National Nursing Home COVID-19 Safety Program
Participation Form

The Mass Senior Care and Hebrew SeniorLife (MSCA/HSL) Command Center is participating in the Center for Medicare and Medicaid Services (CMS), ECHO Institute at UNMHSC (ECHO) and the Agency for Healthcare Research (AHRQ) in a National Nursing Home COVID-19 Safety Program. The National Nursing Home COVID-19 Safety Program is free to facilities and will provide financial incentives to participating nursing homes as well as prepare participating nursing homes for the CMS Infection Control Value-Based Payment Program that is anticipated to begin in September 2020 and conclude in December 2020. But most importantly, the purpose of the program is to rapidly assist nursing homes to develop the capabilities to consistently implement evidence-based best practices to achieve five goals:

Prevent COVID-19 from entering nursing homes via staff, visitors, and patients.
Prevent the spread of the virus among patients, staff, and visitors once it enters a nursing home.
Provide care and treatment for patients who test positive for COVID-19.
Protect staff from infection and provide safety measures to help staff build confidence in their work, feel safe from infection, and keep working at the nursing home.
Ensure patients who are infected with COVID-19 can safely receive visitors.

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* 1. Nursing Facility/Organization Name:

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* 2. Number of Nursing Facilities Participating:
Please list how many nursing facilities in your organization are participating. Corporate offices can register for multiple facilities. If you are at an individual facility, please enter "1".

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* 3. Contact Person

Name:

Title:

E-Mail Address:

Telephone Number:

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* 4. My nursing facility/organization is interested in participating in the National Nursing Home COVID-19 Safety Program.

Yes

National Nursing Home COVID-19 Safety ProgramParticipation Form

Question Title

* 1. Nursing Facility/Organization Name:

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* 2. Number of Nursing Facilities Participating:Please list how many nursing facilities in your organization are participating. Corporate offices can register for multiple facilities. If you are at an individual facility, please enter "1".

Question Title

* 3. Contact Person

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* 4. My nursing facility/organization is interested in participating in the National Nursing Home COVID-19 Safety Program.

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* 5. Please let Mass Senior Care know if you have any questions related to the National Nursing Home COVID-19 Safety Program.

National Nursing Home COVID-19 Safety Program
Participation Form

* 2. Number of Nursing Facilities Participating:
Please list how many nursing facilities in your organization are participating. Corporate offices can register for multiple facilities. If you are at an individual facility, please enter "1".