This application must be completed for each facility andWord文档格式.docx
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This application must be completed for each facility andWord文档格式.docx
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6.DateBusinessStarted:
7.CorporateContact:
Name
Address
Phone#
Emailaddress
FEIN
8.Listallaffiliatesandsubsidiariestowhichthisinsurancewillapply.Includeacompletedescriptionoftheoperationofeachaffiliate/subsidiaryanditsrelationshiptothenamedinsured.Includeaddress,facilitycontact,phoneandemailaddress.Attachaseparatesheetofpaper,oruseAcordsupplementalapplication.Includeaseparateapplicationforeachfacilitylisted:
Description
NamedInsured:
SectionII.FacilityGeneralInformation:
1.FacilityNameandanydba:
2.Address:
3.Facilitycontact:
4.Facilityis(checkallthatapply):
Profit
HospitalAffiliated
AccreditedbyJCAHO
NotforProfit
MedicareCertified
AHCA
Corporation
MedicaidCertified
IHCA
Partnership
Governmental
LicensedbyState
Individual
Charitable
Other(define)
5.Istheabovenamedinsuredtheparentcompanyandsoleownerofeachlocationlistedabove?
YesNo
Ifnot,providedetails.
6.IsthefacilityrununderamanagementcontractYesNo
7.Ifyes,nameandaddressandofmanagementcompany:
8.Expirationdateofcontract:
9.Lengthoftimeundercurrentmanagement:
10.Lengthoftimeundercurrentownership:
11.Namedinsuredis:
BuildingownerTenant
12.NameandaddressofbuildingownerifotherthanthenamedInsured:
13.Officers/GeneralPartners:
Name:
Title:
%ofOwnership:
15.Arethereanyotheroccupantsofthepremises?
YesNo
16.Ifyes,describeandidentify.
SectionIII.LicenseandAccreditation:
1.Provideacopyofeachlicenseheldbyyourfacility.
2.Hasthefacility’scertificate/licenseeverbeenrevokedorsuspended?
YesNo
3.Ifyes,pleaseexplain.
4.Dateoflaststateinspection.
SectionIV.StaffingandPersonnel:
1.Staffing:
(completeCMS671)
Title
LicenseNumber
FacilityStartDate
YearsExperience
#inpast5years
Administrator
Dir.ofNursing
MedicalDirector
RiskManager
2.TurnoverratioforNursingstaff(calculatedbytotalnewhireddividedbytotalonstaff)forlast12months.
a.RN:
b.LPN/LVN:
c.NursesAid:
3.Whatistheturnoverrateforemployedstaff?
4.Totalnumberoffulltimeemployees:
5.Totalnumberofparttimeemployees:
6.Totalnumberofmanagementemployees
7.IstheMedicalDirectoremployedfulltime?
8.IstheMedicalDirectorundercontract?
YesNo
9.Ifyes,provideacopyofthecontract.
10.IstheMedicalDirectoralsoanattendingphysicianprovidingdirectpatient
care?
YesNo
11.Areanyofyouremployeesleased?
YesNo
12.Ifyes,indicatetypeofemployeesleased.
13.Provideleasingcompanyname,address,phone#,andemailaddress,FEIN.
14.Attachacopyoftheleasingcontract.
15.StafftoResidentRatios:
Staff
DayShiftRatio
EveningShiftRatio
NightShiftRatio
Example
1RN/20residents
1RN/40residents
1RN/40residents
Nurses(RN’s)
LPN/LVN
NursesAides
OtherStaff
16.Indicatewhichmethodsareusedinhiringnewemployees(medicalstafftoincludephysicians,RN’sLPN’s)
Method
MedicalStaff
AllEmployees
Criminalbackgroundchecks
Conductpersonalinterview
Validateworkhistory
Validateeducation
Drugtesting
Referencechecks
17.Areallnursesaidescertifiedpriortohiring?
Ifno,describecertificationprocess.
18.Arethereanyvolunteersorvolunteerprograms?
19.Ifyes,describetasksperformed.
20.Doyouprovidemonetaryincentiveforcontinuingeducation?
YesNo
21.Doyouconductformal,ongoingskillassessmentsandtrainingofallstaffprovidingresidentcare?
YesNo
22.Ifyes,howoftenisitdone?
23.Howisitdocumented?
24.Listandprovideacopyofallindependentcontractorserviceagreementsthatdirectlyrelatetoresidentcare.Useseparatepieceofpaperifnecessary.
25.Doestheinsuredprovidewrittennoticetoresidentsandtheirrepresentativesofindependentcontractoragreements?
26.DoyourequireALLindependentcontractors(nurses,laboratory,psychiatric,therapy,pharmacy,dental,etc.)tocarryliabilitylimitsequaltoorgreaterthanyourown?
YesNo
27.Ifno,listwhichservicesandwhy.
28.Arecertificatesofinsurancemaintainedfortheindependentcontractors?
YesNo
29.WhatisthenameofthecarrierprovidingyourWorkers’Compensation
Insurance?
30.Haveyouconfirmedcoverageisinforce?
31.Totalmonthlypayroll:
%clerical%nursing
32.Provide5-7yearsoflosshistorycurrentlyvaluedwithin90days.
SectionV.ResidentInformation:
1.CompleteandattachCMS671,(FacilityStaffing)
2.NumberofResidentsbyage:
<
30
30-64
65-74
75-84
85-94
>
95
3.Numberofpatientsineachcategory:
PrivatePay
Medicaid
Medicare
Other
4.Percentageofresidentsreceivingservicesrelatedto:
Alcoholandordrugabuse
Mentalretardation
5.PercentageofresidentswhosePRIMARYdiagnosisisrelatedto:
PsychiatricCare
Alzheimer’s
Dementia
6.Percentageofresidentswhoseaveragelengthofstayis:
9-60days
61-180days
Over180days
7.WhatarethegrossannualreceiptsofthefacilityincludingMedicaidand
Medicare?
8.Restraints--Numberofresidentsonrestraintsand/orrestraintandenabler
combined:
Type
#ofResidents
Bedrail/siderail
GeriChair
MerryWalkers
Other(Define)
Chemical
Vest
LapBuddy
SpecialtyBed
WaistBelt
Numberofresidentsonmorethanonerestraint
Totalnumberofresidentsonrestraints
Numberofresidentswithenablersonly
9.Howoftenisthenursingstafftrainedontheuseandmonitoringofrestraints?
10.Doyouhaveawanderguard,codealertorsimilarsecuritysystem?
Describe.
11.Doyouusetheservicesofwoundcarespecialists(fulltimeorcontract)?
12.Aregaitbeltsused?
YesNo
13.Aremechanicalliftsused?
14.Arechairalarmsused?
15.Numberofresidentfallsrelatedtolifting,movingandtransportinginthelast12months?
16.CompleteandattachCMS672,(ResidentCensusandConditionofResidents)
17.DescriptionofServices—Facilityclassificationandbedcensus
Category
Total#oflicensedbeds
Total#ofunlicensedbeds
Averagelicensedoccupancy
Averageunlicensedoccupancy
SkilledCareServices—Professionalnursingcare,24hoursbylicensednurses.Residentsrequireoneormoreofthefollowingkindsofcare:
physicaltherapy,routineintravenous/intramuscularmedications,routinewoundcare,enteraltubefeeding,routineoxygenandinhalationtherapies,urinarycatheterinsertionandsterileirrigation,and/orroutinetracheotomycare.Residentsareisolatedforinfectiousdiseaseprecautions.(80908or80929)
IntermediateCareServices—Nursingcareduringdayshift,7daysaweek.Nocomplexnursingcare.Residentsrequireadministrationoforalmedicationsandsomeintramuscularandsubcutaneousinjects.Residentsrequireassistancewithturning/positioning.Residentshavedependencieswithactivitiesofdailyliving.Residentsareprovidedmaintenancerehabilitativeservicesbynurses.(80920or80914)
Residential/AssistedLivingServices--Residentsareambulatorywithpossibleminordisorders,providedprotectedenvironments(mealsandplannedprograms.Residentsareeligibleforincidentalhealthcareservicesincludingassistancewithmedications.Designedforindividualsneedinghelpwithactivitiesofdailyliving,butnotskilledmedicalcare.(80920)or(80932)
PersonalCare—Security,nutritionalmeals,transportation,recreation,selfadministrationorassistancewithmedications,guidancewithactivitiesofdailyliving(ADL’s—bathing,dressing,eatingwalking)
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