Form Alp 6000 – Fill Out and Use This PDF

Assisted Living Program (ALP) 6000 – OPPORTUNITY FOR DEVELOPMENT (OFD)

IMPORTANT: Please read the ALP 6000 – OPPORTUNITY FOR DEVELOPMENT FORM INSTRUCTIONS before completing this form.

1. ELIGIBLE APPLICANT

FACILITY INFORMATION

County

APPLICANT INFORMATION* (Please check one:		฀Lead Applicant ฀Co-applicant)
	Name	Title
	Address (Street and Number, Building and Floor)	City	Zip Code

Telephone No. E-Mail Address

*Must be an eligible applicant (see Form Instructions, Section 3)

NAME & ADDRESS TO WHOM CORRESPONDENCE SHOULD BE SENT (If different from Applicant)

Name	Title
Address (Street and Number, Building and Floor)	City	Zip Code
	Telephone No.	E-Mail Address

2. OFD PROPOSAL SUMMARY

A concise summary of your proposal must be attached. The proposal must specifically state the following:

Othe Economic Development Region and County in which ALP beds will be located (List of Regions available at http://www.health.ny.gov/health_care/medicaid/redesign/index.htm);

Ohow your proposal fits into the current long-term care continuum in the Region;

Odocumented information to support your proposal to expand access to Assisted Living Program (ALP) beds and where there may be unmet demand; include incidences of those moving from an Adult Care Facility (ACF) or hospital setting to a Residential Health Care Facility (RHCF) due to their care needs;

Oif a new licensed ACF, the type of ACF proposed (i.e., Adult Home or Enriched Housing Program);

Othe total number of new licensed ACF beds proposed and the total number of ALP beds proposed;

Oif already licensed as an ACF, clearly indicate whether you are proposing to convert licensed ACF beds to ALP beds and/or proposing to add new ACF/ALP beds;

Othe number of RHCF beds you propose to decertify, if any. Note: Decertification of RHCF beds is not a requirement for selection under this opportunity;

Othe projected timeline for the ALP beds to become operational (i.e., when the ALP beds become licensed) and;

Oyour commitment to the admission and retention of individuals eligible for or in receipt of Supplemental Security Income, safety net assistance or Medical Assistance Your proposal must indicate the expected number and percentage of ALP residents upon admission by payer source.

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NEW YORK STATE DEPARTMENT OF HEALTH
Division of Long Term Care	ALP 6000 – OPPORTUNITY FOR DEVELOPMENT

3. PROGRAM INFORMATION

Provide information as stated in the Form Instructions, (Section 3.), and complete the chart below.

ACF RESIDENTIAL SERVICES - Bed Complement

	Adult Home or	Assisted Living	Skilled	Other
TYPE	Enriched	Program (ALP)	Nursing	Beds	Total
	Housing Beds	Beds	Facility Beds	(specify)

Licensed Adult Care Facilities:

1.Licensed ACF Beds: ฀AH ฀EHP

2.Licensed ALP Beds

3.Change in licensed ACF Beds

Unlicensed beds/facilities:

4.Proposed ACF Beds: ฀AH ฀EHP

5.Proposed ALP Beds

Total Current and Proposed ACF beds

6.RHCF Beds being Decertified, if any

4. LEGAL REQUIREMENTS

The entity must have ownership of or right of access to real property (18 NYCRR 485.6(d)(11),(12) and (13)) for example, a deed, lease, sales contract or agreement.

5. FINANCIAL INFORMATION

Estimate of Total Project Cost: The total cost must be provided by applicants who are proposing new construction or rehabilitation/purchase of an existing structure, or are planning to purchase a licensed ACF. Examples of costs that should be included are land acquisition (if applicable), cost of building (purchase price of licensed facility, cost of new construction or cost of rehabilitation of existing building), site development, architect cost, soft costs, an any applicable RHCF decertification costs.

6. ARCHITECTURAL COMPONENT(S)

The process for completing the architectural component is addressed in the Assisted Living Program (ALP) Certificate of Need (CON) application.

7. LICENSED HOME CARE SERVICES AGENCY (LHCSA)

The applicant proposing to operate an Assisted Living Program must obtain licensure as a LHCSA or a Certified Home Health Agency (CHHA) with approval to serve the county in which the ALP will operate.

Is the applicant shown above an existing LHCSA, or a CHHA? ฀ YES ฀ NO

If yes, provide the following:

LHCSA License # _____________________ CHHA Operating Certificate # _____________________

Agency Name ____________________________________________

Counties currently served: ______________________________________________________________

Operator ____________________________________________

Please be advised that a $2,000.00 application fee is required for submitting a LHCSA Addendum. After submission of your LHCSA addendum, you will be contacted by the Department’s Bureau of Project Management regarding payment of the application fee.

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NEW YORK STATE DEPARTMENT OF HEALTH
Division of Long Term Care	ALP 6000 – OPPORTUNITY FOR DEVELOPMENT

8. CERTIFICATION

I/We certify that the information submitted on this form and on any attachment to this form is true, accurate and complete in all material respects. (Attach additional sheets if necessary.)

APPLICANT SIGNATURE(S):

By: __________________________________________ Date: ____________

(signature)

Printed Name: _________________________________

Title: _________________________

By: __________________________________________ Date: ____________

(signature)

Printed Name: _________________________________

Title: _________________________

STATE OF NEW YORK					)
						)SS.:
County of						)
On the		day of			in the year ______ before me, the undersigned, personally appeared

___________________________________, personally known to me or proved to me on the basis of

satisfactory evidence to be the individual(s) whose name(s) is(are) subscribed to the within instrument and acknowledged to me that he/she/they executed the same in his/her/their capacity(ies), and that by his/her/their signature(s) on the instrument, the individual(s), or the person upon behalf of which the individual(s) acted, executed the instrument.

_____________________________________

(Signature and office of the individual taking acknowledgement)

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