Safe Patient-handling Grant Program application and instructions

Application open Oct. 19 through Dec. 7, 2007
This grant application is used to review facility qualifications and project information. Receipt of a state grant requires completion of a state grant agreement.

Instructions
Check off each item to ensure the grant application is complete. • • All required answers and attachments must be submitted with your application. Incomplete applications will be returned and any re-submission must be received or postmarked by the application deadline. The completed application must include the following attachments: a safety and health hazard-assessment with safe patient-handling recommendations; a recent (one full-year) profit and loss statement and a current balance sheet; vendor quotes for proposed purchases, including the type of equipment, itemized costs and/or training proposal; a written safe patient-handling program, if established (if not, submit your AWAIR safety and health plan); completed "Part B” if applying for financial hardship consideration; and

additional pages with project description.

Definitions
Direct patient care worker means an individual doing the job of directly providing physical care to patients, including nurses as defined by section 148.171, who provide physical care to patients. Health care facility means a hospital as defined in section 144.50, subdivision 2; an outpatient surgical center as defined in section 144.55, subdivision 2; or a nursing home as defined in section 144A.01, subdivision 5. (Many facilities that care for five or more people would be eligible, but most clinics and doctor’s offices generally would not be. Check the definitions in the law to ascertain eligibility.) Safe patient-handling means a process, based on scientific evidence about causes of injuries, that uses safe patient-handling equipment – rather than people – to transfer, move and reposition patients, in all types of health care facilities, in an effort to reduce workplace injuries. This process also reduces the risk of injury to patients. Safe patient-handling equipment means engineering controls, lifting and transfer aids, or mechanical assistive devices used by nurses and other direct patient care workers instead of manual lifting to perform the acts of lifting, transferring and repositioning health care facility patients and residents. Safety patient-handling grant eligibility means that for health care facilities that provide evidence of hardship, the commissioner may waive the 50 percent matching requirement and may grant such a facility more than $40,000. Questions may be directed to Workplace Safety Consultation by: phone at (651) 284-5433, toll-free at 1-800-731-7232; TTY at (651) 297-4198; fax at (651) 284-5739; or e-mail at james.collins@state.mn.us. Completed applications should be sent to: Minnesota Department of Labor and Industry Workplace Safety Consultation – Grant Applications 443 Lafayette Road N., St. Paul, MN 55155 Fax: (651) 284-5739 More information is available at: www.doli.state.mn.us/grants.html.

Company information
Who conducted the safety and health on-site hazard assessment you are attaching? (check one)

This document can be provided in different formats, such as large print, Braille or audiotape, by calling (651) 284-5162 or (651) 297-4198/TTY.

Minnesota OSHA safety and health investigator Workplace Safety Consultation safety and health consultant In-house employee safety and health committee (fill in report form and include committee minutes) Workers' compensation underwriter (cannot be a loss-control specialist) Private safety and health consultant Person under contract with the Assigned Risk Pool

Part A – Application
Facility name Address E-mail address Organization (company name) Organization address (if different from above) Type of business hospital nursing home Phone number Facility federal I.D. number City Number of direct patient care workers at facility Contact person City Fax number Facility license number State ZIP code Title State ZIP code

Unemployment I.D. number

outpatient surgical center

Resident/patient profile and patient-handling equipment
Nursing homes only
# of # of # of # of # of # of resident beds at your facility residents currently at facility residents requiring limited assistance residents requiring extensive assistance residents who are totally dependent each type of equipment your facility operates: electrical total lifts hand-operated total lifts sit-to-stand devices repositioning aides other (explain)

Hospitals only

# of patients beds at facility Average % of bed occupancy within past six months Average % of patients requiring assistance for: standing transferring repositioning % of patient lifts and transfers performed manually 0 to 10% 11to 20% 21 to 30% >30%

Surgical centers only
# of surgical beds Average % of patients requiring assistance for: standing transferring repositioning % of patient lifts and transfers performed manually 0 to 10% 11 to 20% 21 to 30% >30%

% of resident lifts and transfers performed manually 0 to 10% 11 to 20% 21 to30% >30%

Safe patient-handling project description
• Have you adopted a written safe patient-handling program that meets the stated requirements of Minn. Stat. §182.6553, Subd. 1(b), for achieving the goal of minimizing manual lifting of patients by patient care workers Yes No through the use of safe patient-handling equipment? (If yes, attach a copy of the written program.) 1. Detailed project description ("project" means what you want to purchase with your grant money) – Explain what equipment and/or training you are buying and why. Explain how it will minimize the manual lifting of patients, based on the recommendations made during the on-site hazard survey. The description must include all project activities. Give the name and address of the person(s) who will be primarily responsible for completing this project, as well as the name of each person who will be involved in each activity. List employees and vendors separately; provide titles and credentials to show qualifications. 2. Implementation schedule with all timelines – Explain when you are going to order, receive and install the equipment, or conduct training. You are allowed 120 days from the date of the last signature on the grant agreement to finish your project. Training and education tied to the purchase of equipment will be granted an additional 30 days. 3. Economic feasibility – Explain the anticipated return on the investment during the life of the project. Provide a recent profit/loss statement and current balance sheet. Will you be able to provide the dollar for dollar match? 4. Items and costs – List the item(s) to be purchased, the cost of each item and any training to be conducted. Attach a vendor quote for each piece of equipment and a syllabus for any training.

Training about safe patient-handling and safe patient-handling equipment 5. Training for equipment purchase – Describe who will provide the training, the trainer’s credentials, what the training will
cover and how it relates to the equipment purchase. Attach all training material. Project costs (total eligible grant of $40,000; additional funding may be granted to facility showing evidence of hardship) Total project costs: Grant amount requested for: equipment training costs Employer contributions, including matching funds
(maybe waived under hardship on page 2)

Amount received or anticipated from other sources Llist sources and amounts

The information contained in this application is accurate and true to the best of my knowledge. I am authorized by my employer to make this request. I agree that all applicable regulations will be adhered to in completing the proposed project(s). I understand that the State Grant Agreement form, with its required assurances, will be required and agreed to. Signature of authorized representative Title Date

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Application and instructions

Part B – Attachment

Financial hardship
(complete only if applying for financial hardship consideration) Facilities deemed as operating under financial hardship can be given an exemption from matching dollar amounts and the $40,000 cap toward purchase of equipment and training.
Check all of the following that apply, to demonstrate evidence of financial hardship.

Facility shows evidence that providing employer funds to match state grant funds for safe patient-handling equipment and
training will strain the finances of the facility, such as threatening its viability (evidence must be attached) Facility profit/loss operating margin is no greater than 3 percent Facility is reimbursed through the Medicaid program Facility is reimbursed through the Medicare program Describe the nature of any financial hardship in more detail:

Costs without dollar-for-dollar employer contribution
Total project costs Grant amount requested for: equipment training costs Employer contribution Amount received or anticipated from other sources (list sources and amounts):
The information contained in this application is accurate and true to the best of my knowledge. I am authorized by my employer to make this request. I agree that all applicable regulations will be adhered to in completing the proposed project(s). I understand that the State Grant Agreement form, with its required assurances, will be required and agreed to. Signature of authorized representative Title Date

Completed applications should be sent to: Minnesota Department of Labor and Industry Workplace Safety Consultation – Grant Applications 443 Lafayette Road N., St. Paul, MN 55155

WSC 01 Safe Patient Handling Grant (10/07)

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Application and instructions