CMS-10240 nhvbp-paperburden

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Overview

Sections A and B
Section C
Section D
Section E

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Sheet 1: Sections A and B

Nursing Home Value-Based Purchasing (NHVBP):

Data Collection Form

Reporting Period:

January 1 - March 31

April 1 - June 30

July 1 - September 30

October 1 - December 31

Date Submitted:

M

M

D

D

Y

Y

Using the Instructions provided, complete Sections A - E.

Section A: General Information

Name of Facility

Medicare Provider number

Street Address

City

State

Zip Code

Telephone number

Section B: Resident Census

Primary Payor

Total resident days

Line 1

Medicare

Line 2

Medicaid Dual Eligible

Line 3

Medicaid Only (Not Medicare eligible)

Line 4

Other

Line 5

Total (Sum of Lines 1-4)

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Sheet 2: Section C

Section C: Nursing Temporary Agency Staff

Record the number of hours worked in this reporting period

Staff Type

Hours worked

Line 1

Director of Nursing

Line 2

RN

Line 3

LPN/LVN

Line 4

Nurse aides (including Certified Nurse Aides, nurse aides in training, medication aides/technicians)

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Sheet 3: Section D

Section D: Staff Influenza Immunizations

Report the following information:

1

How many staff were employed at your facility as of February 1, 2007? (Include all full-time, part-time and per diem staff)

1 Number of Staff Employed

2

Of the staff employed in your facility on February 1, 2007, how many were immunized against influenza for the 2006-2007 influenza season, regardless of where the vaccine was received? (Note: 2a + 2b + 2c should equal Total Number of Staff employed in 1 above).

2a Number of staff immunized

2b Number of staff not eligible for immunization due to contraindications

2c Number of staff not immunized

2d If insufficient supply of vaccine available, check here

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Sheet 4: Section E

Section E: Use of Resident Care Experience Surveys

1

Does your facility conduct any resident care experience survey?

If your answer to question 1 is yes, please answer questions 2-4.

2

Is the survey conducted in-house or by an external vendor?

3

What percentage of total residents were included in the survey sample?

4

Who has access to the survey results?

Residents

Check all that apply.

Facility management

All facility staff

Families

Facility owners/operators

Medical Director

Physicians/nurse practictioners/physician assistants

Pharmacy/pharmacy consultant

Consultants - please specify

Other - please specify

5

How is the survey information used? (Check all that apply)

Informing quality improvement activities

As a measure of quality of care

Identifying strengths and weaknesses

Peer group comparison (I.e.,benchmarking)

To identify service-related issues

Linked to financial incentives (e.g., bonuses)

Marketing purposes

Accreditation purposes

Other (please specify)