Form Cms-671 - Ltc Facility Application For Medicare/medicaid Page 4
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6GENERAL INSTRUCTIONS AND DEFINITIONS
(use with CMS-671 Long Term Care Facility Application for Medicare and Medicaid)
Block F26 - Check "yes" if the facility conducts
Column A-1 - Refers to those services provided onsite to
experimental research; otherwise check "no." Experimental
residents, either by employees or contractors.
research means using residents to develop and test clinical
treatments, such as a new drug or therapy, that involves
Column A-2 - Refers to those services provided onsite to
treatment and control groups. For example, a clinical trial of a
non-residents.
new drug would be experimental research.
Column A-3 - Refers to those services provided to residents
Block F27 - Check "yes" if the facility is part of a
offsite/or not routinely provided onsite.
continuing care retirement community (CCRC); otherwise
check "no." A CCRC is any facility which operates under
Column B - Full-time staff, C - Part-time staff, and
State regulation as a continuing care retirement community.
D - Contract - Record hours worked for each field of
full-time staff, part-time staff, and contract staff (do not
Blocks F28 – F31 - If the facility has been granted a nurse
include meal breaks of a half an hour or more). Full-time is
staffing waiver by CMS or the State Agency in accordance
defined as 35 or more hours worked per week. Part-time is
with the provisions at 42CFR 483.30(c) or (d), enter the last
anything less than 35 hours per week. Contract includes
approval date of the waiver(s) and report the number of hours
individuals under contract (e.g., a physical therapist) as well as
being waived for each type of waiver approval.
organizations under contract (e.g., an agency to provide
nurses). If an organization is under contract, calculate hours
Block F32 - Check "yes" if the facility has a State approved
worked for the individuals provided. Lines blocked out (e.g.,
Nurse Aide Training and Competency Evaluation Program;
Physician services, Clinical labs) do not have hours worked
otherwise check "no."
recorded.
REMINDER - Use a 2-week period to calculate hours worked.
FACILITY STAFFING
GENERAL INSTRUCTIONS
DEFINITION OF SERVICES
This form requires you to identify whether certain services are
Administration - The administrative staff responsible for
provided and to specify the number of hours worked providing
facility management such as the administrator, assistant
those services. Column A requires you to enter "yes” or "no”
administrator, unit managers and other staff in the individual
about whether the services are provided onsite to residents,
departments, such as: Health Information Specialists
onsite to nonresidents, and offsite to residents. Columns B-D
(RRA/ARTI), clerical, etc., who do not perform services
requires you to enter the specific number of hours worked
described below. Do not include the food service supervisor,
providing the service. To complete this section, base your
housekeeping services supervisor, or facility engineer.
calculations on the staff hours worked in the most recent
complete pay period. If the pay period is more than 2 weeks,
Physician Services - Any service performed by a physician at
use the last 14 days. For example, if this survey begins on a
the facility, except services performed by a resident's personal
Tuesday, staff hours are counted for the previous complete pay
physician.
period.
Medical Director - A physician designated as responsible for
Definition of Hours Worked - Hours are reported rounded to
implementation of resident care policies and coordination of
the nearest whole hour. Do not count hours paid for any type
medical care in the facility.
of leave or non-work related absence from the facility. If the
service is provided, but has not been provided in the
Other Physician - A salaried physician, other than the
2-week pay period, check the service in Column A, but leave
medical director, who supervises the care of residents when
B, C, or D blank. If an individual provides service in more
the attending physician is unavailable, and/or a physician(s)
than one capacity, separate out the hours in each service
available to provide emergency services 24 hours a day.
performed. For example, if a staff person has worked a total of
80 hours in the pay period but has worked as an activity aide
Physician Extender - A nurse practitioner, clinical nurse
and as a Certified Nurse Aide, separately count the hours
specialist, or physician assistant who performs physician
worked as a CNA and hours worked as an activity aide to
delegated services.
reflect but not to exceed the total hours worked
Nursing Services - Coordination, implementation, monitoring
within the pay period.
and management of resident care plans. Includes provision of
personal care services, monitoring resident responsiveness to
Completion of Form
environment, range-of-motion exercises, application of sterile
Column A - Services Provided - Enter Y (yes), N (no) under
dressings, skin care, naso-gastric tubes, intravenous fluids,
each sub-column. For areas that are blocked out, do not
catheterization, administration of medications, etc.
provide the information.
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