American Health Care Association/

National Center for Assisted Living

2017 BOARD MEMBER
CANDIDATE APPLICATION

All Candidates Must Complete and Submit No Later than May 22, 2017

TABLE OF CONTENTS

Part I:Candidate InformationPage 3

Part II:Candidate Public QuestionnairePage 7

Part III:Candidate Confidential QuestionnairePage 9

APPLICATION CHECK LIST

All Candidates Must Complete and Submit no Later than May 22, 2017

Please review and check off as completed the following list prior to submitting your application.

  1. Answer all of the questions in Part I Candidate Information within the maximum word requirement.

Complete: ___

  1. Answer all of the questions in Part II Candidate Public Questionnaire within the maximum word requirement.

Complete: ___

  1. Answer all of the questions in Part III Candidate Confidential Questionnaire.

Complete: ___

  1. Attach necessary supporting documentation on questions 1 – 5 in Part III where you did not check the response “None.”

Complete: ___

  1. Attached three reference letters on company letterhead that include the current date and original signatureby the author.
  1. Two signed professional references letters (not affiliate staff)Complete: ___
  1. One signed reference letter from the state affiliateComplete: ___
  1. Submit a current resume or Curriculum Vitae (CV) including work history, education history and dates. Complete: ___
  1. Complete and sign with electronic signature the following forms which will be emailed to you via DocuSign once your completed application is received.
  1. Signed Consent and Release FormComplete: ___
  1. Signed Code of Ethics AcknowledgementComplete: ___
  1. Signed Conflict of Interest Policy and Confidentiality CertificationComplete: ___
  1. Signed Disclosure and Authorization Form for consent of a background, education and US Department of Health and Human Services, Officer of the Inspector General Exclusion list check. Complete: ___

Part I

  1. Office being sought:

(Please check one)

AHCA: ___NCAL: ___

(Please check one)

Chair: ___

Vice Chair: ___

Secretary/Treasurer: ___

Independent Owners Representative*: ___ (AHCA Applicants Only)

Regional Multifacility Representative*: ___ (AHCA Applicants Only)

Member At-large: ___

* Ifelected, I agree to Chair the related AHCA constituency group council. (Check yes if you agree)

Yes: ___No: ___

  1. Total number of beds for all nursing home facilities you own or within the chain where you work: (check one)

None: ___

Less than 1200 beds: ___

More than 1201 but less than 4000 beds: ___

More than 4001 beds: ___

  1. Total number of beds for all assisted living/residential care you own or within the chain where you work: (check one)

Total number of beds: ___

  1. Candidate Contact Information

First Name:

Last Name:

Nickname:

Title:

Organization Name:

Address:

City:State:Zip Code:

Phone:

Cell Phone:

Fax:

E-mail address:

State where you are registered to vote:

NOTE AHCA CANDIDATES ONLY: If a member operates facilities in more than one state and is thus a member of more than one Affiliate Association, they must declare from the Affiliate Association in the state in which they vote in a federal election.

  1. Please list the states where your organization operates facilities.
  1. Is/are your facility(ies) currently member(s) in its(their) respective AHCA/NCAL state affiliate(s)?
    Yes: ___No: ___

Please list all of the states where your facilities are not members and explain why. Include details concerning the plan to join those state affiliates.

  1. Direct Supervisor:

Name:

Title:

Address:

City:State:Zip Code:

Phone:

Cell Phone:

Fax:

E-mail address:

  1. Length of time in current position:
  1. Length of service in long term care field:
  1. Type of Facility:

(Please check all that apply)

Nursing Home/Facility

Assisted Living/Residential Care

MR/DD Residential/ID/DD

Continuing Care Retirement Community

Other: ______

  1. Facility Ownership Type:

(Please check all that apply)

For Profit Non-Profit

(Please check all that apply)

National Multifacility (more than 4001 beds)

Regional Multifacility (more than 1201 but less than 4000 beds)

Independent Owner (less than 1200 beds)

Municipal or Federal

None / Not applicable

  1. Status of Candidate:

(Please check all that apply)

I am currently an AHCA or NCALBoard Member.

Title:

I have served as an AHCA or NCALBoard Member in the past.

Title:

Years Served:

Title:

Years Served:

Title:

Years Served:

I have never held an AHCA or NCALBoard Member position.

Part II

  1. Why are you seeking national office in AHCA or NCAL? (no more than50 words)

2. Please discuss:

a. Your qualifications for national office within the AHCA/NCAL (particularly the one you are seeking).(no more than 50 words)

  1. Please describe other leadership positions in which you have served including community service.(no more than 50 words)

3.How would your regulatory/compliance history contribute to the credibility of AHCA/NCAL in Washington policymaking circles and with the public at large? (no more than50 words)

4.Please discuss your long-range goals for AHCA or NCAL and for the entire long term

care field.(no more than 75 words)

5.What do you consider to be the single most important issue facing the frail elderly and disabled in this country? How should these issues affect AHCA’s or NCAL’s action agenda? (no more than 50 words)

6.Please identify the three issues you believe AHCA/NCAL member providers would say are most critical to their future. Discuss how you would address them.(no more than 125 words)

7. Does your facility(ies) have quality measurements in place? What kind of procedures or instruments? If you are not currently using quality measurements, do you have future plans to do so? (no more than 50 words)

  1. Please provide a vision statement for the future of the long term care profession in general and AHCA or NCAL in particular.
  1. Current Board Members will provide a statement outlining accomplishments while serving in current position.

Note: Please proceed to the next page for additional information required to complete the application submission process.

Part III

Required to Be Submitted By All Candidates

Each prospective candidate must provide the following:

  1. A list of all facilities(including Medicare and Medicaid provider numbers), with which the prospective candidate has been associated in and responsible for the past three years.
  1. Survey history of associated facilities. A list of--and information about all survey findings of substandard quality of care, temporary management, denial of payment for new admissions, denial of payment for all residents, or termination. Candidates should point out for the Committee any actions that the candidate feels may negatively affect AHCA/NCAL’s credibility with the public or in the policymaking arena. Candidates should supply background information about the circumstances around such enforcement actions, any extenuating circumstances that the Committee should be aware of, and action taken by the facility or corporation to ensure the safety of facility residents and/or staff.

Please check one.

Attached: ___None: ___

  1. A list of and information about any pending or ongoingcriminal lawsuits or settlements that have affectedthe prospective candidate.

Please check one.

Attached: ___None: ___

  1. Information about the candidate’s personal or professional integrity or honesty, or any other actions that could limit AHCA/NCAL’s standing in the eyes of the public.

Please check one.

Attached: ___None: ___

  1. Do you currently have any facilities that you own, operate or are responsible for managing that are decertified, facing possible shutdown by state authorities or that have a ban on new admissions? If yes, how long has the facility(ies) been operated by the current ownership company? Please attach additional details.

Please check one.

Attached: ___None: ___

  1. Two currentprofessional letters of reference from outside the candidates’ own organization, business partnerships, or investment associates(for example:from providers, state regulators etc.) The letters must be on company letterhead and include a current date and signature. Credentialing Committee members may not submit a letter of reference on behalf of any candidate.
  1. One letter of reference from the AHCA/NCAL state affiliate executive or another AHCA/NCAL state affiliate staff member in the state in which you or your organization is most active. The letter must be on state affiliate letterhead and include a current date and signature.
  1. Submit a current resume or Curriculum Vitae (CV).
  1. The following forms must becompleted and signed with electronic signature via DocuSign. Once your completed application is received an email will be sent to you via DocuSign to sign the forms. Please sign the forms electronically through the DocuSign website. Do not print, email, FAX or mail hard copies.
  1. Consent and ReleaseForm
  2. Code of Ethics Acknowledgement
  3. Conflict of Interest Policy and Confidentiality Certification
  4. Disclosure and Authorization Form for consent of a background, education and US Department of Health and Human Services, Officer of the Inspector General Exclusion list check.

1