A Long Term Care Nursing Home Facility's design and function is to meet the health needs of two or more elderly or disabled individuals who, at a minimum, require inpatient care and services for 24 or more consecutive hours.
Inpatient care is necessary for unstable or chronic health problems requiring:
- Daily professional nursing supervision and licensed nursing care
- Restorative care
- Rehabilitative care
- Assistance in meeting daily needs
Medical supervision is necessary on a regular but not daily basis.
The Nursing Home facility licensing packet includes items that must be submitted and approved by the Department prior to the initial survey being conducted.
1: Complete the Nursing Home Application.
2: Complete the Health Insurance Benefit Agreement: CMS Form 1561 (CMS-Form 1561) – (two originals required)
3: Complete the Fiscal Year Ending Form: form
4: Complete the “Office of Civil Rights Clearance for Medicare Certification” (OCR) Information is available at Assurance of Compliance with Non-Discrimination Laws and Regulations.
5: CMS requires all new applicants for skilled nursing facilities to complete the form CMS-Form 855a, Medicare Application for Health Care Providers that will Bill Fiscal Intermediaries, and forward it to the fiscal intermediary (FI)/carrier for approval. The form CMS-855A can be downloaded from the Internet or requested directly from your FI:
Read the instructions on the web site and obtain the form by clicking on the version you will need for your computer. Be sure to choose: Health Care Providers that will Bill Medicare Fiscal Intermediaries (FI) (CMS 855A).
The FI for Idaho is:
Noridian Administrative Services
P.O. Box 6726
Fargo, ND 58108-6726
6: Complete and submit a full copy of the Facilities Policies and Procedures.
You will need to develop your policies and procedures and send them to this office to be reviewed at least ninety (90) days prior to your scheduled opening. The policies and procedures may be submitted electronically on a CD or DVD. The following are guidelines for developing your policies and procedures:
- They should address, but not be limited to, all federal regulations and state rules as they apply to the provision of care for residents in the SNF.
- Use consistent style and format throughout the documents.
- If using policies established by other facilities, ensure they reflect only the name of the facility requesting the license.
- Be organized with a table of contents and/or index, indicating page numbers and sections. Use tab dividers whenever possible (if the documents are not submitted electronically).
- Policies listed in table of contents should indicate the general areas to federal regulations and state rules to which they apply.
7: S&C-08-03 Initial Surveys This CMS Letter is included to alert you that there will be significant delays in our ability to conduct an initial certification survey.
8: IDAPA 16.03.02 Rules and Minimum Standards for Skilled Nursing and Intermediate Care Facilities: IDAPA 16.03.02, Rules and Minimum Standards for Skilled Nursing and Intermediate Care Facilities, Idaho Administrative Rules for Skilled Nursing and Intermediate Care Facilities.
9: Chapter 7, CMS State Operations Manual (SOM)Manual (SOM), Survey and Enforcement Process for SNF and NF
10: Appendix PP , Guidance to Surveyors for Long Term Care Facilities – the Federal Regulations and Interpretive Guidance
11: Appendix Q, Federal Guidelines for Determining Immediate Jeopardy
12: Fire Safety Survey Report - CMS form 2786R (New or Existing)
13. Medicaid Provider Enrollment: reach out to Gainwell Technologies at 1-866-686-4272 which is the Provider line or go to www.idmedicaid.com and look under the Provider tab for information on how to become a Medicaid provider or by email at firstname.lastname@example.org
14. All state licensed and/or federally certified health care facilities must complete the Facility Fire Safety and Construction requirements. Fire and Safety Standards
The LTC Provider Reporting Tool allows providers to electronically report events and view the facility's investigation for that event. Review the instructions and tools to the right to gain access, report events, and access information.
Instructions for provider reporting portal
Participating in a survey can be a stressful event for administrators, staff, and residents. Being prepared by having required documentation organized and ready can help to reduce this stress.
- Entrance Conference Form (one copy needed)
- Additional Questions for the Administrator
- Matrix with Instructions (one copy needed)
- Beneficiary Notice Worksheet For Facility (three copies needed)
- CMS form 672 - Resident Census and Conditions, with instructions
- Three-week Nursing Staff Scheduling form
- LTCSP Procedures Guide
Informal Dispute Resolution Process: This document describes how to submit an appeal after the facility receives the formal written survey report. IDR Process - Overview
Informal Dispute Resolution Request Form: IDR Request Form
Review our Frequently Asked Questions document if you have additional questions about how to submit an Informal Dispute after you receive your survey results: IDR Frequently Asked Questions (FAQs)
Electronic Plan of Correction
- Steps to Access ePOC Application
- CMSNet Frequently Asked Questions
- CMSNet Online Enrollment
- CMSNet Installation Instructions
- ePoC Facility Webinar Handouts (Please see ePOC Presentation PowerPoint slides #21 for viewing the webinar)
- Required CCN number
- Form completed to request removal of ePOC access