Workforce Retention Funding for Critical Access Hospitals and Their Owned and Operated Clinics

Provide the following background information:

• Organization Name and Background – Provide the name of your Critical Access Hospital, noting its location and the owned or operated clinics it includes, and the estimated population served.
• Project Lead and Contact Information – Identify the project lead who will serve as the primary point of contact to receive communications about your application. Provide first and last name, title, phone number, and email. 
• Project title and brief description of why you’re applying.

The project narrative must clearly address the identified need and the planned strategies, services, tasks or activities. Be as specific and concise as possible, keeping the narrative focused on how the project will strengthen rural health workforce retention.

a. Identified Need and Proposed Goals

Identify the need for the proposed project

• Discuss the workforce challenges and retention issues your organization aims to address through the proposed project (e.g., staff turnover, vacancy rates, burnout, child care barriers, staffing shortages, gaps in training and professional development).
• Describe the specific retention issues impacting your critical access hospital and its owned or operated clinics.
• When available, include relevant local data to demonstrate the scope and urgency of the need.

Outline the overarching goals of your proposed project and the workforce groups who will benefit (e.g., medical and nursing staff, allied health professionals such as behavioral health specialist, radiology technician, respiratory therapist, laboratory technician, physical therapist, occupational therapist, dietitians, etc.). 

• Goals should describe the broad, high‑level change your organization seeks to achieve (e.g., Strengthen workforce stability by improving retention among nursing staff and allied health professionals through initiatives that support long‑term engagement and reduce turnover; enhance workplace well‑being by strengthening support systems for medical staff, nursing teams and allied health professionals, fostering a more resilient and engaged rural health workforce). 

Identify any similar projects being implemented and their funding sources. Explain how your proposed project will enhance, rather than duplicate, existing efforts, including how you plan to coordinate with partners to prevent duplication. If requesting funds for an expansion, describe why the expansion is needed and how the new funds will support additional efforts. RHTP funds cannot be used to duplicate or replace existing funding, known as supplanting. RHTP funds may be used to expand or enhance an existing project. See the Budget section for additional details.

b. Strategies, Activities, and Measurable Outcomes*

Describe, in outcome‑focused terms, the specific strategies, services, tasks or activities your project will implement to address identified workforce retention needs. Outcomes should be specific, realistic and directly linked to the strategies, services, tasks or activities described. They should also reflect how the project will support the goals of the Rural Health Transformation Program, including improvements in rural provider retention, reductions in HPSA designations or a decrease in HPSA scores. 

• Please number your strategies, activities and measurable outcomes in order of priority. Approximately $10,000,000 in federal funding is available in year one for critical access hospitals and their owned and operated clinics, to support rural health care workforce retention efforts. An estimated 37 awards of approximately $270,000 each are expected to be made in year one. Applicants may submit a prioritized funding proposal and requested amounts may exceed $270,000. Activities not funded in the initial agreements may be considered later in the year, pending a review of available funds in August 2026.
  • Example: Reduce vacancy rates in nursing staff from 25% to 15% by September 30, 2027, by implementing retention bonuses, enhancing child care supports and covering license renewal fees, contributing to improved rural provider retention.
• In addition, each strategy, service, task or activity must include sufficient detail to ensure the scope is measurable and aligned with program goals. Using the example above, the following information also needs to be provided:
• Retention Bonuses: Describe the structure of the retention bonuses, including how bonus amounts will be determined (e.g., by role, tenure or performance). Specify the types of bonuses offered (e.g., milestone‑based, performance‑based) and outline the criteria and process used to select eligible recipients. Clarify whether the bonuses are tied to a five‑year service commitment.
• Enhancing Child care Supports: Clearly explain what child care supports will be offered and how they will be implemented (e.g., child care provided at no cost or reduced cost to nursing staff, use of vouchers or stipends, minor renovations or equipment purchases for on-site child care). If applicable, describe how ongoing operational costs will be funded. Describe how the enhanced child care supports will be implemented.
• Covering License Renewal Fees: Identify which license types (e.g., RN, LPN, CNA) will be covered, who is eligible and how the fee‑coverage process will work. Additionally, explain how covering license renewal fees is expected to support staff retention and ultimately contribute to reducing vacancy rates.
• Financial incentives must be tied to a minimum five‑year service commitment. On a prorated basis, the employer (grantee) is required to return the corresponding funds to the state for any participant who fails to complete their five‑year service commitment, within 90 days of the default. 

Applicants must have policies, procedures and systems in place to manage these incentives, including a five‑year service‑commitment agreement with participating staff and a process for monitoring compliance. Refer to the Funding Opportunity section of the Funding Overview to determine which incentives are tied to the five-year service commitment. 

• Provide a description of the policies and monitoring procedures your organization has established or plans to establish to meet the above-described requirements.
• Copies of these policies, procedures and service commitment agreements must be submitted to the state office for review and approval before any financial incentive can be issued to an employee and before submission of a request for reimbursement. Instructions on how to submit these will be included in the agreement.   

Applicants will be required to attach documentation demonstrating formal approval of the grant application by the hospital’s governing body.

• For privately or nonprofit owned hospitals, this should include either:
  • A copy of the board of trustees/board of directors (or similar governing body) meeting minutes showing approval of the grant application, or
  • A letter of approval signed by the chair of the board of trustees/board of directors (or similar governing body).
• For county‑owned hospitals, applicants must also provide documentation of approval from the County Commission, such as approved meeting minutes or a letter signed by the chair of the County Commission. 

*Applicants must propose strategies, activities and measurable outcomes that align with the RHTP evaluation plan and metrics for the Strengthen and Stabilize Rural Health Workforce Initiative, identified on pages 52-53 of the project narrative and pages 10-11 of the appendices. 

• Increase the rural provider retention rate at 3 and 5 years
• Expand remote monitoring and AI-assisted care to reduce staffing needs
• Reduce Health professional Shortage Area (HPSA counties)
• Increase the rural primary care provider retention rate

Refer to the Funding Opportunity section of the Funding Overview for examples of eligible workforce retention projects.

Using the prioritized numbers, explain how the applicant will sustain successful retention strategies after the funding period ends. Describe how effective practices such as incentive programs, child care supports, wellness initiatives, flexible scheduling approaches or professional‑development activities will be integrated into ongoing operations and be maintained beyond RHTP funding. If the proposed project includes the purchase of equipment or technology, outline the plan for maintaining and continuing to use these tools beyond the funding period. Applicants should consider the following questions when assessing sustainability:

• How will the applicant continue supporting the retention activities that prove most effective?
• Are there opportunities to integrate these strategies into existing policy, operational budgets or workforce planning efforts?
• Do any of the proposed strategies reduce costs associated with staff turnover, burnout or vacancy and can those savings be used to sustain the program?
• Is there a long‑term plan or model to ensure ongoing stability of the retention efforts?

As it relates to your strategies, activities and measurable outcomes, please check the boxes that apply and briefly explain how your project aligns with each selected statutory element of the Rural Health Transformation Program Notice of Funding Opportunity:

Improving access:

• How will the proposed workforce retention project improve rural residents’ access to care by stabilizing staffing levels?

Improving outcomes:

• What are the baseline metrics (e.g., turnover rates, vacancy rates, time‑to‑hire)? How will the proposed project improve retention‑related outcomes identified in this application (listed in the Strategies, Activities, and Measurable Outcomes section of this guidance)?

Technology use:

• How will new and emerging technologies support workforce retention, such as reducing administrative burden, expanding telehealth capacity, or improving staff efficiency? How will these technologies be sustained long term?

Partnerships:

• Which partnerships will be leveraged to support retention in your rural care setting?

Workforce:

• What training, upskilling, or professional‑development activities will be provided to address gaps in the current rural workforce and support long‑term retention?

Data-driven solutions:

• How will data and workforce‑retention strategies guide the project’s activities and decisions?

Financial solvency strategies:

• How will the proposed project enhance financial stability by reducing turnover‑related costs and supporting a sustainable rural workforce?

Cause identification:

• How will the proposed project address the root causes of workforce challenges and retention gaps in the rural continuum of care?
   

Complete a comprehensive action plan detailing how the applicant will carry out the proposed strategies, activities and measurable outcomes. As a reminder, the funding period will start upon execution of the agreement with all required approvals and signatures. The funding period will end on September 30, 2027, and all funds must be expended by this date. Please identify the corresponding priority numbers from the project narrative in the action plan, as applicable. Being as concise as possible, the action plan must include:

a. Timeline and Milestones:

• Provide the timeline the applicant will follow to successfully implement the proposed project.
• The timeline should identify key milestones and include estimated completion dates for each key strategy and activity.

b. Metrics:

• For each measurable outcome, identify specific metrics that will be used, and describe how progress will be tracked for reporting requirements.
• As a reminder, templates will be provided for reporting requirements. Due dates and additional information will be provided in the agreement.

c. Key Personnel:

• Identify key personnel, including a project lead. Describe the type of work each person will perform in carrying out the project. Include relevant credentials and experience managing grants and special projects.
• If the applicant plans to use external sources, such as consultants, please identify them, describe their experience and outline their role in the project. These external sources must also be identified in the budget.

Provide an itemized budget with appropriate justification for each cost category (personnel, fringe, travel, supplies, etc.). If applicable, include any indirect cost paid under the subrecipient and the indirect cost rate used.

RHTP funds are governed by applicable provisions of 2 CFR Part 200 and 2 CFR Part 300, with guidance from the federal RHTP Notice of Funding Opportunity and CMS’s Frequently Asked Questions document. The limits and unallowable costs detailed in this section come from federal guidance and are non-negotiable.

Administrative costs are not allowed in this funding opportunity.

Approximately $10,000,000 in federal funding is available in year one for critical access hospitals and their owned and operated clinics, to support rural health care workforce retention efforts. An estimated 37 awards of approximately $270,000 each are expected to be made in year one. Applicants may submit a tiered or prioritized funding proposal, and requested amounts may exceed $270,000. Activities not funded in the initial awards may be considered later in the year, pending a review of available funds in August 2026. Please apply the corresponding priority numbers from the project narrative to the related budget items.

Staff receiving a financial incentive must be employed and on the payroll at the time this funding application was posted.

RHTP funding is designed to support expansion and scale to better serve rural communities, not to replace or duplicate existing funding sources. When using funds to expand an exiting pilot program or initiative or to develop a new training program with existing partners, the funds may only be applied to the costs associated with the new population, new activities, new program milestones, etc.

If retaining a clinical workforce will be supported by ancillary positions (CEO’s, CFO’s, Administrators), using funds to pay them may be allowable. However, all activities must be sustainable, so there mut be a clear plan of maintaining a given position without RHTP funds.

Additional Unallowable and Limited Costs

• Pre-award costs.
• Meeting matching requirements for any other federal funds or for local entities. 
• Providers currently participating in a state loan repayment program that includes a service commitment are not eligible for financial retention incentives under this funding opportunity.
• Contracted or locum tenens providers are not eligible for retention incentives or projects, as these efforts are intended to focus on developing a long-term provider base. 
• Services, equipment or supports that are the legal responsibility of another party under federal, state, Tribal, or civil rights law.
• Supplanting existing state, local, tribal or private funding of infrastructure or services (ex. staff salaries).
• The cost of independent research and development.
• Funds related to any activity designed to influence the enactment of legislation, appropriations, regulation, administrative action or executive order. 
• Financial assistance to households for installation and monthly broadband internet costs.
• Meals, unless in limited circumstances such as:
  • Subjects and patients under study.
  • Where specifically approved as part of the project or program activity, such as in programs providing children’s services.
  • As part of a per diem or subsistence allowance provided in conjunction with allowable travel in accordance with the U.S. General Services Administration (GSA) established rates. 
• Replacing payment(s) for clinical services that could be reimbursed by insurance.
• Direct health care services may be funded if not currently reimbursable, will fill a gap in care coverage and/or may transform current care delivery model.
• Provider payments cannot exceed 15% of total funding in a budget period.*
• No more than 5% of total funding in a budget period can support funding the replacement of an Electronic Medical Record (EMR) system if a previous Health Information Technology for Economic and Clinical Health (HITECH) Act certified EMR is in place as of September 1, 2025.* Upgrades, enhancements, added modules, interfaces or functionality to existing EMR systems are allowable and not subject to the 5% limitation.
• Funding toward projects similar to the “Rural Tech Catalyst Fund Initiative” cannot exceed the lesser of 10% of total funding or $20 million of total funding awarded in a budget period.*
• Clinician salaries/wages for facilities that subject clinicians to non-compete clauses.
• Demolition of aged buildings.
• Administrative costs, capital expenditures and vehicle purchases are not allowed under this funding opportunity.

*Limits apply to ND HHS’s spending of RHTP funds. Individual agreements may be considered for costs exceeding the budget limitations.

Applications will be reviewed and scored solely on what is presented within the application materials. The reviewing committee will score applications based on criteria in the Scoring Tool.

ND HHS aims to notify applicants about their award in a timely manner. ND HHS reserves the right to support applicants with changes to their project proposals to ensure HHS’s RHTP commitments are upheld. ND HHS is in a cooperative agreement with CMS for RHTP and is subject to substantial CMS project involvement. This may impact funding timelines.

The awarded applicant(s) will be sent an agreement to sign and return to ND HHS. The awarded applicant(s) shall comply with the agreement provisions set out in the “Sample Funding Agreement” document. Due to the limited timeframe associated with the funding source for this funding opportunity, ND HHS will not entertain any changes to the funding agreement Terms and Conditions. 

Updated: April 24, 2026

Can two facilities that fall under the same EIN both apply for this funding?
Answer: Yes, if they are in separate locations.

Are funds available for a long-term care facility that is connected to the critical access hospital (CAH)?
Answer: Yes, if it is part of the system that makes up the CAH and their owned and operated clinics.

I am an independent provider, optometry office, EMS, etc. am I eligible for this funding?
Answer: No, only CAHs and their owned and operated clinics are eligible to apply under this Workforce Retention Funding Opportunity Solicitation Number: 210-22102.

Are other provider/workgroup types (business, housekeeping, dietary, admin) included in this retention opportunity?
Answer: We have submitted this question to the Centers for Medicare and Medicaid Services (CMS) and are waiting for a response.

Where is the information on creating a portal to begin the application process?
Answer: This information can be found in the Funding Announcement in the Application Submission section. Applications must be submitted to North Dakota Health and Human Services (ND HHS) through Qualtrics.

Can we get a full copy of the application, so we do not have to go through Qualtrics?
Answer: The funding opportunity application is available in its entirety on the webpage - Workforce Retention Funding for Critical Access Hospitals and Their Owned and Operated Clinics. Applications must be submitted to ND HHS through Qualtrics.

Do all organizations need to register with SAMS.gov and receive a UEI number to receive these funds?
Answer: Yes.  

If a Critical Access Hospital has an adjoining nursing home they own, is it allowable to include the nursing home employees in addition to the CAH employees in the retention strategy?
Answer: Yes, if they are employees of the CAH and their owned and operated clinics.

Would passes to a nearby state park for all employees qualify?
Answer: As stated in the funding announcement, CAHs could explore partnerships to support employee wellness, resilience and burnout prevention. This could include partnerships with state parks.    

How would service commitments be enforced and by who?
Answer: ND HHS will have an agreement with the CAH. The CAH will have a relationship with the employee and the service commitment must be managed at the CAH level.

Are remote patient monitoring systems to decrease strain on staff an acceptable project?
Answer: No, remote patient monitoring falls under a different aspect of North Dakota’s Rural Health Transformation Program (RHTP) and additional funding opportunities will continue to be posted to address the projects identified in North Dakota’s application. However, if appropriate justification can be made on how this project would retain staff and fit as a technology or workflow solution that assists in administrative efficiency, the CAH could include it in their application.

If the nursing staff is privately contracted, can they be converted to permanent employees?
Answer: No, as noted in the application guidance, staff receiving a financial incentive must be employed and on the payroll at the time this funding announcement was posted.  

Can these funds be used to recruit a physician who is currently in residency?
Answer: No, this funding opportunity supports only retention strategies. As noted in the application guidance, staff receiving a financial incentive must be employed and on the payroll at the time this funding application was posted. Recruitment was also included in North Dakota’s RHTP and additional funding opportunities will continue to be posted to address the projects identified in North Dakota’s application.

What employees qualify for the retention bonuses?
Answer: Medical and nursing staff and allied health professionals such as behavioral health specialists, radiology technicians, respiratory therapists, laboratory technicians, physical therapists, occupational therapists, dietitians, etc. ND HHS is seeking guidance from CMS if additional work groups can receive individual financial incentives.

Does repayment occur if an employee resigns even after signing retention agreement? Who will take legal action to make this occur?
Answer: ND HHS will have an agreement with the CAH. The CAH will have the relationship with the employee and the service commitment must be managed at the CAH level. For employees of the CAH who do not meet the threshold of the five-year service commitment, ND HHS will require reimbursement back from the CAH. The CAH must determine their action in relation to the employee.

Are those participating in loan reimbursement programs all excluded? Does this include Career Builders?
Answer: Yes, providers who are participating in state or federal loan repayment programs or any other financial programs that require a service commitment (such as Career Builders), are not eligible for a financial incentive under this funding opportunity. Additionally, while tuition reimbursement and professional development are allowable uses of funds, loan repayment is not an allowed retention strategy.

Would leadership development opportunities for employees qualify for reimbursement (i.e. purchase of leadership courses)?
Answer: Yes.

Are expenses for remodeling to create a more desirable work setting allowable?
Answer: No, capital expenditures are unallowable expenses for this funding opportunity, this includes new construction, minor renovations or alterations, building expansion, purchasing of buildings, significant retrofitting of buildings, cosmetic updates and any other cost that materially increases the value of the capital.

Are the repayment of retention incentives prorated over the five years or 100% of what was given if to the employee?
Answer: The five-year service commitment is required. The CAH must determine their action in relation to the employee if they do not fulfill the five-year service commitment, which may include a prorated approach and include this in their policies and procedures.

Is there flexibility in how a retention bonus is paid? For example, can a portion be paid after each year of the five-year commitment is worked? Does this allow the CAH to pay annually and prevent the need to pay back the reimbursement if the employee leaves before five years are up? 
Answer: No, all funds must be liquidated by September 30, 2027. The CAH will have the relationship with the employee and the service commitment must be managed at the CAH level. The CAH must determine their action in relation to the employee and include this in their policies and procedures.

If a participant has to repay any amount, is it minus taxes taken from the disbursement they received? 
Answer: No, a flat dollar amount in a contract is typically treated as gross pay, meaning the employee or contractor is responsible for taxes, not the sponsor. If the CAH wants employees to receive a specific net (after-tax) amount, they will need to increase the payment to cover those taxes.

Could the retention payments be put into accounts that the person could only access at specific times, such as bonds cashable at a specific date?
Answer: No, the full dollar amount must be liquidated by September 30, 2027, and funds cannot generate income.

When calculating potential employee bonuses and we plan for 10 employees for a total cost estimate, what if only five employees decide to take the retention bonus? Can the funds be moved elsewhere?
Answer: Any changes to the initial budget submission will need a budget amendment that is resubmitted to ND HHS and receive approval from CMS. Any changes would also need to be in accordance with the Workforce Retention Funding for Critical Access Hospitals and Their Owned and Operated Clinics funding opportunity.

Housing is a retention option, but we cannot purchase a building. Can CAHs purchase a house as it is residential, not commercial space?
Answer: No, capital expenditures are unallowable expenses for this funding opportunity, this includes new construction, building expansion, purchasing of buildings, significant retrofitting of buildings, cosmetic updates and any other cost that materially increases the value of the capital. Housing stipends and partnerships with landlords for short-term lease arrangements are examples of allowable uses for housing support.

Who can provide formal approval of the grant application? Does it need to be a governing body?
Answer: As stated in the application, applicants are required to attach documentation demonstrating formal approval of the grant application by the hospital’s governing body. For privately or nonprofit hospitals, this should include either a copy of the board of trustees/board of directors (or similar governing body) meeting minutes showing approval of the grant application or a letter of approval signed by the chair of the board of trustees/board of directors (or similar governing body).

Will there be a standard form for organizations to use for approval from the governing board or should we craft our own?
Answer: No, ND HHS will not be providing a standard form.

While this is directed at certain medical-related staff at this time, can all staff be included in any wellness or staff engagement programs developed with this funding?
Answer: Funds can be used for developing and implementing staff engagement programs for all staff. Individual financial incentives can be provided to eligible workgroups including medical and nursing staff, allied health professionals such as behavioral health specialists, radiology technicians, respiratory therapists, laboratory technicians, physical therapists, occupational therapists and dietitians. ND HHS is seeking guidance from CMS if additional work groups can receive individual financial incentives.

Is this reimbursable funding?
Answer: Yes, prior to requesting reimbursements, a fully executed agreement must be in place. In addition, the CAH must have policies, procedures and systems in place to manage financial incentives, including a five‑year service commitment agreement with participating staff and a process for monitoring compliance. Copies of these policies, procedures and service commitment agreements must be submitted to the ND HHS for review and approval before any financial incentive can be issued to an employee and before submission of a request for reimbursement. Instructions on how to submit these will be included in the agreement.  

Since grants do not go through the Board of Trustees or the Board of Directors, would a letter from the Authorized Signing Representative be sufficient for that requirement?  
Answer: As stated in the application, applicants are required to attach documentation demonstrating formal approval of the grant application by the hospital’s governing body. For privately or nonprofit hospitals, this should include either a copy of the board of trustees/board of directors (or similar governing body) meeting minutes showing approval of the grant application or a letter of approval signed by the chair of the board of trustees/board of directors (or similar governing body).

First, regarding the potential $270,000 award in year one—can you confirm whether this amount represents a total of $270,000 distributed over the full five-year period or if it is $270,000 awarded annually over the course of five years?
Answer: The funds available for the Workforce Retention funding opportunity for Critical Care Access Hospitals and their owned and operated clinics are only for year one of the RHTP. The award received must be liquidated by September 30, 2027. Funds available for future years of the RHTP will have a separate application and award process.

Are social workers classified as clinical staff?
Answer: Yes, social workers are health care professionals who provide direct patient support.

We would like to fund nine retention bonuses for employees in various clinical disciplines. This is contingent on five-year service commitment. Therefore, we would not like to list the staff person, but instead list current employee. Would this be acceptable?
Answer: As stated in the application guidance, staff receiving a financial incentive must be employed and on the payroll at the time the funding application is posted. Therefore, the employee’s name must be associated with the bonus.

Is a workforce retention intervention tool designed to proactively identify turnover risk, improve staffing efficiency and strengthen nurse engagement an eligible expense?
Answer: Likely yes, if the tool directly supports retention, reduces staff turnover or improves staff stability, and if it is clearly tied to the program’s workforce goals and outcomes. All awardees must report on retention results.

Is a workforce resilience and burnout prevention tool aimed at improving staff well-being and reducing turnover risk an eligible expense?
Answer: Likely yes, if the tool directly supports retention, reduces staff turnover or improves staff stability, and if it is clearly tied to the program’s workforce goals and outcomes. All awardees must report on retention results.

Is a program that provides specialized education and training solutions for health care staff an eligible expense?
Answer: Yes, education and training are allowable expenses. However, if tuition reimbursement, education awards or support for upskilling or career pathway development (e.g., LPN to RN) are part of the specialized education and training solutions, a five-year service commitment is required.  

If an agreement spans multiple years but requires full payment upfront (for example, a three-year agreement totaling $45,000 paid at signing), would the full amount be considered an eligible expense in year one or would it need to be allocated across the term of the agreement (e.g., $15,000 per year)?
Answer: The full amount must be paid in year one since the funds received must be liquidated by September 30, 2027. Funds available for future years of the RHTP will have a separate application and award process.

We currently have agreements in place with students who are still in school, where we fund their education in exchange for a commitment to work at our facility upon graduation. If these individuals are not yet on payroll but have signed commitments, would their education expenses be eligible under this funding?
Answer: No, this funding opportunity supports only retention strategies. As noted in the application guidance, staff receiving a financial incentive must be employed and on the payroll at the time this funding application was posted. Recruitment was also included in North Dakota’s RHTP and additional funding opportunities will continue to be posted to address the projects identified in North Dakota’s application.

If we reimburse a provider for attending a conference, would both the direct costs (such as registration and travel) and the wages paid for their time spent attending (for example, paying eight hours at their hourly rate) be considered eligible expenses? If so, are these types of expenses expected to be tied to a five-year retention requirement?
Answer: Yes, both the direct costs for attending a conference (such as registration fees and travel) and the wages paid for the hours the employee spends attending the conference are allowable expenses. If the conference/training event results in a certification that provides upscaling or career pathway development, such as RN to RN CEN (Certified Emergency Nurse), then a five-year service agreement is required.

Are grantees required to have a sustainability plan in place past the five-year commitment?
Answer: Yes, CMS requires a sustainability plan past the five-year service commitment.

Is there a five-year commitment for licensure reimbursement?
Answer: Yes, CMS requires a five-year service commitment for licensure reimbursement, regardless of dollar value. The applicability of five-year requirement is not dependent on the incentive or payment cost; it is based on (1) is the individual receiving something of value and (2) is the individual receiving a certification? If both, then it applies because that is in statute. If the service commitment does apply, there is no flexibility in the length of the commitment.

If the hospital owns the ambulance service, and the employees of the ambulance department are employees of the CAH, would they then qualify as allied medical personnel?
Answer: Yes

Am I correct in understanding that the period of performance is 16 months?
Answer: The period of performance will begin once the agreement has been fully executed, following all required approvals and signatures. It will end on September 30, 2027, and all funds must be fully expended by that date.

Must retention bonuses be tied to a service commitment? If so, what is the minimum service requirement and does it vary by role? 
Answer: As noted in the funding opportunity section of the grant guidance, retention bonuses are tied to the five-year service commitment. This is a federal requirement for all employees receiving a financial incentive.

We are struggling conceptually with the question of whether we must pay a retention bonus upfront or if we could time it to achievement of time- based milestones? Should we anticipate funding for retention bonuses in years 2-5 of the RHTP?
Answer: The full amount must be paid in year one since the funds received must be liquidated by September 30, 2027. Funds available for future years of the RHTP will have a separate application and award process.

We are interested in renting a home for our providers/staff who travel a long distance and experience travel related challenges. This is in scope for RHTP funds, correct? Any funding exclusions?
Answer: Yes, housing supports for staff who travel long distances or face weather-related commute challenges, such as renting or stipends, are indicated as an eligible workforce retention project under this funding opportunity. Five-year service commitment may apply. Awardees will need to report use and provide a sustainability plan.  

For initiatives that require a five-year service commitment, is the repayment typically expected to be prorated if an employee does not fulfill the full term? Additionally, how is this handled in situations where an employee resigns versus being terminated?
Answer: Yes, the repayment of the incentive amount will be prorated to reflect the length of service provided to the rural community during the five-year service requirement. Five-year service requirement applies to a situation where an employee resigns or is terminated.

Are there any guidelines or flexibility built into the five-year commitment requirement for significant life events (for example, medical issues, maternity leave or other circumstances that may require an employee to step away from their role)?
Answer: CMS has stated that a state is able to submit a request with documentation substantiating a staff’s death or disability to CMS for review and approval in order to write-off or otherwise forgive the five-year service obligation.

Regarding child care support, can funds be used to assist employees with their existing child care expenses or must the support be structured through a program or service provided directly by the hospital? 
Answer: The provision of child care vouchers or subsidies as retention incentives for staff do not need to be structured through a program or service provided directly by the hospital.

Should we submit a single application (approximately $270,000) that encompasses our hospital, skilled nursing facility and clinic as a unified workforce strategy? Or would it be appropriate to submit separate applications (approximately $540,000 total) by distinguishing between SNF workforce stabilization and hospital/clinic workforce retention, assuming clear separation of staff roles and justification?
Answer: Please submit one application per CAH and their owned and operated clinics system.

May a critical access hospital include the cost of a technology vendor platform subscription—specifically an AI-assisted specialty telehealth service that reduces the referral coordination burden on rural clinical staff—as an eligible budget line item in their application?
Answer: No, retention efforts should focus on staff that are within the rural facility. Telehealth and technology were also included in North Dakota’s RHTP and additional funding opportunities will continue to be posted to address the projects identified in North Dakota’s application.

Additionally, it was noted that there is no place to attach the documents citing board approval. How would you like these submitted?
Answer: There is an area in the Qualtrics application to upload and submit these documents.

We would like to pursue a leadership program that provides mentorship and structured evaluations to help support a positive work environment and improve hospital wide culture which aids in retention.
Answer: Yes, as noted in the guidance under Shared Learning, Mentorship and Professional Support Networks, mentorship programs, clinical supervision partnerships or structured on-going evaluations designed to improve job satisfaction and support a positive work environment are allowed.

Can we provide tuition reimbursement for our athletic trainer to return to physical therapy school and rejoin the workforce after completion of her program which aids in retention of our existing staff?
Answer: Yes, tuition reimbursement is an allowable expense, as noted in the grant guidance under Employee Incentive and Support Strategies.

Is a payment towards an employees HSA for high-deductible plans allowed?
Answer: We have submitted this question to CMS and are waiting for a response.

Can leadership training include staff across various positions throughout the hospital or can it only be for those that are direct patient care providers?
Answer: We have submitted this question to CMS and are waiting for a response.

I am writing to see if a barometric chamber for wound care - which is not currently available in our community - would be an allowable expenditure.
Answer: No, adding services is not an eligible strategy for retention. This may fall under a different aspect of North Dakota’s RHTP and additional funding opportunities will continue to be posted to address the projects identified in North Dakota’s application.

We would like to introduce a new service line: Interventional Radiology which is not currently available in our community. Provided our expenses are for equipment and renovation - not construction, would this be allowable?
Answer: No, adding services is not an eligible strategy for retention. This may fall under a different aspect of North Dakota’s RHTP, and additional funding opportunities will continue to be posted to address the projects identified in North Dakota’s application.

On page 3 in the scoring tool under Project Narrative - Identified Need and Proposed Goals for the 20-18 point criteria level, it asks if the application "fully aligns with RHTP allowable uses." What are the RHTP allowable uses?
Answer: Allowable and unallowable uses are identified in the funding opportunity and budget sections of the application guidance.

On page 4 in the scoring tool under Project Narrative - Strategies, Activities & Measurable Outcomes for the 30-26 point criteria level, it asks if the application "Strongly addresses one or more key elements." Are these the key elements - Improving access, Improving outcomes, Technology use, Partnerships, Workforce, Data-driven solutions, Financial solvency strategies, Cause identification?
Answer: Yes, those are the key elements identified in the project narrative section of the application guidance.

On page 5 of the scoring tool under Action Plan - timeline and Milestones for the 10-9 point criteria level, it asks if the application "Strongly supports successful implementation and aligns with federal RHTP timelines." Do they mean the timelines listed in the Implementation plan and timeline section in the CMS NOFO, pg. 34?
Answer: The timeline refers to the September 30, 2027, when funds must be fully expended. This is identified in the funding section of the guidance.

On page 8 of the scoring tool under Priority for the 10-9 point criteria level, it asks if the application "Clearly addresses one or more priority areas identified in North Dakota's RHTP application." Are these the priority areas? Increase the rural provider retention rate at 3 and 5 years, Expand remote monitoring and AI-assisted care to reduce staffing needs, Reduce Health Professional Shortage Area (HPSA) counties, Increase the rural primary care provider retention rate.
Answer: Upon further consideration, that scoring section will not be used for this funding opportunity.

If specific staff listed in the application do not accept the bonus due to the five-year work commitment, can we than change staff that can get the bonus, as long as they are in roles that the state has listed as eligible?
Answer: Any changes to the initial budget submission will need a budget amendment that is resubmitted to ND HHS and receive approval from CMS. Any changes would also need to be in accordance with the Workforce Retention Funding for Critical Access Hospitals and Their Owned and Operated Clinics funding opportunity. Furthermore, staff receiving a financial incentive must be employed and on the payroll at the time the funding application is posted.

CMS has provided additional guidance on a five-year service commitment fact sheet.