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* 1. Facility Information

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* 2. Point of Contact Information:

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* 3. Is a change in your capacity relative to an increase or decrease in unit size?

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* 4. Which designation does your facility currently maintain as it relates to the CRF Status?

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* 5. Current approved number of CR Facility-designated beds:

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* 6. I am seeking the ability to:

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* 7. What is the new, total number of CR Facility beds you are seeking approval for?

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* 8. Check the areas your facility will continue have as dedicated to the COVID unit

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* 9. Please upload your floor plan showing: COVID Unit location, occupancy of each room in COVID unit, resident shower for COVID unit, staff restroom, staff breakroom, medication room or cart, nursing station, storage facility for COVID unit, PPE donning area, PPE doffing area, and staff entrance and exit.

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* 10. By checking this box, you are attesting that you will maintain a COVID-designated staffing plan to accommodate the requested bed or capacity change.

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* 11. Are you making changes to the temporary or existing physical barriers documented in your original application?

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* 12. What is the new barrier being utilized?

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* 13. Check the box for PPE capacity strategy that your facility is currently practicing:

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* 14. You have read and understand the most current long-term care (LTC) infection control guidelines published by the Centers for Disease Control (CDC) including the following sections on: Interim Infection Prevention and Control Recommendations for Healthcare Personnel During the Coronavirus Disease 2019 (COVID-19) Pandemic Interim Infection Prevention and Control Recommendations to Prevent SARS-CoV-2 Spread in Nursing Homes Optimizing Supply of PPE and Other Equipment during Shortages

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* 15. Please provide any additional details you would like to provide related to your COVID Relief Facility Capacity Change Request.

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* 16. I understand failure to provide the above information accurately and completely may result in a denial of my capacity change request. I understand that my request will be subject to a complete desk review by Michigan's Department of Health and Human Services (MDHHS) and Licensing and Regulatory Affairs (LARA). MDHHS retains discretionary rights to consider additional criteria, request additional information, and the right to approve or deny any capacity change requests. Applying entities are not entitled to appeal rights but may submit supplemental information during the review process if requested by MDHHS.

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