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NPI Number Facility Name Phone
Street Address City State Zip
Contact Name Email

Please Enter Actual Number Or 0 If Not Applicable
Part I: CNA Data
1 CNA Employee Salary Cost
2 CNA Employee Benefits Cost
3 CNA Employee Hours Worked
4 CNA Employee Paid Leave Hours
5 CNA Outside Agency Personnel Cost
6 CNA Outside Agency Hours Purchased
7 CNA Corporate Agency and/or Related Personnel Cost
8 CNA Corporate Agency and/or Related Party Hours Purchased

Part II: LPN Data
9 LPN Employee Salary Cost
10 LPN Employee Benefits Cost
11 LPN Employee Hours Worked
12 LPN Employee Paid Leave Hours
13 LPN Outside Agency Personnel Cost
14 LPN Outside Agency Hours Purchased
15 LPN Corporate Agency and/or Related Personnel Cost
16 LPN Corporate Agency and/or Related Party Hours Purchased

Part III: RN Data
17 RN Employee Salary Cost
18 RN Employee Benefits Cost
19 RN Employee Hours Worked
20 RN Employee Paid Leave Hours
21 RN Outside Agency Personnel Cost
22 RN Outside Agency Hours Purchased
23 RN Corporate Agency and/or Related Personnel Cost
24 RN Corporate Agency and/or Related Party Hours Purchased

Part IV: Non-Nursing Data

Reference Schedule A-3 or B-5, Part 1, of the PIRS 1090 Series as a basis for allocations. Do not include therapy costs in the part of costs allocated from the home office.

25 Non-Nursing Employee Salary Cost
26 Non-Nursing Employee Benefits Cost
27 Non-Nursing Employee Hours Worked
28 Non-Nursing Employee Paid Leave Hours
29 Non-Nursing Outside Agency Personnel Cost
30 Non-Nursing Outside Agency Hours Purchased
31 Non-Nursing Corporate Agency and/or Related Personnel Cost
32 Non-Nursing Corporate Agency and/or Related Party Hours Purchased

Part V: Therapist Data

Employee only, not agency personnel.
33 Therapist Employee Salary Cost (IT/RT, OT and Speech)
34 Therapist Employee Benefits Cost (IT/RT, OT and Speech)

Part VI: Total Salary Costs

Sum of lines 1, 9, 17, 25 and 33.
35 Salary Costs of All Nursing Home Employees

Part VII: Benefit Cost Data

Sum of lines 2, 10, 18, 26 and 34.
36 Employee Total Benefit Cost

Part VIII: Liability Insurance Data

If separate premiums for Professional, General and Umbrella coverage are not available, provide total premium only.

Past Year (2017) Insurance Premium Paid
37 Professional Liability Premium
38 General Liability Premium
39 Umbrella Coverage Premium
40 Total Premium (Professional Liability, General Liability and Umbrella Coverage Premiums)
41 Past Year Deductibles Paid

Coming Year (2018) Insurance Premium
42 Total Premium (Professional Liability, General Liability and Umbrella Coverage Premiums)

Part IX: Nursing Staff Turnover/Retention

INSTRUCTIONS FOR REPORTING ADDITIONAL INFORMATION

The nursing staff information requested below should include all nursing staff as defined in section 2 of the cost data instructions excluding agency and corporate nursing staff.
43 Number of Nursing Staff Employed on January 1, 2017 (CNA, LPN, RN)
44 Number of Nursing Staff Employed on December 31, 2017 (CNA, LPN, RN)
45 Number of Nursing Staff Hired During Year (CNA, LPN, RN)
46 Number of Nursing Staff Whose Employment Ended During Year (CNA, LPN, RN)
47 Number of Nursing Staff Employed For All Year (CNA, LPN, RN)

Part X: Total Bed Days
48 Total Bed Days of All Nursing Home Residents

Comments

Certification by Officer or Administrator of Provider

Intentional misrepresentation or falsification of any information contained in this survey response may be punishable by fine and/or imprisonment under Federal and/or State law.

I hereby certify, that I have read the above statement and examined the responses to the accompanying Survey of Nursing Facility Labor Costs for the period beginning January 1, 2017 and ending December 31, 2017. To the best of my knowledge and belief, it is a true, correct, and complete statement prepared from the books and records of:
Name of Facility
Name and Title of the Person Completing Survey


Please remember to print a copy of this form for your records before hitting the 'Submit Data to DMAS' button.