Certified nursing facilities must complete the Long Term Care Facility Application for Medicare and Medicaid (CMS-671) at every annual resurvey. At the time of the annual resurvey, the survey team leader provides the administrator with the application and instructions for its completion. The application and instructions are also accessible at http://www.cms.hhs.gov/cmsforms/downloads/CMS671.pdf.
To avoid common errors when completing the application:
- Fill out the form completely and answer every question. Print all numbers and other information legibly.
- Facility staffing hours should only be reported for care provided in certified beds. If a facility is distinct part (not fully certified), then staffing hours for the non-certified beds should not be reported.
- Ensure all three boxes in each staffing category are completed under Column A, Services Provided. Enter a Y for Yes, or N for No.
- Do not enter any information in the gray boxes.
- If there are no staffing hours to report under Columns B, C and D leave the box blank – do not enter zeros in every blank box.
- Enter all hours in whole numbers. Do not use decimals or fractions.
- Staffing hours provided by hospice staff or private duty staff (not hired and paid for by the facility) should NOT be included.
- Report actual hours worked (reference timesheets, electronic time records or calendar notes).
- Salaried employees should report the actual hours they work.
- The form must be signed.
It is very important to report data accurately on the application. The Centers for Medicare & Medicaid Services (CMS) uses this data for calculation of staffing hours on Nursing Home Compare and the star ratings. This information is available on line, http://www.medicare.gov/nursinghomecompare/search.html.
This coming year, CMS will require Missouri to conduct Minimum Data Set (MDS) Focused Surveys that will be sampled to verify the staffing data self-reported by a nursing home during the most recent recertification survey.
If you have any questions regarding completing the Long Term Care Facility Application for Medicare and Medicaid (CMS-671), please speak to the survey team leader during the survey, or contact Tracy Niekamp in the Licensure and Certification Unit at tracy.niekamp@health.mo.gov or 573-526-8522.