SADC Certification Form

Office of the Medicaid Inspector General

Social Adult Day Care (SADC) Certification

MLTC Name:*
Contact First Name:*	Middle Initial: Last Name:
Phone Number: (e.g.(123) 456-7890)*

Social Adult Day Care Certification

Directions:

In order to assure the health and safety of Managed Long Term Care Plan Enrollees, all providers of Social Adult Day Care Services that contract with a Managed Long Term Care (MLTC) Plan must meet the standards and requirements set forth in Title 9 NYCRR §6654.20, and complete this certification form. If you have any questions regarding this form, please email SADCcertification@omig.ny.gov.

Helpful links:

Title 9 - Title 9 NYCRR - 6654.20 Social adult day care programs
MLTC Contract - Managed Care Model Contracts
DOH Policy Documents (MRT # 90 PAGE) - MRT 90: Mandatory Enrollment Managed Long Term Care
NYS Office for the Aging - Annual Self-Monitoring Process to be Completed Prior to Certification - NYS Office for the Aging
DOH Frequently Asked Questions about the SADC Certification process

Social Adult Day Care (SADC) Information

Note: A separate SADC certification form must be submitted for each location.

* Required field

Federal Employer Identification Number (FEIN) or Social Security Number (SSN) [Please use whichever identifier is used on your 1099 Tax Form] (no dashes):*
Re-Enter FEIN:*
SADC/Corporation Name:*
DBA Name (enter N/A if none):*
Address Line 1:*
Address Line 2:
City:*
State:*
Zip Code:*

SADC Owner Information

* Not applicable to/required for not-for-profit SADC entities

First Name:		Middle Initial:
Last Name:		Suffix:
Title:
Phone Number: (e.g.(123) 456-7890)
Email Address:
Re-Enter Email Address:

Click this button to add an additional Owner ->

SADC Director Information

(9 NYCRR 6654.20(d)(2)(iv)(b)(1))

* Required Field

First Name:*		Middle Initial:
Last Name:*		Suffix:
Title:*
Phone Number: (e.g.(123) 456-7890)*
Email Address:*
Re-Enter Email Address:*

Questions

* Required Field

In order to complete the SADC certification form, you must answer the following questions:

* 1.	The SADC has a current, valid certificate of occupancy (CO) approved for a Social Adult Day Care (SADC) facility for the premises?	Yes No CO not required by municipality
* 2.	The SADC meets all appropriate Fire Safety Codes?	Yes No
* 3.	The SADC meets all relevant Department of Health Codes?	Yes No
* 4.	The SADC has implemented policies and procedures from 9 NYCRR §6654.20(d)(2)(i)(a-i) addressing participant eligibility, admissions/discharge, service plan, staffing plan, participants rights, service delivery, program self-evaluation, records, and emergency preparedness?	Yes No
* 5.	Participant files are updated to document: There was an assessment prior to admission? That a service plan was developed within 30 days of admission? Service planning input from the participant and/or caregiver (9 NYCRR §6654.20(d)(1)(ii)(b) and 9 NYCRR §6654.20(d)(1)(iii)(a)(b))?	Yes No
* 6.	The SADC adheres to the nutrition standards required under 9 NYCRR 6654.20(d)(1)(iv)(a)(4)?	Yes No
* 7.	Staff and volunteer health records are documented to demonstrate: The health status of each staff person is assessed and documented prior to contact with participants and annually thereafter? Each staff person has undergone a ppd test prior to employment and no less than every two years thereafter (9NYCRR §6654.20(d)(2)(iv)(a)(3)(i)(ii)) ?	Yes No
* 8.	The SADC has documentation and records demonstrating staff and volunteer training including fire/emergency safety, new staff orientation for 20 hours within 3 months and includes personal care skills taught by an RN and CPR/AED training (9 NYCRR §6654.20(d)(2)(iv)(c)(1) and 9 NYCRR §6654.20(d)(2)(iv)(d)(1)(2)(3))?	Yes No
* 9.	The SADC has demonstrated the ability to perform the services necessary to contract with a MLTC plan?	Yes No
* 10.	The SADC has documentation that fire drills have been conducted twice per year (9 NYCRR §6654.20(d)(2)(vii)(c))?	Yes No SADC not yet in operation
* 11.	The SADC is in compliance with all Title 9 NYCRR §6654.20 requirements?	Yes No
* 12.	The SADC has conducted, completed, and has documented the annual self-evaluation which includes an administrative, program and fiscal review of operations including input from participants and caregivers (9 NYCRR §6654.20(d)(2)(ii)(a))?	Yes No SADC not yet in operation

Managed Long Term Care Providers

* Required Field

Add all Managed Long Term Care Providers (MLTC) with which you currently have a contract.

MLTC Name:*
Contact First Name:*	Middle Initial: Last Name:
Phone Number: (e.g.(123) 456-7890)*

Click this button to add an additional MLTC ->

Check if appropriate:
At this time, there are no existing contracts with any MLTC Plans

Certification

* Required Field

IMPORTANT: Making a false statement in this certification, may subject you to criminal prosecution for a misdemeanor or felony under the New York State Penal Law.

The person selecting the button below, declares, affirms and certifies (hereinafter certification) that the information entered as part of this form is true and that:

he/she is the certifying official whose name and contact information appears above;
the certifying official has undertaken due diligence and conducted all reasonable inquiry prior to making any of the statements in this certification and has sufficient knowledge to complete this form;
the certifying official acknowledge that this certification is being made in order to comply with the requirements outlined in the questions answered above.

* I agree. First Name: Middle Initial: Last Name:

Captcha

When you click the Submit button, a Confirmation Page will appear. Please print a copy of the Confirmation Page for your records.