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

1、 6. Date Business Started: 7. Corporate Contact:NameAddressPhone #Email addressFEIN8. List all affiliates and subsidiaries to which this insurance will apply. Include a complete description of the operation of each affiliate/subsidiary and its relationship to the named insured. Include address, faci

2、lity contact, phone and email address. Attach a separate sheet of paper, or use Acord supplemental application. Include a separate application for each facility listed:DescriptionNamed Insured:Section II. Facility General Information:1. Facility Name and any dba:2. Address:3. Facility contact:4. Fac

3、ility is （check all that apply）: Profit Hospital Affiliated Accredited by JCAHO Not for Profit Medicare Certified AHCA Corporation Medicaid Certified IHCA Partnership Governmental Licensed by State Individual Charitable Other （define） 5. Is the above named insured the parent company and sole owner o

4、f each location listed above? Yes No If not, provide details.6. Is the facility run under a management contract Yes No7. If yes, name and address and of management company:8. Expiration date of contract:9. Length of time under current management:10. Length of time under current ownership:11. Named i

5、nsured is: Building owner Tenant12. Name and address of building owner if other than the named Insured:13. Officers/General Partners:Name:Title:% of Ownership:15. Are there any other occupants of the premises? Yes No16. If yes, describe and identify. Section III. License and Accreditation:1. Provide

6、 a copy of each license held by your facility.2. Has the facilitys certificate/license ever been revoked or suspended?Yes No3. If yes, please explain.4. Date of last state inspection.Section IV. Staffing and Personnel:1. Staffing: （complete CMS 671）TitleLicense NumberFacility Start DateYears Experie

7、nce# in past 5 yearsAdministratorDir. of NursingMedical DirectorRisk Manager2. Turnover ratio for Nursing staff （calculated by total new hired divided by total on staff） for last 12 months.a. RN:b. LPN/LVN:c. Nurses Aid:3. What is the turnover rate for employed staff?4. Total number of full time emp

8、loyees:5. Total number of part time employees:6. Total number of management employees 7. Is the Medical Director employed full time?8. Is the Medical Director under contract? Yes No9. If yes, provide a copy of the contract.10. Is the Medical Director also an attending physician providing direct pati

9、entcare? Yes No 11. Are any of your employees leased? Yes No 12. If yes, indicate type of employees leased.13. Provide leasing company name, address, phone #, and email address, FEIN.14. Attach a copy of the leasing contract.15. Staff to Resident Ratios:StaffDay Shift RatioEvening Shift RatioNight S

10、hift RatioExample1RN/20 residents1RN/40 residents1 RN/40 residentsNurses （RNs）LPN/LVNNurses AidesOther Staff16. Indicate which methods are used in hiring new employees （medical staff to include physicians, RNs LPNs）MethodMedical StaffAll EmployeesCriminal background checksConduct personal interviewV

11、alidate work historyValidate educationDrug testingReference checks17. Are all nurses aides certified prior to hiring?If no, describe certification process.18. Are there any volunteers or volunteer programs?19. If yes, describe tasks performed. 20. Do you provide monetary incentive for continuing edu

12、cation? Yes No21. Do you conduct formal, ongoing skill assessments and training of all staff providing resident care? Yes No22. If yes, how often is it done?23. How is it documented?24. List and provide a copy of all independent contractor service agreements that directly relate to resident care. Us

13、e separate piece of paper if necessary. 25. Does the insured provide written notice to residents and their representatives of independent contractor agreements?26. Do you require ALL independent contractors （nurses, laboratory, psychiatric, therapy, pharmacy, dental, etc.） to carry liability limits

14、equal to or greater than your own? Yes No27. If no, list which services and why. 28. Are certificates of insurance maintained for the independent contractors? Yes No29. What is the name of the carrier providing your Workers Compensation Insurance? 30. Have you confirmed coverage is in force?31. Tota

15、l monthly payroll: % clerical % nursing32. Provide 5-7 years of loss history currently valued within 90 days.Section V. Resident Information:1. Complete and attach CMS 671, （Facility Staffing）2. Number of Residents by age:953. Number of patients in each category:Private PayMedicaidMedicareOther4. Pe

16、rcentage of residents receiving services related to:Alcohol and or drug abuseMental retardation5. Percentage of residents whose PRIMARY diagnosis is related to:Psychiatric CareAlzheimersDementia6. Percentage of residents whose average length of stay is:9-60 days61-180 daysOver 180 days7. What are th

17、e gross annual receipts of the facility including Medicaid and Medicare?8. Restraints-Number of residents on restraints and/or restraint and enablercombined:Type # of ResidentsBed rail/side railGeri ChairMerry WalkersOther （Define）ChemicalVestLap BuddySpecialty Bed Waist BeltNumber of residents on m

18、ore than one restraintTotal number of residents on restraintsNumber of residents with enablers only9. How often is the nursing staff trained on the use and monitoring of restraints?10. Do you have a wander guard, code alert or similar security system?Describe. 11. Do you use the services of wound ca

19、re specialists （full time or contract）?12. Are gait belts used? Yes No13. Are mechanical lifts used?14. Are chair alarms used?15. Number of resident falls related to lifting, moving and transporting in the last 12 months?16. Complete and attach CMS 672, （Resident Census and Condition of Residents）17

20、. Description of ServicesFacility classification and bed censusCategoryTotal # of licensed bedsTotal # of unlicensed bedsAverage licensed occupancyAverage unlicensed occupancySkilled Care ServicesProfessional nursing care, 24 hours by licensed nurses. Residents require one or more of the following k

21、inds of care: physical therapy, routine intravenous/intramuscular medications, routine wound care, enteral tube feeding, routine oxygen and inhalation therapies, urinary catheter insertion and sterile irrigation, and/or routine tracheotomy care. Residents are isolated for infectious disease precauti

22、ons. （80908 or 80929）Intermediate Care ServicesNursing care during day shift, 7 days a week. No complex nursing care. Residents require administration of oral medications and some intramuscular and subcutaneous injects. Residents require assistance with turning/positioning. Residents have dependenci

23、es with activities of daily living. Residents are provided maintenance rehabilitative services by nurses. （80920 or 80914）Residential/Assisted Living Services- Residents are ambulatory with possible minor disorders, provided protected environments （meals and planned programs. Residents are eligible

24、for incidental healthcare services including assistance with medications. Designed for individuals needing help with activities of daily living, but not skilled medical care. （80920） or （80932）Personal CareSecurity, nutritional meals, transportation, recreation, self administration or assistance with medications, guidance with activities of daily living （ADLsbathing, dressing, eating walking）