Document
CMS-10240 nhvbp-paperburden
ICR 201009-0938-004 · OMB 0938-1039 · Object 20194401.
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Document Metadata
| File Type | application/vnd.ms-excel |
|---|---|
| File Title | CMS-10240 nhvbp-paperburden |
| Author | Administrator |
| Last Modified By | Calc |
| File Modified | 2007-06-29 |
| File Created | 2026-10-06 |
| Conversion State | complete |
Extracted Text
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 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) Page 1 State Zip Code 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) Page 2 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 1 Number of Staff Employed per diem staff) 2a Number of staff immunized 2 2b Number of staff not eligible for Of the staff employed in your facility on February 1, immunization due to contraindications 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 2c Number of staff not immunized above). 2d If insufficient supply of vaccine available, check here Section E: Use of Resident Care Experience Surveys 1 Does your facility conduct any resident care experience survey? Yes No 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? In-house 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 External vendor 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)