MassHealth

Nursing Facility Pay for Performance (NF P4P) 
Program FY 13 Application Form


Application Instructions

Applications must not exceed 15 pages in length 
and must not be handwritten. All applications must 
be submitted to MassHealth by February 6, 2013. 
A copy of the written policy for a cooperative effort 
process and minutes from the most recent Quality 
Committee meeting must be included with this 
application. Applications can be sent electronically to 
NFP4PProgram@state.ma.us or by U.S. mail to the 
following address.

Nursing Facility Pay for Performance Program 
Office of Long Term Services and Supports 
One Ashburton Place, 5th Floor 
Boston, MA 02108

Important! 
If you are submitting your application via e-mail, 
make sure you send it by midnight, February 6, 2013. 
If you are submitting it by mail, please post mark the 
envelope by midnight, February 6, 2013.


Facility Information

Facility legal name: 	
	 
Facility address: 	
	
Primary contact name: 	
	
Primary contact e-mail address: 	
	
Facility administrator’s name: 	
	
Facility administrator’s e-mail address: 	
	
Provider ID: 	
	
Business office administrator’s name: 	


NF-P4P-APP (Rev. 12/12)

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Component Selection

Select the component of the NF P4P Program that your facility will participate in. 
(You can select only one.)

Option 1: 	Quality Measure     

Option 2: 	Consistent Assignment   



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Cooperative Effort Policy

1.	Describe the written policy for a cooperative effort policy in the facility. 
	(Note: For facilities that have passed and participated in the FY 12 NF P4P 
	program, the same policy may be used for this application.)









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Cooperative Effort Policy  (cont.)

2.	Provide a copy of the minutes from the last Quality Assurance Committee (QC) 
	meeting. Minutes must be typed and include names, titles, and signatures of 
	the key members attending the meeting (refer to #3, Table 1: Quality Committee 
	Staff Roster). Information in the minutes that do not pertain to the MassHealth 
	NF P4P program must be redacted from the minutes submitted to MassHealth. (Note: 
	Minutes must be from a meeting that took place between October 1, 2012, and 
	February 5, 2013.)







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Cooperative Policy  (cont.)

3.	Provide details of the key staff members attending the QC meeting in the 
	following Quality Committee Staff Roster table. The committee must include a 
	non-licensed direct care staff member. A non-licensed staff must be a Certified 
	Nursing Assistant or Geriatric Nursing Assistant.  

Table 1-Quality Committee Staff Roster 

Position	
Printed Staff Name 	
Credentials	
Signed Staff Name	
Date 




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Consistent Assignment (Option 2)

4.	Submit data consisting of the current level of consistent assignment. 
	Use the methodology from the Advancing Excellence in America’s Nursing Homes 
	Campaign and Consistent Assignment Tracking Tool found at 
	www.nhqualitycampaign.org/star_index.aspx?controls=PreviewGoals. 
	(Select Consistent Assignment: Identify Baseline, and then click on 
	AE_ConsistentAssignmentTRACKINGTOOL v2.2 12-3-12.xls.) 
	Submit a copy of the Data for Website Entry worksheet from the tracking tool, 
	which contains a snapshot of the data for consistent assignment. 
				




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If you have any questions about this application, please send inquiries to 
NFP4PProgram@state.ma.us.


Attestation (Please read carefully and sign.)

I certify under the pains and penalties of perjury that the information on this form 
and any attached statement that I have provided has been reviewed and signed by me, 
and is true, accurate, and complete, to the best of my knowledge. I also certify that 
I am the provider or, in the case of a legal entity, duly authorized to act on behalf 
of the provider. I understand that I may be subject to civil penalties or criminal 
prosecution for any falsification, omission, or concealment of any material fact 
contained herein.

I also certify that this nursing facility is in compliance with the Cooperative Effort 
Policy for participation in the Nursing Facility P4P Program. This policy includes the 
existence of a committee that will include a non-licensed direct care staff member. A 
non-licensed staff must be a Certified Nursing Assistant or Geriatric Nursing Assistant.  

I understand that the Office of Long Term Services and Supports (OLTSS) may audit this 
facility to ensure that the standard is being met. This may include, but not be limited 
to, providing documentation about the committee, on-site review of documentation, and 
discussions with applicable facility staff, and other activities as determined necessary 
by OLTSS.

Provider’s signature (Signature and date stamps, or the signature of anyone other than 
the provider or a person legally authorized to sign on behalf of a legal entity, are 
not acceptable.): 

	 


Printed legal name of provider: 

	


Printed legal name of individual signing (if the provider is a legal entity): 

	 


Date:

				

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