Application for Pre-Approval for the Higher Accommodation Supplement for a Proposed Refurbishment

Application for Pre-Approvalfor the Higher Accommodation Supplement for aProposed Refurbishment

Purpose of this form

Use this form to apply for the higher level of accommodation supplement if you are an approved provider of a residential aged care service that has a proposed refurbishmentproject for which you are seeking pre-approval.

An online version of this form can be completed at the DSS Forms Administration Portal.

Note:

  • If you are seeking to confirm a completed refurbishmentthat received pre-approval, please complete the form ‘Confirmation of Completion of a Pre-Approved Significant Refurbishment’.

For more information

Please read the Guidelines for applying for the higher accommodation supplementon the Department’s website before completing this form.

Should you require further assistance with completing this application form, please contact Forms Administration by telephone: (02) 4403 0640or email:

Filling in this form

  • Please use black or blue pen
  • Print in BLOCK LETTERS
  • Mark boxes like this ☐with a ✗

Returning your form

Check that you have answered all the questions you need to answer and that you have signed and dated this form.

Submit the completed form and supporting documentation via one of the methods below:

E-mail / Post / Fax
/ Forms Administration
PO BOX 5008
NOWRA DELIVERY CENTRE NSW 2541 / (02) 4447 8711

Section 1. Applicant information

Residential care service name

National Approved Providers System (NAPS) Service ID

Approved provider’s full name

Section 2. Contact person’s details

Full name

Position held

Address for correspondence

Contact phone number

Contact e-mail address

Section 3. Self-assessment against significant refurbishment conditions

The conditions that must be met for a proposed refurbishment project to qualify as a ‘significant refurbishment’ are set out inthe Subsidy Principles 2014.Refer to the Guidelines for more information.

  1. The proposed refurbishment will include alterations, updates or other improvements that will result in the service being significantly different in form, quality or functionality.
/ Yes No
  1. A significant proportion of the service areas that are proposed to be refurbished will be accessible to, and for the use of, care recipients.
/ Yes No
  1. The refurbishment will provide significant benefits to eligible care recipients[1].
/ Yes No
  1. What is the total number of care recipientrooms[2] in the service before the refurbishment?
(Note:For each bedroom, the equivalent number of care recipient rooms is determined by the number of care recipients that can be accommodated in the room. For example, where 3 people share a room, this is counted as 3 care recipient rooms.)
  1. What will be the total number of care recipient roomsin the service after completion of the refurbishment?

  1. The proportion of the total number of care recipientrooms available to eligible care recipients after the refurbishment will be at least equal to the proportion before the refurbishment.
/ Yes No
  1. The refurbishment will result in (at least one of the following):

a)at least 40% of care recipients having a significantly refurbished care recipient room. / Yes No
b)significant benefit to at least 40% of care recipients. / Yes No
c)an extension increasing the number of care recipientrooms by at least 25%. / Yes No
  1. What is the estimated total cost of the proposed refurbishment?
/ $
a)The estimated total cost includes an amount relating to installing fire safety improvements[3] in the facility. / Yes No
b)If ‘Yes ’ to the above, please enter the estimated cost of that fire safety work. / $
  1. The eligiblerefurbishment cost[4]will be at least equal to the minimum monetary spend amount. The latter can be worked out by multiplying 40% of the total number of care recipientrooms (the lower of the total number before orafter refurbishment) by $25,000.
/ Yes No
  1. The relevant cost of the proposed refurbishment will be capitalised in accordance with Australian accounting standards.
/ Yes No

Please assess your proposed refurbishment against the conditions below.
Section 4. Supporting statement for pre-approval

Please attach a typed description (approximately 1-2 pages) of the proposed refurbishment, noting what will be done to benefit care recipients (particularly eligible care recipients) with relation to care recipient rooms and common areas, and noting any areas to be refurbished that will not be for the use of care recipients.

You may choose, if you wish, to attach clearly labelled photographs and/or designs to help you explain the changes.

IMPORTANT:Please be clear in describing the differences that will be made as a result of the refurbishment by making references to the current and proposed post-refurbishment condition.

Section 5. Supporting evidence for pre-approval

Please attach the following documents:

  • relevant proposed site, floor, and/or building plans

Section 6. Key personnel declaration

This declaration must only be completed by key personnel of the approved provider as defined under Section 8-3A of the Aged Care Act 1997.

WARNING:Giving false or misleading information is a serious offence. There are offences established by the Aged Care Act 1997 and the Criminal Code Act 1995 relating to the provision of false or misleading information.

I declare that:

  • I am authorised to sign on behalf of the approved provider of the residential aged care service.
  • The information I have provided on this form is complete and correct.
  • I understand the Secretary’s determination will not take effect unless the significant refurbishment criteria aredemonstrated to be met at completion of the project.

Full name

Position held

Signature

Date

Please retain a copy of this form (including all attachments) for your records

Page 1 of 4

[1]Eligible care recipients are those in respect of whom the accommodation supplement is payable. For care recipients in care before 1July 2014, these care recipients are those defined as ‘concessional’, ‘assisted’ or ‘supported’ under clause 1 of Schedule 1 to the Aged Care (Transitional Provisions) Act 1997. For care recipients entering care on or after 1July 2014, these care recipients are those defined as ‘low-means’ under section 5 of the Subsidy Principles 2014.

[2]A care recipient room is a room or part of a room intended to be occupied as personal space by a care recipient where this includes the bed used by a care recipient and the areas immediately around the bed.

[3]Refer to “What constitutes ‘fire safety improvements’?” in the Guidelines for details.

[4]The eligible refurbishment cost may not be the same amount as the total cost of the refurbishment. The eligible refurbishment cost may include only up to a maximum of 25% of the calculated minimum monetary spend amount for expenditure relating to fire safety related work.Refer to “Working out the refurbishment cost” in the Guidelines for details