin BellKarin.bell@512-460-5263Tungsten877-489-6135Reports Schedule1. Daily Reportsa. Daily Census – Provided by Pruitt from each home directly to VA, with copy furnish to Pruitt Regional Financial Counselorb. Deposits – Provided by Pruitt from each home directly to Pruitt Regional Financial Counselorc. RA2. Weekly Reportsa. Weekly Census Roll Up – Provided by Pruitt Regional Financial Counselor to NCDMVA Friday 10:00 AM3. Monthly Reports4. Annual Reports5. As Required Reportsa. CER – From Pruitt to NCDMVAAppendicesA. Key LogB. Key Receipt and Agreement FormC. Driver Authorization Verification Checklist FormAppendix A – Key LogAppendix B – Key Receipt and Agreement FormAppendix C - Driver Authorization Verification Checklist FormDRIVER NAME:DATE:INITIAL APPLICATION:ANNUAL RECERTIFICATION:DOCUMENTATION COMPLETED AND PLACED IN PERSONNEL FILE:DATE OF COMPLETION:INITIALS OF PERSON VERIFYING COMPLETION:Current Driver’s License (at least 21 years old)Evidence of InsuranceCompleted & Signed Driver History FormCompleted Motor Vehicle Record CheckMeets Company Safe Driver CriteriaComplete Van Transportation Certification ProgramSigned Job DescriptionCOMMENTSI have reviewed the above documents and authorize (driver)To operate the transportation van.ADMINISTRATOR:DATE: ................
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