Form Dma 3136 - Internal Quality Improvement Program Attestation Form - North Carolina Department Of Health And Human Services
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N.C. Department of Health and Human Services – Division of Medical Assistance
INTERNAL QUALITY IMPROVEMENT PROGRAM ATTESTATION FORM
Completed form should be submitted via email to NC - Division of Medical Assistance
DMA.PCSQualityImprovement@lists.ncmail.net
For
questions, contact 919-855-4360 or send an email to PCS_Program_Questions@dhhs.nc.gov
SUBMISSION REQUIREMENTS
PCS Providers shall submit this Attestation to DMA by December 31st of each year certifying compliance with “a”
through “d” of Clinical Coverage Policy 3L Section 7.7 by initialing each of the items described below.
PROVIDER TYPE (select one)
Home Care Agency
Family Care Home
Adult Care Home
Adult Care Bed in Nursing Facility
SLF-5600a
SLF-5600c
Special Care Unit (stand-alone Special Care Unit or SCU bed)
Non-Provider: __________________________
SUBMITTER INFORMATION
NPI: ___________________________________________________________
Provider Name: __________________________________________________________________________________________________________
Address:
City: __________________________________________
County:
Zip:
(zip code + 4 digit extension) Phone: _________________________
Suite: _____________________________ Email: _________________________________ Fax (If Applicable):_________________________
INTERNAL QUALITY IMPROVEMENT REQUIREMENTS - C
C
P
3L S
7.7
INITIAL
LINICAL
OVERAGE
OLICY
ECTION
a.
Develop, and update at least quarterly, an organizational Quality Improvement Plan or set of quality
improvement policies and procedures that describe the PCS CQI program and activities;
_________
b.
Implement an organizational CQI Program designed to identify and correct quality of care and quality of
service problems;
_________
c.
Conduct at least annually a written beneficiary PCS satisfaction survey for beneficiaries and their
legally responsible person;
_________
d.
Maintain complete records of all CQI activities and results
_________
Person Completing this Form:
___________________________________
_______________________________________
Name (Printed)
Title
SIGNATURE
DATE
(mm/dd/yyyy)
(______/ ______/______)
______________________________________________________________
(LEGIBLY SIGN YOUR NAME (STAMPS and ELECTRONIC SIGNATURES ARE NOT ACCEPTABLE FOR THIS FORM.)
I hereby attest that I am in compliance with the items described in Clinical Coverage Policy 3L Section 7.7. I also agree to provide any
of the referenced documents to DMA or a DHHS designated contractor upon request in conjunction with any on-site or desktop
quality improvement review.
DMA 3136
INTERNAL QUALITY IMPROVEMENT PROGRAM ATTESTATION FORM
6/10/2015
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