Form Snh F1 PDF Details

In the realm of skilled nursing facilities, detailed and precise reporting plays a pivotal role in sustaining transparency and ensuring compliance with regulatory standards. The SNH F1 form, a document meticulously designed and revised as of May 26, 2010, serves this exact purpose. Crafted by the State Health Planning and Development Agency, it is an annual report mandating submission by skilled nursing facilities to provide a comprehensive overview of their operations, a task to be completed by August 15, 2010, for the reporting period of July 1, 2009, through June 30, 2010. This form delves into various facets of facility operation, including ownership type, whether corporation, non-profit, individual, or government, to name a few, and operational details such as the capacity of beds licensed and utilized, demographic data of admissions, and financial metrics including expenses and revenues. Critical segments of this form address admissions by source of payment, demographic breakdowns of residents, discharge figures, resident day statistics, hospice service data, and a financial snapshot detailing expenses versus income. Such thorough reporting underlines the facility’s commitment to transparency and the provision of high-quality care, while also fulfilling regulatory requirements aimed at scrutinizing and improving healthcare services for vulnerable populations in skilled nursing settings.

QuestionAnswer
Form NameForm Snh F1
Form Length5 pages
Fillable?No
Fillable fields0
Avg. time to fill out1 min 15 sec
Other namesPREPARER, VIII, I-a, 2009

Form Preview Example

FORM SNH-F1

THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010

Revised 05/26/2010

 

 

STATE HEALTH PLANNING AND DEVELOPMENT AGENCY

MAILING ADDRESS (U.S. Postal Service)

STREET ADDRESS (Commercial Carrier)

PO BOX 303025

 

100 NORTH UNION STREET STE 870

MONTGOMERY AL 36130-3025

MONTGOMERY AL 36104

TELEPHONE:

(334) 242-4109

FAX: (334) 242-4113

www.shpda.alabama.gov

paul.may@shpda.alabama.gov

2010 ANNUAL REPORT FOR SKILLED NURSING FACILITIES

Mailing Address:

STREET ADDRESSCITYSTATEZIP

Physical Address:

 

 

 

 

 

 

 

 

 

AL

 

 

STREET ADDRESS

 

 

CITY

 

 

 

 

 

 

ZIP

County of Location:

 

 

 

 

 

 

 

 

 

 

 

 

 

Facility Telephone:

 

 

 

 

Facility Fax:

 

 

 

 

 

 

 

 

 

(AREA CODE) & TELEPHONE NUMBER

 

 

 

(AREA CODE) & TELEPHONE NUMBER

This reporting period is for July 1, 2009, through June 30, 2010*; or for partial year of operation beginning

 

 

and ending

 

 

a period of

 

 

 

 

 

 

days.

MONTH DAY

 

 

MONTH DAY

 

 

 

 

 

 

 

 

 

 

*Data for the agency’s fiscal year, other than the time frame specified, may be provided, but no more than 12 months of consecutive data should be reported. If there was a change in ownership during the reporting period, data for the full year should be reported by the current owner.

We hereby affirm and attest that the reported information has been verified, and to the best of our knowledge, the information contained in the following pages of this report is a true and accurate representation of the services, equipment, and utilization of this facility.

PRINTED NAME OF PREPARER

 

SIGNATURE OF PREPARER

 

DATE

 

 

 

 

 

DIRECT TELEPHONE NUMBER

 

TITLE OF PREPARER

 

E-MAIL ADDRESS

A member of administration MUST also sign below verifying the accuracy of the information contained herein, as reported by the preparer listed above.

 

PRINTED NAME OF ADMINISTRATION OFFICIAL

 

SIGNATURE OF ADMINISTRATION OFFICIAL

 

 

DATE

 

 

 

 

 

 

 

 

DIRECT TELEPHONE NUMBER

 

TITLE OF ADMINISTRATION OFFICIAL

 

E-MAIL ADDRESS

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

FOR OFFICE USE ONLY

 

 

 

 

 

 

 

Facility Verified:

 

 

 

Initial Scan:

 

 

Completed:

 

 

 

 

 

Entered:

 

Final Scan:

Audited:

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

 

Page 1

FORM SNH-F1

THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010

Revised 05/26/2010

 

 

 

OWNERSHIP (check one)

 

Corporation

Non-Profit Organization

Partnership

Individual

Healthcare Authority

LLC

Joint Venture

Government

Other (specify)

Does this facility operate under a management contract? ______ Yes

______

No

 

Management Firm:

_____________________________________________________________________________

 

Name

 

 

 

 

_____________________________________________________________________________

 

Base Address

City

State

Zip

I.FACILITIES

Skilled Nursing Home

Skilled Nursing Unit of Hospital

a.TOTAL beds licensed by the Alabama Department of Public Health

b.Number of staffed and operational beds on last day of reporting period

c.Number of beds certified for Medicare patients (NOTE: Medicaid patients ARE

ALLOWED to reside in Medicare beds)

d.Number of beds certified for Medicaid patients (NOTE: Medicare patients ARE

NOT ALLOWED to reside in Medicaid beds)

e.Was this facility licensed for the number of beds indicated in item I-a for the entire reporting period?

f.If “No” was answered in item (e), indicate the number of licensed beds and the number of days those beds were licensed.

g.Additional licensed beds and the number of days those beds were licensed

II. ADMISSIONS

TOTAL ADMISSIONS FOR THE REPORTING PERIOD

ADMISSIONS BY SOURCE OF PAYMENT:

Private Pay

Workman’s Compensation

Medicare

Medicaid

Tricare

Blue Cross (not Long Term Care Insurance)

Other Insurance Companies (not Long Term Care Insurance)

No Charge (charity & other)

Hospice

Long Term Care Insurance

Other (specify)

YES NO

BEDS DAYS

BEDS DAYS

Page 2

FORM SNH-F1

THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010

Revised 05/26/2010

 

III.DEMOGRAPHICS

A.TOTAL ADMISSIONS BY RACE FOR THE ENTIRE REPORTING PERIOD

(Total must agree with The totals provided in Section II and Section III-B.)

a.White/Caucasian

b.Black/African American/Negro

c.Hispanic/Spanish/Latino

d.Asian

e.American Indian/Alaskan Native

f.Pacific Islander

g.India

h.Middle Eastern

i. Other (specify)

B.TOTAL ADMISSIONS BY AGE AND GENDER FOR THE ENTIRE REPORTING PERIOD

(Total must agree with the totals provided in Section II and Section III-A.)

AGE GROUPS

MALE

FEMALE

TOTALS

18 & under

19 – 34 Years

35 – 54 Years

55 – 64 Years

65 – 74 Years

75 – 84 Years

85 Years and Older

TOTALS

(Please verify the information provided balances in each row and column)

IV. DISCHARGES

Total discharges (including deaths)

Discharges due to death

Page 3

FORM SNH-F1

THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010

Revised 05/26/2010

 

V.RESIDENT DAYS

(This information is to be provided for the number of individuals in residence during the reporting period.)

OCCUPIED

BED

TOTAL

RESIDENT

HOLDING

RESIDENT

DAYS

DAYS

DAYS

Private Pay

Workman’s Compensation

Medicare

Medicaid

Tricare

Blue Cross (not long term care insurance)

Other Insurance Companies (not long term care

No Charge (charity & other)

Hospice

Long Term Care Insurance

Other (specify) ___________________________

TOTALS

VI. HOSPICE

1.Total hospice service days (regardless of payer source):

2.Number of hospice discharges:

a.Deaths

b.Home

c.Hospital

3.Number of provider contracts:

4. Dedicated hospice unit?

YES NO

5. (If Yes) Number of beds in dedicated hospice unit:

Page 4

FORM SNH-F1

THIS REPORT IS DUE ON OR BEFORE AUGUST 15, 2010

Revised 05/26/2010

 

VII. EXPENSES & REVENUES (AMOUNTS DO NOT HAVE TO BE AUDITED)

Payroll Expenses

$

.00

Non-Payroll Expenses

$

.00

TOTAL EXPENSES

 

$

.00

Medicare

$

.00

Medicaid

$

.00

Long Term Care Insurance

$

.00

Hospice

$

.00

Private Pay

$

.00

Other Insurance

$

.00

Other

$

.00

TOTAL REVENUES

 

$

.00

VIII. CHARGES (rounded off to whole dollars)

 

 

 

BASIC RESIDENT CHARGE

 

MONTHLY

 

 

DAILY

Private Room

$

.00

 

$

.00

Semi-Private Room

$

.00

 

$

.00

Page 5