Credentialing Attestation for Adult Day Care Centers Providing Enhanced Services

State of Rhode Island Provider Certification Standards Adult Day Care
Neighborhood Health Plan of Rhode Island’s (Neighborhood’s) participating Adult Day Health Providers should refer to the State of Rhode Island’s Certification Standards for detailed requirements to provide Enhanced Level of Services. A copy of that documentation can be found above.
Directions:
1. A facility must already be credentialed in Neighborhood’s network.
2. List facility’s Legal name and NPI in boxes provided below.
3. An authorized individual of the facility must attest that the following criteria are met by placing their initials adjacent to each criterion.
4. Same authorized individual signs / dates attestation with their title.
Legal Name of Facility*
NPI (Type II)*
Please attest to the below information by providing your initials in the box provided below.
Complies with State of Rhode Island’s Certification Standards for Adult Day Care Centers*
Affirmation: Please Initial
Meets minimum hours of operation*
Affirmation: Please Initial
Provides prerequisite nursing and therapeutic services with existing staff or by contracting with Neighborhood participating provider*
Affirmation: Please Initial
Maintains established process for tracking and reporting incidents, complaints and grievances*
Affirmation: Please Initial
Maintains daily attendance records inclusive of each participant’s arrival and departure times*
Affirmation: Please Initial
If transportation is provided by the facility, maintains a copy of agency’s insurance coverage in commercially reasonable amounts, including liability, for the purposes of providing transportation to individuals the agency serves*
Affirmation: Please Initial
Authorized Individual/Title*
Date*
MM slash DD slash YYYY
Signature of Authorized Individual*
Date*
MM slash DD slash YYYY
Submission of this form does not guarantee participation in the Neighborhood Health Plan of Rhode Island network.
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