Data Collection for the Nursing Home Value-Based Purchasing (NHVBP) Demonstration: ONGOING DATA(CMS-10240)

DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES

NURSING HOME VALUE BASED PURCHASING DEMONSTRATION
DATA COLLECTION FORM
SECTION A: GENERAL INFORMATION

Name of Facility:

Medicare Provider ID

Name, phone number, and email address of current person to be contacted in matters involving the demonstration:

Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-1039. The time required to complete this information collection is
estimated to average 12 minutes, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time estimates or suggestions for improving the form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

NURSING HOME VALUE-BASED PURCHASING DEMONSTRATION
SECTION B: RESIDENT CENSUS
This section collects information on total resident days, for the period 10/1/09 through
12/31/09. This information should be based on the daily resident census information for this
period.

Category
B1

Total Medicare days

B2

Total Medicaid days

B3

Total other days

B4

Total resident days

Number of Days

0

Instructions:
B1 : Total Medicare Days: Enter t h e t o t al num ber of r es ident days from 10/1/09 12/3 1 /0 9 fo r wh i ch M e di c are w a s t h e p ri m ary p a yo r.

B2 : Total Medicaid days: T otal nu m ber of r esident days from 10/1/09 - 12/31/09 for
wh ich Medic a id w a s th e p ri m ary p a yor.

B3 : Total other days: T o t al nu mbe r o f re s ide nt da ys f ro m 10/1/09 - 12/31/09 for which
nei th e r M edi care nor M e di c a id w a s th e p ri mar y payo r.
B4 : Total resident days: Total resident days from 10/1/09 - 12/31/09. This will equal
t he sum of rows B1-B3.

Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a
collection of information unless it displays a valid OMB control number. The valid OMB control number for this
information collection is 0938-1039. The time required to complete this information collection is estimated to average 1
hour, including the time to review instructions, search existing data sources, gather the data needed, and complete and
review the information collection. If you have any comments concerning the accuracy of the time estimates or
suggestions for improving the form, please write to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer,
Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

NURSING HOME VALUE-BASED PURCHASING DEMONSTRATION
SE CTION C: PAYROL L DA T A
One data record (row of data) should be submitted for each nursing employee who worked at your
nursing home in the previous quarter. The following information should be included in columns in
each data record: the nursing home’s provider number, a unique identifier for the employee (e.g.,
their employee number), the employees’ job category and starting date, the employee’s termination
date (if applicable), the pay period start and end dates, the number of hours worked in the payroll
period and the number of non-productive hours during the payroll period. Each of these data
elements is described in greater detail below.

Note that if the payroll period that includes October 1, 2009 began prior to October 1, then this
payroll period should have already been reported in your last submission so it does not need to be
reported again. But if the payroll period that includes December 31, 2009 ends after December 31,
then data from the entire payroll period should be reported with this submission.
The following fields are included in the payroll reporting form:

Medicare provider number
This is the facility’s assigned six-digit provider code. The first two digits identify the state and the
3rd-6th digits uniquely identify the facility.

Employee number or other unique identifier
A unique employee identifier must be submitted with each payroll record. The unique employee
identification should not contain identifying information such as name or social security number.
The same employee identifier should be used throughout the employee’s tenure with the nursing
home. If the employee leaves the nursing home and returns to its employ at a later point in time the
facility may choose to retain the original employee ID or assign a new employee ID. A new employee
ID should not be assigned when an employee is promoted within a nursing home facility.

Employee Start Date
The Employee Start Date is the date the employee began their employment at the nursing home.
For employees with multiple periods of employment with the nursing home, the most recent start
date should be reported.

Employee Termination Date
The Employee Termination Date is the date of the employee's last day of employment. A
termination date should be reported for both voluntary and involuntary departures. For employees
who were not terminated during the reporting period, leave this field blank. Do not report
instances of temporary leave of absences such as maternity leave or other absences covered under
the Family and Medical Leave Act.
Employee job category
Nursing homes are required to classify staff into one of the four job categories as defined below.
Staff should be classified into one of the four job categories based on the job title on the first day of
the pay period being reported. IF YOUR ORGANIZATION USES DIFFERENT TITLES THAN THE
FOUR LISTED BELOW, PLEASE RE-CATEGORIZE INTO ONE OF THE FOUR TITLES. ONLY JOB
TITLES THAT CAN BE CLASSIFIED INTO ONE OF THESE FOUR CATEGORIES CAN BE USED IN
THE STAFFING CALCULATIONS.

•

Director of Nursing (DON) – Professional registered nurse(s) administratively responsible
for managing and supervising nursing services within the facility. This category includes RN
assistant directors of nursing (ADONs).
• Registered Nurse (RN) – Those persons licensed to practice as registered nurses in the
State where the facility is located.
• Licensed Practical/Vocational Nurse (LPN)– Those persons licensed to practice as
licensed practical/vocational nurses in the State where the facility is located.
• Certified Nurse Aide (CNA) – Individuals who have completed a State approved training
and competency evaluation program, or competency evaluation program approved by the
State, or have been determined competent as provided in 483.150(a) and (3) and who are
providing nursing or nursing-related services to residents. This category includes State
certified Medication Aides and Restorative Aides. CNAs in training should not be included.
If an individual works in two positions (e.g., CNA and housekeeping) all hours for this
employee should be reported as CNA hours.
Use the following coding for the employee job categories (do not place periods within these codes):
DON= Director of Nursing (Please list at least one staff member as a DON)
RN= Registered Nurse
LPN=Licensed/vocational nurse
CNA= Certified nurse aide

Note that nursing homes should not submit payroll-based staffing information for non-nursing staff.
Pay Period Start Date
The Pay Period Start Date is the first day of the pay period being reported. The date should not
overlap with prior pay periods.

Pay Period End Date
The Pay Period End Date is the last day of the pay period being reported. The date should not
overlap with subsequent payroll periods. The number of days between the pay period start and end
dates will be equal to either 7, 14, bi-monthly, or monthly pay period.

Number of hours worked
The number of hours worked includes the total number of hours worked during the pay period.
This number cannot include hours for vacation leave, sick leave, corrections to reconcile errors
from previous pay periods, etc. This number does reflect hours worked in both direct and nondirect patient care. If an employee covers a shift at a facility within a nursing home corporation, the
hours worked should be assigned to the respective facility and not allocated to a “home” or
“primary” facility. If no productive hours were worked during a pay period the data element should
be submitted with zero hours. Fractional hours should be reported at the level of precision with
which they are recorded in your payroll system.

Nonproductive Hours
Nonproductive hours include the total number of hours paid during the pay period for leave (sick,
vacation, holidays, disability, administrative), bonuses, employee payouts, etc. If no nonproductive
hours were paid during the pay period the data element should be submitted with zero hours.
Fractional hours should be reported at the level of precision with which they are recorded in your
payroll system.
Note that agency staff should not be in the data submission. These should be reported in
Section D of the NHVBP Data Collection Form.

NURSING HOME VALUE-BASED PURCHASING DEMONSTRATION
SECTION C: PAYROLL DATA
One data record (row of data) should be submitted for each nursing employee who worked at your nursing home in the previous quarter. The following information should
be included in columns in each data record: the nursing home’s provider number and facility name, a unique identifier for the employee (e.g., their employee number), the
employees’ job category and starting date, the pay period start and end dates, the number of hours worked in the payroll period and the number of non-productive hours
during the payroll period. Each of these data elements is described in greater detail below.
Note that if the payroll period that includes October 1, 2009 began prior to October 1, then data for this payroll period should have been reported in your previous
submission. However, if the payroll period that includes December 31, 2009 ends after December 31, then data from the entire payroll period should be reported in this
submission.
Nursing homes SHOULD NOT submit payroll-based staffing information for non-nursing staff.

Medicare
Provider ID

Employee ID

Employee
starting date

Employee
Employee job
Termination Date category*

Payroll period
start date

Payroll period
end date

Productive
hours

Non-productive
hours

You should use this spreadsheet for submitting payroll data electronically, but note that each facility should report one row
(record) for each employee per payroll period. Thus, you will need to add additional rows to this spreadsheet.

* For the employee job category column, please use one of the following codes ONLY : DON, RN, LPN, or CNA.
Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond to a collection of information unless it displays a
valid OMB control number. The valid OMB control number for this information collection is 0938-1039. The time required to complete this information collection is
estimated to average 5.67 hours, including the time to review instructions, search existing data sources, gather the data needed, and complete and review the
information collection. If you have any comments concerning the accuracy of the time estimates or suggestions for improving the form, please write to: CMS, 7500
Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore, Maryland 21244-1850.

NURSING HOME VALUE-BASED PURCHASING DEMONSTRATION
SECTION D: NURSING TEMPORARY AGENCY STAFF

Record the total number of nursing temporary agency staff hours worked during the period 10/1/09 12/31/09 by staff type.

Staff Type

Total number of nursing temporary
agency staff hours: 10/1/09 12/31/09

D1 Director of Nursing

D2 RN

D3 LPN/LVN

D4 Certified nurse aide (CNA)

Instructions:
Record the total number of nursing temporary agency staff hours worked during the period
10/1/09 - 12/31/09, by staff type. Nursing temporary agency staff include individuals who
work at the facility but who are not paid through the facility’s payroll system. Hours worked by
these individuals should not be recorded in Section C. Temporary agency staff employees
should be classified into one of four job categories described below:
•

•
•
•

Director of Nursing (DON) – Professional registered nurse(s) administratively
responsible for managing and supervising nursing services within the facility. This
category includes RN assistant directors of nursing (ADONs).

Registered Nurse (RN) – Those persons licensed to practice as registered nurses in the
State where the facility is located.
Licensed Practical/Vocational Nurse (LPN)– Those persons licensed to practice as
licensed practical/vocational nurses in the State where the facility is located.

Certified Nurse Aide (CNA) – Individuals who have completed a State approved
training and competency evaluation program, or competency evaluation program
approved by the State, or have been determined competent as provided in 483.150(a)
and (3) and who are providing nursing or nursing-related services to residents. This
category includes State certified Medication Aides and Restorative Aides. CNAs in
training should not be included. If an individual works in two positions (e.g., CNA and
housekeeping) all hours for this employee should be reported as CNA hours.

Fractional hours should be reported at the level of precision at which they are recorded in the
invoices that you receive from staffing agencies. If an invoice overlaps the beginning or end
dates, then apportion the invoice hours by the number of days the invoice is in the quarter
being reported.

Disclosure Statement According to the Paperwork Reduction Act of 1995, no persons are required to respond
to a collection of information unless it displays a valid OMB control number. The valid OMB control number for
this information collection is 0938-1039. The time required to complete this information collection is estimated to
average 24 minutes for nursing homes that use agency staff, including the time to review instructions, search
existing data sources, gather the data needed, and complete and review the information collection. If you have
any comments concerning the accuracy of the time estimates or suggestions for improving the form, please write
to: CMS, 7500 Security Boulevard, Attn: PRA Reports Clearance Officer, Mail Stop C4-26-05, Baltimore,
Maryland 21244-1850.