This application must be completed for each facility andWord文档格式.docx

资源描述

This application must be completed for each facility andWord文档格式.docx

《This application must be completed for each facility andWord文档格式.docx》由会员分享，可在线阅读，更多相关《This application must be completed for each facility andWord文档格式.docx（21页珍藏版）》请在冰豆网上搜索。

This application must be completed for each facility andWord文档格式.docx

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

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:

30-64

65-74

75-84

85-94

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