FORMS:
- DS 1851 – Specialized Procedures Request Cover Sheet
- DS 1852 – Health Facilities Program Application Form (complete both pages)
- DS 1853 – Training Program for ICF/DD-N Attendant
- STD 204 – Payee Data Record
- ICF DD SPA Acknowledgement and Authorization Form
- Program Plan Template
- Consultants/Professional Staff ICF/DD-N
- Consultants/Professional Staff ICF/DD-H
- ICF/DD-H Facility Staff Schedules
- ICF/DD-N Facility Staff Schedules
- ICF/DD-Nursing Changes in Required Staff Hours
CHECKLISTS:
- ICF/DD-H Program Plan | ICF/DD-H Medication Training Program Plan
- ICF/DD-N Program Plan | ICF/DD-N Medication Training Program Plan
REGULATIONS, STATUTE, GUIDANCE AND RESOURCES THAT APPLY TO ICF/DD, ICF/DD-N, ICF/DD-H, ICF/DD-CN:
- Appendix J, State Operations Manual
- Code of Federal Regulations, Title 42, Chapter IV, Subchapter G, Part 483, Subpart 1, Section 483.400-480 Federal Conditions of Participation for Intermediate Care Facilities for Individuals with Intellectual Disabilities
- Centers for Medicare & Medicaid Services Emergency Preparedness Rule
- California Code of Regulations (CCR), Title 22, Section 51343 Intermediate Care Facilities for the Developmentally Disabled
- CCR, Title 17, Section 54327 Requirements for Special Incident Reporting by Vendors and Long-Term Care Facilities
- Health and Safety Code, Section 1276.5 (d) (1) (Administrator qualifications)
- CCR, Title 17, Section 50515 Use of Seclusion or Restraint, “Time Out”
- Health and Safety Code, Section 1180.3, 1180.4 and 1180.5 Use of Restraints in Facilities
- Welfare and Institutions Code, Sections 4502-4505 Persons With Developmental Disabilities Bill of Rights
- CCR, Title 17, Sections 50500-50550 Clients’ Rights
- Health and Safety Code, Section 1268.6 New Provider Orientation
- Welfare and Institutions Code, Section 15630 (b) Mandatory and Nonmandatory Reports of Abuse
- California Association of Health Facilities Disaster Preparedness Program
ADDITIONAL REGULATIONS THAT APPLY TO ICF/DD-H ONLY:
- CCR, Title 22, Section 76800-76962 Definitions, License, Services, Administration, Physical Plant, and Violations and Civil Penalties
- CCR, Title 22, Section 51343.1 Intermediate Care Facility Services for the Developmentally Disabled Habilitative (services & qualifying conditions)
ADDITIONAL REGULATIONS THAT APPLY TO ICF/DD-N ONLY:
Please note, this is not an exhaustive list of all regulations, statutes, guidance, and resources associated with these facilities.WHEN YOUR PROGRAM PLAN IS COMPLETED, SUBMIT THE FOLLOWING TO THE EMAIL OR FAX LISTED BELOW:
- Program Plan packet and attachments
- Consultants qualifying documents
- Completed checklists
Last modified: October 22, 2024
