New Jersey Administrative Code
Title 10 - HUMAN SERVICES
Chapter 164 - ADULT DAY HEALTH SERVICES
Appendix C

OUTLINE FOR WRITTEN NARRATIVE STATEMENT ON PROPOSED ADULT DAY HEALTH SERVICES FACILITY

1.

Describe the proposed therapeutic milieu through which the proposed Adult Day Health Services Facility would provide medical and ancillary health services to support the ability of clients to remain in the community and to age well in place.

2.

Describe the physical facilities to be used for the proposed Adult Day Health Services Facility (diagram acceptable).

3.

Describe the proposed Adult Day Health Services Facility, including hours of operation, services to be provided, in-house and/or by arrangement, and the staff members who would be implementing the program.

4.

Provide staff position descriptions and state the qualifications of personnel selected for each position.

5.

State the total number of participants the proposed Adult Day Health Services Facility would serve and the anticipated daily population.

6.

Submit a projection of anticipated costs the proposed Adult Day Health Services Facility would incur. State the period of the projection and provide the basis of cost allocation, if applicable.

7.

State whether the proposed Adult Day Health Services Facility would be supported by a funding source other than Title XIX, such as Title XX and/or Title III.

8.

State whether the proposed Adult Health Services Facility would be a new facility or an expansion of an existing facility.

9.

Provide additional comments relevant to the application for approval of the proposed Adult Day Health Services Facility under the New Jersey Medicaid Program.