Fillable CMS671 Long-Term Care Facility Application for Medicare and Medicaid

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CMS671 Long-Term Care Facility Application for Medicare and Medicaid

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1 Form CMS-671 (06/2018)
Standard Survey: Extended Survey:
From: F1 (mm/dd/yyyy) To: F2 (mm/dd/yyyy) From: F3 (mm/dd/yyyy) To: F4 (mm/dd/yyyy)
Name of Facility Provider Number Fiscal Year Ending: F5 (mm/dd/yyyy)
Street Address
City County State Zip Code
Telephone Number: F6 State/County Code: F7 State/Region Code: F8
F9
01 Skilled Nursing Facility (SNF) - Medicare Participation
02 Nursing Facility (NF) - Medicaid Participation
03 SNF/NF - Medicare/Medicaid
Is this facility hospital based? F10
........................
Yes
No
If yes, indicate Hospital Provider Number: F11
Ownership: F12
For-Profit Non-Profit Government
01 Individual
02 Partnership
03 Corporation
13 Limited Liability Corporation
04 Church Related
05 Nonprofit Corporation
06 Other Nonprofit
07 State
08 County
09 City
10 City/County
11 Hospital District
12 Federal
Owned or leased by Multi-Facility Organization: F13
............................................................................................................................
Yes
No
Name of Multi-Facility Organization: F14
Dedicated Special Care Units: (show number of beds for all that apply)
F15 AIDS
F16 Alzheimer’s Disease F17 Dialysis
F18 Disabled Children/Young Adults F19 Head Trauma F20 Hospice
F21 Huntington’s Disease F22 Ventilator/Respiratory Care F23 Other Specialized Rehabilitation
Does the facility currently have an organized residents’ group? F24 ....................................................................................................
Yes
No
Does the facility currently have an organized group of family members of residents?
......................................................................
Yes
No
Does the facility conduct experimental research? F26
...........................................................................................................................
Yes
No
Is the facility part of a continuing care retirement community (CCRC)? F27
........................................................................................
Yes
No
If the facility currently has a staffing waiver, indicate the type(s) of waiver(s) by writing in the date(s) of last approval. Indicate the number of
hours waived for each type of waiver granted. If the facility does not have a waiver, write NA in the blanks.
Waiver of seven day RN requirement: Waiver of 24 hr licensed nursing requirement:
Date: F28 (mm/dd/yyyy)
Hours waived per week: F29 Date: F30 (mm/dd/yyyy) Hours waived per week: F31
Does the facility currently have an approved Nurse Aide Training and Competency Evaluation Program? F32
...............................
Yes
No
Name of Person Completing Form Time
Signature Date
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
LONG-TERM CARE FACILITY APPLICATION FOR MEDICARE AND MEDICAID
OMB Exempt
click to sign
signature
click to edit
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
1
GENERAL 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 business and mailing purposes. This includes
components or units of a larger institution.
Provider Number: Leave blank on initial certifications.
On all recertifications, insert the facility’s assigned six-
digit provider code.
Street Address: Street name and number refers to
physical location, not mailing address, if two addresses
differ.
City: Rural addresses should include the city of the
nearest post office.
County: County refers to parish name in Louisiana and
township name where appropriate in the New England
States.
State: For U.S. possessions and trust territories, name is
included in lieu of the State.
Zip Code: Zip Code refers to the “Zip-plus-four” code, if
available, otherwise the standard Zip Code.
Telephone Number: Include the area code.
State/County Code: LEAVE BLANK. State Survey Office
will complete.
State/Region Code: LEAVE BLANK. State Survey Office
will complete.
Block F9: Enter either 01 (SNF), 02 (NF), or 03 (SNF/NF).
Block F10: If the facility is under administrative control
of a hospital, check “yes,” otherwise check “no.”
Block F11: The hospital provider number is the
hospital’s assigned six-digit Medicare provider number.
Block F12: Identify the type of organization that
controls and operates the facility. Enter the code as
identified for that organization (e.g., for a for profit
facility owned by an individual, enter 01 in the F12
block; a facility owned by a city government would be
entered as 09 in the F12 block).
Definitions to determine ownership are:
For-Profit: If operated under commercial ownership,
indicate whether owned by individual, partnership,
corporation, or limited liability corporation (LLC).
Non-Profit: If operated under voluntary or other
nonprofit auspices, indicate whether church related,
nonprofit corporation or other nonprofit.
Government: If operated by a governmental entity,
indicate whether State, City, Hospital District, County,
City/County, or Federal Government.
Block F13: Check “yes” if the facility is owned or leased
by a multi-facility organization, otherwise check “no.”
A Multi-Facility Organization is an organization
that owns two or more long term care facilities. The
owner may be an individual or a corporation. Leasing
of facilities by corporate chains is included in this
definition.
Block F14: If applicable, enter the name of the multi-
facility organization. Use the name of the corporate
ownership of the multi-facility organization (e.g., if
the name of the facility is Soft Breezes Home and the
name of the multi-facility organization that owns Soft
Breezes is XYZ Enterprises, enter XYZ Enterprises).
Block F15 – F23: Enter the number of beds in the
facility’s Dedicated Special Care Units. These are
units with a specific number of beds, identified and
dedicated by the facility for residents with specific
needs/diagnoses. They need not be certified or
recognized by regulatory authorities. For example,
a SNF admits a large number of residents with head
injuries. They have set aside 8 beds on the north wing,
staffed with specifically trained personnel. Show “8”
in F19.
Block F24: Check “yes” if the facility currently has an
organized residents’ group, 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 sup- port each other;
to plan resident and family activities; to participate
in educational activities or for any other purposes;
otherwise check “no.”
Form CMS-671 INSTRUCTIONS (06/2018)
OMB Exempt
2
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.”
Block F26: Check “yes” if the facility conducts
experimental research; otherwise check “no.”
Experimental research means using residents to develop
and test clinical treatments, such as a new drug or
therapy, that involves treatment and control groups.
For example, a clinical trial of a new drug would be
experimental research.
Block F27: Check “yes” if the facility is part of a
continuing care retirement community (CCRC);
otherwise check “no.” A CCRC is any facility which
operates under State regulation as a continuing care
retirement community.
Blocks F28 – F31: If the facility has been granted a
nurse staffing waiver by CMS or the State Agency in
accordance with the provisions at 42CFR 483.35(e) or
(f), enter the last approval date of the waiver(s) and
report the number of hours being waived for each type
of waiver approval.
Block F32: Check “yes” if the facility has a State
approved Nurse Aide Training and Competency
Evaluation Program; otherwise check “no.”
Form CMS-671 INSTRUCTIONS (06/2018)
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Completed 18 September 2019

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