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Civil Money Penalty (CMP) Reinvestment Application Template

Coronavirus Disease 2019 (COVID-19)

In-Person Visitation Aids Request Instructions

1. Project and Applicant Requirements to use the In-Person Visitation Aids Application Template.
Projects must:

Directly address the need to facilitate in-person visits for residents.
Fall within the following parameters for use of funds:
- Funds must only be used to purchase the types of visitation aids described above.
- Tent size must allow for social distancing to be observed.
- Maximum allowance of $3,000 per facility.
Ensure appropriate LSC requirements found at 42 CFR 483.90 are met, unless waived under the PHE declaration.
Ensure core principles of infection prevention and control practices. Surfaces must be cleaned and disinfected between resident use. Review the EPA’s List N: Disinfectants for Use Against SARS-CoV-2 to determine if the disinfectant identified in the manufacturer’s instructions meet EPA’s criteria.
Work with state officials to determine the appropriate level of visitation restrictions within available guidelines from the CDC (e.g., limiting the number of individuals visiting with any one resident).

To be considered for funding, each application must include the following information:

Name(s) of facility(ies) to receive equipment (and CMS Certification Numbers (CCNs)).
Medicaid Provider Id.
Number of certified facility beds.
Type(s) of equipment (brand and model).
Cost per equipment item.
Total number of items (equipment) requested.
Costs for shipping, handling, installation, and taxes (are permitted for this project and can be totaled on one line).
Total funds requested.

2. Eligibility Guidelines – confirm this project meets criteria outlined in Section 1.

Yes

3. Applicant Contact and Background Information

Organization Contact Information

Corporation

Name

Phone

Address of Payee

City

Zip

State

Name of Payee

Add Facility

Facility-

Details for Facility-

4. Total CMP Fund Request Amount Note: this amount should match the total cost of the items in section 5 below.

5. Budget Applicants must provide a line-item budget for all items, broken down per facility, for which CMP funding is requested. All items must directly relate to in-person visitation aids.

Facility Name

Medicaid Provider Id

CMS Certification Number (CCN)

Number of Certified Facility Beds

	Type of Visitation Aids (e.g. tents, clear dividers)	Cost per Visitation Aid	Number of Visitation Aids	Total Cost

Total Cost

6. Attestation Statement

CMP funds have been provided for the express purpose of enhancing quality of care and quality of life in nursing homes certified to participate in Title 18 and Title 19 of the Social Security Act. Applicants cannot use the standard CMP application process to supplement their visitation aid request to obtain additional in-person visitation aids in excess of the $3,000 maximum limit.

By typing name below, you are confirming that everything stated in this application is truthful and you are aware and in compliance with the CMP project and applicant requirements.

Name of the Applicant

Submit Timestamp

In order to continue with the application process, applicants must meet the eligibility guidelines.