Form Cms-671 - Ltc Facility Application For Medicare/medicaid Page 3
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6GENERAL INSTRUCTIONS AND DEFINITIONS
(use with CMS-671 Long Term Care Facility Application for Medicare and Medicaid)
This form is to be completed by the Facility
For the purpose of this form “the facility” equals certified beds (i.e., Medicare and/or Medicaid certified beds).
Standard Survey - LEAVE BLANK - Survey team will complete
Extended Survey - LEAVE BLANK - Survey team will complete
INSTRUCTIONS AND DEFINITIONS
Name of Facility - Use the official name of the facility for
Definitions to determine ownership are:
business and mailing purposes. This includes components or
FOR PROFIT - If operated under private commercial
units of a larger institution.
ownership, indicate whether owned by individual, partnership,
or corporation.
Provider Number - Leave blank on initial certifications. On
all recertifications, insert the facility's assigned six-digit
NONPROFIT - If operated under voluntary or other nonprofit
provider code.
auspices, indicate whether church related, nonprofit
corporation or other nonprofit.
Street Address - Street name and number refers to physical
location, not mailing address, if two addresses differ.
GOVERNMENT - If operated by a governmental entity,
indicate whether State, City, Hospital District, County,
City - Rural addresses should include the city of the nearest
City/County, or Federal Government.
post office.
Block F13 - Check "yes" if the facility is owned or leased by a
County - County refers to parish name in Louisiana and
multi-facility organization, otherwise check "no." A
township name where appropriate in the New England States.
Multi-Facility Organization is an organization that owns two
or more long term care facilities. The owner may be an
State - For U.S. possessions and trust territories, name is
individual or a corporation. Leasing of facilities by corporate
included in lieu of the State.
chains is included in this definition.
Zip Code - Zip Code refers to the "Zip-plus-four" code, if
Block F14 - If applicable, enter the name of the multi-facility
available, otherwise the standard Zip Code.
organization. Use the name of the corporate ownership of the
multi-facility organization (e.g., if the name of the facility is
Telephone Number - Include the area code.
Soft Breezes Home and the name of the multi-facility
organization that owns Soft Breezes is XYZ Enterprises, enter
XYZ Enterprises).
State/County Code - LEAVE BLANK - State Survey Office
will complete.
Block F15 – F23 - Enter the number of beds in the facility's
Dedicated Special Care Units. These are units with a specific
State/Region Code - LEAVE BLANK - State Survey Office
number of beds, identified and dedicated by the facility for
will complete.
residents with specific needs/diagnoses. They need not be
certified or recognized by regulatory authorities. For example,
Block F9 - Enter either 01 (SNF), 02 (NF), or 03 (SNF/NF).
a SNF admits a large number of residents with head injuries.
They have set aside 8 beds on the north wing, staffed with
Block F10 - If the facility is under administrative control of a
specifically trained personnel. Show "8" in F19.
hospital, check "yes," otherwise check "no."
Block F24 - Check "yes" if the facility currently has an organized
Block F11 - The hospital provider number is the hospital's
residents’ group, i.e., a group(s) that meets regularly to discuss
assigned six-digit Medicare provider number.
and offer suggestions about facility policies and procedures
affecting residents' care, treatment, and quality of life; to sup
Block F12 - Identify the type of organization that controls and
port each other; to plan resident and family activities; to par
operates the facility. Enter the code as identified for that
ticipate in educational activities or for any other purposes; oth
organization (e.g., for a for profit facility owned by an
erwise check "no."
individual, enter 01 in the F12 block; a facility owned by a
city government would be entered as 09 in the F12 block).
Block F25 - Check "yes" if the facility currently has an
organized group of family members of residents, i.e., a
group(s) that meets regularly to discuss and offer suggestions
about facility policies and procedures affecting residents' care,
treatment, and quality of life; to support each other, to plan
resident and family activities; to participate in educational
activities or for any other purpose; otherwise check "no.”
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