This page is designed for providers who are familiar with the ICF Program Plan process. If you are new to this process, please visit the Program Plan Information and Development web page.
FORMS:
- DS 1851 – Specialized Procedures Request Cover Sheet PDF
- DS 1852 – Health Facilities Program Application Form (complete both pages) PDF
- DS 1853 – Training Program for ICF/DD-N Attendant PDF
- STD 204 – Payee Data Record PDF
- ICF DD SPA Acknowledgement and Authorization Form PDF
- Program Plan Template WORD
- Consultants/Professional Staff ICF/DD-N PDF
- Consultants/Professional Staff ICF/DD-H PDF
- ICF/DD-H Facility Staff Schedules PDF
- ICF/DD-N Facility Staff Schedules PDF
- ICF/DD-Nursing Changes in Required Staff Hours PDF
CHECKLISTS:
- ICF/DD-H Program Plan | ICF/DD-H Medication Training Program Plan WORD
- ICF/DD-N Program Plan | ICF/DD-N Medication Training Program Plan WORD
REGULATIONS:
- State Operation Manuals, Appendix J (Code of Federal Regulations, Centers for Medicare and Medicaid Services) PDF
- California Code of Regulations
- ICF/DD-N Draft and Amended Regulations (For informational purposes – PDF)
- CMS Emergency Preparedness Rule
WHEN YOUR PROGRAM PLAN IS COMPLETED, SUBMIT THE FOLLOWING TO:
- Program Plan packet and attachments
- Consultants qualifying documents
- Completed checklists
The appropriate staff will review your plan for clarity and content and will contact you if changes to your Program Plan are required.
The Nurse Consultant will review and approve the Medication Training Plans, Attendant Training, and Specialized Procedures.
If you have any questions regarding this process, contact the Community Living Section at 916-654-1965 or send an e-mail.
Last modified: July 1, 2021
