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 FacilityProvider NumberFiscal Year Ending: F5 (mm/dd/yyyy)Street AddressCityCountyStateZip CodeTelephone Number: F6State/County Code: F7State/Region Code: F8F9 01 Skilled Nursing Facility (SNF) - Medicare Participation02 Nursing Facility (NF) - Medicaid Participation03 SNF/NF - Medicare/MedicaidIs this facility hospital based? F10 ........................ Yes No If yes, indicate Hospital Provider Number: F11 Ownership: F12 For-Pro037tNon-Pro037tGovernment01 Individual02 Partnership03 Corporation04 Church Related05 Nonpro037t Corporation06 Other Nonpro037t07 State08 County 09 City10 City/County11 Hospital District12 FederalOwned or leased by Multi-Facility Organization: F13 ............................................................................................................................ Yes NoName of Multi-Facility Organization: F14Dedicated Special Care Units: (show number of beds for all that apply)F15 AIDS F16 Alzheimer222s Disease F17 Dialysis F18 Disabled Children/Young Adults F19 Head Trauma F20 Hospice F21 Huntington222s Disease F22 Ventilator/Respiratory Care F23 Other Specialized Rehabilitation Does the facility currently have an organized residents222 group? F24 .................................................................................................... Yes NoDoes the facility currently have an organized group of family members of residents? ...................................................................... Yes NoDoes the facility conduct experimental research? F26 ........................................................................................................................... Yes NoIs the facility part of a continuing care retirement community (CCRC)? F27 ........................................................................................ Yes NoIf the facility currently has a staf037ng 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: F31Does the facility currently have an approved Nurse Aide Training and Competency Evaluation Program? F32 ............................... Yes NoName of Person Completing FormTimeSignatureDateDEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES LONG-TERM CARE FACILITY APPLICATION FOR MEDICARE AND MEDICAIDOMB Exempt American LegalNet, Inc. www.FormsWorkFlow.com 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 223the facility224 equals certi037ed beds (i.e., Medicare and/or Medicaid certi037ed beds).Standard Survey: LEAVE BLANK 226 Survey team will complete. Extended Survey: LEAVE BLANK 226 Survey team will complete.INSTRUCTIONS AND DEFINITIONSName of Facility: Use the of037cial name of the facility for business and mailing purposes. This includes components or units of a larger institution.Provider Number: Leave blank on initial certi037cations. On all recerti037cations, insert the facility222s 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 of037ce.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 223Zip-plus-four224 code, if available, otherwise the standard Zip Code.Telephone Number: Include the area code.State/County Code: LEAVE BLANK. State Survey Of037ce will complete.State/Region Code: LEAVE BLANK. State Survey Of037ce 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 223yes,224 otherwise check 223no.224Block F11: The hospital provider number is the hospital222s assigned six-digit Medicare provider number.Block F12: Identify the type of organization that controls and operates the facility. Enter the code as identi037ed for that organization (e.g., for a for pro037t 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). De037nitions to determine ownership are:For-Pro037t: If operated under private commercial ownership, indicate whether owned by individual, partnership, or corporation.Non-Pro037t: If operated under voluntary or other nonpro037t auspices, indicate whether church related, nonpro037t corporation or other nonpro037t.Government: If operated by a governmental entity, indicate whether State, City, Hospital District, County, City/County, or Federal Government.Block F13: Check 223yes224 if the facility is owned or leased by a multi-facility organization, otherwise check 223no.224 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 de037nition.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 226 F23: Enter the number of beds in the facility222s Dedicated Special Care Units. These are units with a speci037c number of beds, identi037ed and dedicated by the facility for residents with speci037c needs/diagnoses. They need not be certi037ed 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 speci037cally trained personnel. Show 2238224 in F19.Block F24: Check 223yes224 if the facility currently has an organized residents222 group, i.e., a group(s) that meets regularly to discuss and offer suggestions about facility policies and procedures affecting residents222 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 223no.224Form CMS-671 INSTRUCTIONS (06/2018)OMB Exempt American LegalNet, Inc. www.FormsWorkFlow.com 2 Block F25: Check 223yes224 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 residents222 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 223no.224Block F26: Check 223yes224 if the facility conducts experimental research; otherwise check 223no.224 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 223yes224 if the facility is part of a continuing care retirement community (CCRC); otherwise check 223no.224 A CCRC is any facility which operates under State regulation as a continuing care retirement community.Blocks F28 226 F31: If the facility has been granted a nurse staf037ng 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 numb