Nursing Home Supplementary Application

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Nov 3, 2013 (4 years and 1 month ago)

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LTC
-
APP (
04 2012
)


Page
1

Nursing Home

Supplementary Application


Submit to:
CRUNCH CASUALTY

/

PIONEER PROGRAMS INSURANCE SOLUTUIONS


201 South Lake Avenue, Suite 802, Pasadena, CA 91101



Applicant’s Name: __________________________________________________________________________


Headquarters Address
: ______________________________________________________________________


City,

State,

Zip

: ______________________________________________________________________________


Name of contact: ____________________________________________
________________________________


Phone Number: _____________________________________________________________________________


Please Include The Following With Your Submission:

1.

This Supplemental Application

( signed by the Insured and Broker)

2.

A completed
Location Addendum for each covered location

(last three pages of our supplemental)

3.

A fully completed ACORD Application

( signed by the Insured and Broker)

4.

C
opy of most recent
State license & State Inspection (Report & Response) for all locations

5.

Most recen
t
(
audited

preferred)

financial statements

6.

Any available promotional brochures

7.

Professional Liability and General Liability Loss Runs (currently valued) for last five years

8.

Admission, Hiring and Skin Protocol Procedures


SCOPE OF SERVICES


1.

List all Named I
nsureds and describe their operations:

____________________________________________________________________________________________

____________________________________________________________________________________________














2.

List all Additiona
l Insureds and describe their relationship to you:

____________________________________________________________________________________________

____________________________________________________________________________________________
____________________
________________________________________________________________________
____________________________________________________________________________________________


3.

Applicant is (check where applicable):


( ) Individual ( ) Partnership ( ) Corpo
ration ( ) Joint Venture ( ) Not for Profit


( ) For Profit ( ) Subchapter “s” Corporation ( ) Limited Liability Corporation


( ) Governmental Entity and is;


( ) Affiliated with Religious Organization ( ) Accredited by: ______
_____________


___________________________________________________________________


( ) Are you licensed under Division 2 of the Health & Safety Code_______________











4. List any state or national organization of which facility is a memb
er:



________________________________________________________________________________________


________________________________________________________________________________________




LTC
-
APP (
04 2012
)


Page
2


5. Are written orders from an attending physician requ
ired for:


All drugs or medicines




( ) Yes

( ) No


Special dietary requirements



( ) Yes

( ) No


Any specific therapy treatment


( ) Yes

( ) No


Are signatures of the responsible party

of the resident or the resident signing off

on the order before it

is administered

( ) Yes

( ) No


6. Is a nursing assessment conducted for new residents? ( ) Yes

( ) No


If yes, does this assessment include evaluation of:



Mobility limitations


( ) Yes

( ) No



History of prior injuries

( ) Yes

( ) No



Requ
ired assistance


( ) Yes

( ) No



Disorientation



( ) Yes

( ) No



Current medications


( ) Yes

( ) No



Skin Check



( ) Yes ( ) No


7. a. Do you obtain advance written consent from the resident or guardian that


allows your fac
ility to provide emergency medical care if needed?










( ) Yes ( ) No



b. Do you accept current DNR orders? (Do not resuscitate)

( ) Yes ( ) No



8. a. Who determines if a resident must be transferred to anothe
r medical facility for


further medical diagnosis or treatment?


_______________________________________________________________________________


_______________________________________________________________________________



b. Do you contract w
ith another service to provide;


Ambulance Service, Wheelchair Transportation, or Stretcher Van Service Hired Auto











( ) Yes ( ) No


If your answer is ‘yes’;


(i) Do you require proof of insurance for the following coverages:

Auto Liability

_________

General Liability_________

Professional Liability________





(ii) Do you require the contractor to provide proof that all state, county and


city licenses are current?

( ) Yes ( ) No


(iii) Do you require your wheelchair contracto
r to provide proof that all

vehicles comply with current ADA Standards?

( ) Yes ( ) No


9. Is an inventory taken of residents personal effects upon admittance with a copy


maintained in the file?






( ) Yes ( ) No



LIFE SAFETY MEASU
RES


1.

Entry/exit security measures:


In all buildings, are alarms on doors to keep residents from leaving the premises without proper


authorization?






( )Yes ( ) No


LTC
-
APP (
04 2012
)


Page
3


Describe any wander control


___________________________________________________
______________________

_________________________________________________________________________

Describe measures to prevent unauthorized entry by outside parties:

_________________________________________________________________________

_________________
________________________________________________________


2.

Do all buildings comply with current ADA Standards?


( ) Yes ( ) No


3.

Are bathtubs and showers equipped with non
-
slip surfaces?

( ) Yes ( ) No


4. Are all beds equipped with side rails?




( ) Yes

( ) No


5. Are all beds equipped with accessible, functioning call lights?

( ) Yes ( ) No


6. Are written emergency plans posted in all buildings?


( ) Yes ( ) No


7. Are evacuation directions posted in all buildings?


( ) Ye
s ( ) No


8. At all locations, do you conduct annual Fire Drills and Evacuation Drills in conjunction with the

local Fire Department and EMS Provider? _____________________________________________


9. Are records kept of medical equipment malfunctio
ns and repair dates?










( ) Yes

( ) No


10.

Is the facility sprinklered

( ) Yes

( ) No


What is the percentage of coverage _______%


If less than 100% explain areas not covered:
___________________________________________________________________
___________
______________________________________________________________________________
______________________________________________________________________________


11. Does the facility have smoke alarms

( ) Yes

( ) No


1
2
.

a.

Do you have a preve
ntion program for medical problems:

P
ressure ulcers

( ) Yes

( ) No

C
ontractures

( ) Yes

( ) No

N
osocomial infections

( ) Yes

( ) No


M
alnutrition

( ) Yes

( ) No



If yes please give details

and attach the ap
propriate documentation
, and briefly explain
the procedures for each
.

___________________________________________________________________________
___________________________________________________________________________
____________________________________
_______________________________________
___________________________________________________________________________





LTC
-
APP (
04 2012
)


Page
4

b. In

all buildings, are loss control programs in place for the following:


Fall Prevention







( ) Yes

( ) No


Resident Abuse






( ) Yes

( ) No


Patient Restraint






( ) Yes

( ) No


General Incident Rep
or
ts





( ) Yes

( ) No


Decubiti Management






( ) Yes

( ) No



(bed sores)



c. Are

all employees who provide patient care trained in “Patient Handling and


Lifting Techniques?










( ) Yes

( ) No


PHARMACOLOGICAL PRACTICES


1.

Is a licensed pharmacist on staff?





( ) Yes

( ) No


2.

Is there an agreement with an outside pharmacy?


( ) Yes ( ) No


3.

Are records kept of drug supplies and di
spersal?


( ) Yes ( ) No


4. How are drugs stored? ________________________________________________________________


5. Are all controlled drugs and medications administered under orders from the attending physician?











( ) Yes (
) No



If no, explain _____________________________________________________________________


6. Any sales to the public?






( ) Yes

( ) No


Receipts _________________________________________________________________________


Details __________________
_________________________________________________________


GENERAL LIABILITY


1. List all contractual professional services performed for you and the minimum

professional liability limits required ( include physicians, therapists, etc)


Service



Li
mits





Certificates on file


___________


___________




( ) Yes

( ) No

___________


___________




( ) Yes

( ) No

___________


___________




( ) Yes

( ) No



2. Do you have Professional Liability Coverage for the following employees:



RN’s, LPN’s, Licensed Care Givers, Nurses Aides, Inhalation Therapy Technicians,


Physical Therapists, Emergency Medical Technicians and Paramedics?

( ) Yes

( ) No

If no, please explain ____________________________________________________
_____________________
___________________________________________________________________________________________












3. Do you hold any service contractors or equipment lessors harmless?



( ) Yes

( ) No

Explain:
__________________________
_________________________________________________________________
___________________________________________________________________________________________
__________________________________________________________________________________


4.

Describe any exp
osure on the premises such as restaurant sales to the public, liquor sales, publishing,
mobile equipment or fund raising events:
______________________________________________________________________________________________
______________________________
________________________________________________________________



LTC
-
APP (
04 2012
)


Page
5

5.

Describe off premises activities including an estimate of the number of such activities each year and the
number of residents and others who participate:
___________________________________
___________________________________________________________
______________________________________________________________________________________________
______________________________________________________________________________________________


6.

Swimmin
g pools: How many and at which locations? ______


Are they open to the general public?



( ) Yes

( ) No

Locked when not in use?





( ) Yes

( ) No

Depth markings?






( ) Yes

( ) No

Diving board?






( ) Yes

( ) No

Lifeguard on duty when in use?




( ) Yes

( ) No

Fenced with self
-
closing/self
-
latching gate?


( ) Yes

( ) No


7.

Does the facility sell or rent prosthetic or aid devices?





( ) Yes

( ) No

If so, annual receipts for: Sales _________________ Rentals
______________


8.

Any s
ales or distribution of products, including any manufactured by residents?

( ) Yes

( ) No
If yes, advise list of all products and receipts for each:
__________________________________________________________________________________________
____
______________________________________________________________________________________________
______________________________________________________________________________________________


EMPLOYEE BENEFITS LIABILITY


1. Total number of employees___
__________________________________________________________________


2. Total payroll _________________________________________________________________________________


3. Do programs permitting optional enrollment of employees require acceptance or

re
jection signed by each employee?







( ) Yes

( ) No


4. Does facility currently carry this liability coverage?





( ) Yes

( ) No


5. Do you have information of any incident which may give rise to a claim?


( ) Yes

( ) No















If yes, describe: _____________________________________________________________________________


___________________________________________________________________________________________






IF YOUR FACILITY PROVIDES SKILLED OR INTERMEDIATE NUR
SING CARE SERVICES, PLEASE ANSWER
THE FOLLOWING QUESTIONS:


1. Do all residents have their own attending physician?



( ) Yes

( ) No


If no, who performs the role of attending physician? _______________________________________


__________________
___________________________________________________________________


_____________________________________________________________________________________


2. Are written orders from an attending physician required for:


Special dietary requirements?






( ) Yes

( ) No


Physical or chemical restraints?





( ) Yes

( ) No


Any other specific therapy/treatment?





( ) Yes

( ) No


3. If verbal orders are permitted from attending physicians:


Is the phone call witnessed and documented?



( ) Y
es

( ) No


What is the time limit within which the physician must sign off on the


verbal orders? ___________________________________________


LTC
-
APP (
04 2012
)


Page
6



4. How often are attending physicians required to update their patient’s charts?


____________________
____days


5. Is a medical assessment conducted for all new residents by a physician?












( ) Yes ( ) No


If not, is a medical assessment conducted by a registered nurse for all new


patients?








( ) Yes

( ) No


6.

Does the facility maintain daily nurses records of each resident?

( ) Yes ( ) No


Are they subject to periodic physician review?




( ) Yes

( ) No


7. a. Do you notify all Patient Care Employees of residents/patients with infectious



diseases
-

i.e. AIDS, Hepatitis, Tuberculoses?











b. Are all employees tested for HIV/AIDS?




( ) Yes


( ) No



ADMINISTRATION & STAFF


1.

Do you require criminal record checks
and sexual offender checks

for pre
-
employment

screening?

( ) Yes ( ) No


2. Do you check the state nurses aide registry for new hires?


( ) Yes ( ) No


3. If Physicians and Dentists are on staff, do you request proof of Professional Liability coverage?


( ) Yes

( ) No

If no, ple
ase explain:
______________________________________________________________________________________________
________________________________________________________________________________________















If as a result of this Application (including
any information attached hereto), a policy of insurance is issued
to the Applicant, the insurer will have relied on the accuracy of the information contained in this Application
(including any information attached hereto). If information contained in the
Application, or attachments
hereto, is false or misleading, the insurer may have the right to rescind all insurance coverage provided by
the policy. This Application and any information attached hereto will constitute the applicant’s Complete
Application
and will become part of, and will be considered physically attached to, any policy issued.


The undersigned warrants that to the best of his or her knowledge and belief the statements set forth herein
are true.





The undersigned authorizes the release an
d exchange of information involving past and future underwriting
and claims matters between the Company and/or its representatives and the present and any past
professional association/society of each of the healthcare facility’s members or employees, the
county
association/society in the county in which the healthcare facility operates or operated, its respective
committees and insurance consultants, any prior insurance company, and any state licensing board or other
governmental agency.


The undersigned w
arrants that he or she is authorized and has the power to complete and execute this
application on behalf of the healthcare facility, its subsidiaries and their directors, officers, or insured
persons.


The undersigned understands that any binder of covera
ge or policy of insurance issued by the Company as
a result of this application is contingent upon compliance with Risk Management recommendations,
signing
a Self
-
Insured Retention Third party Claims Agreement and implementation of The Critical Incident Gr
oup’s
Incident Reporting Program
.













LTC
-
APP (
04 2012
)


Page
7

Signed: __________________________________________________________________________




Name (Please Print):________________________________________________________________


Title:________________________________
______________________


Date:______________________________________________________












(1)

Whoever is engaged in the business of insurance whose activities affect interstate commerce and


knowingly, with the intent to deceive, makes any false mat
erial statement or report or willfully and


materially overvalues any land, property or security
-

-


(A)

in connection with any financial reports or documents presented to any insurance
regulatory official or agency or an agent or examiner appointed by
such official or agency
to examine the affairs of such person, and

(B)

for the purpose of influencing the actions of such official or agency or such an appointed
agent or examiner,



shall be punished as provided in paragraph (2).


(2)

The punishment for an
offense under paragraph (1) is a fine as established under this title or
imprisonment for not more than 10 years, or both, except that the term of imprisonment shall be
not more than 15 years if the statement or report or over valuing of land, property, or

security
jeopardized the safety and soundness of an insurer and was a significant cause of such insurer
being placed in conservation, rehabilitation, or liquidation by an appropriate court.






LTC
-
APP (
04 2012
)


Page
8

Location Addendum

(Complete one addendum for each additional

location. Please photocopy as needed)


Facility Address: ____________________________________________________________________________


City, State, Zip: _____________________________________________________________________________


Name of contact for
inspection: _______________________________________________________________


Phone Number: _____________________________________________________________________________


1.

Number of years this facility has been: Operating _________ Under present

managemen
t___________
Under present ownership _________________


2.

Are you licensed under Division 2 of CA Health and Safety Code? ____________


3.

List all state, county and city licenses held by the facility including number and expiration dates:


_______
______________________________________________________________________________


_____________________________________________________________________________________


_____________________________________________________________________________________


__
___________________________________________________________________________________

Have any of these licenses been suspended, revoked or placed under probation within the last five
years? ( ) Yes ( ) No

If yes, please explain:

_______________________
_______________________________________________________________

______________________________________________________________________________________


4. Do you provide any medical care to your residents with the following medical

conditions?


Alzheimer’s/Dementia

( ) Yes

( ) No


__________% of residents


Patients on Ventilator

( ) Yes

( ) No


__________% of residents


Patients on Dialysis

( ) Yes

( ) No


___
_______% of residents


Head Trauma


( ) Yes

( ) No


__________% of residents





Short stay/Post Op

( ) Yes

( ) No


__________% of residents


Spinal Cord Injury

( ) Yes

( ) No


__________% of residents


Infectious Diseases

( ) Yes

( ) No


_________
_% of residents



i.e. AIDS, Hepatitis, Tuberculosis
,

Contractual Nosocomial ( ) Yes ( ) No

__________% of residents

Malnutrition


( ) Yes

( ) No


__________% of residents


Non
-
Ambulatory


( ) Yes

( ) No


__________% of residents


Tube Feeding


(

) Yes

( ) No


__________% of residents



Any other special services?

_____________________________________________________________


_____________________________________________________________________________________


5.
Facility Classification and
Bed Census



Total # of beds_

# Occupied



Skilled Care Services


Residents require complex health

services which cannot be provided

without licensed nursing services

available on a 24 hour basis.

Services must be performed by or

under supervision of
professionally

trained personnel.





----------------


---------------


Intermediate Care Services

Residents require health care services


LTC
-
APP (
04 2012
)


Page
9

on a daily basis, are incapacitated, or ill

to a degree requiring limited nursing

supervision but whose general cond
ition

allows considerable independent activity



-----------------


---------------






Personal Care/Assisted Living Services

Some nursing and/or health related care

to residents who do not require the degree

of care and treatment described as skilled

or

intermediate. Residents may require

some minor nursing care or help in activities

such as eating, bathing, dressing, walking,

taking medication, laundry, housekeeping,

and preparation of special diets.




------------------


------------------












Independent Living Services

Retirement communities where residents

live in apartments, houses, townhouses,

etc. Nursing or personal care is provided

on an incidental basis only




-------------
(units)

------------------

6. Resident Classification
(% Population)


Medicaid __________% Medicare __________% Private Pay ____________%



# ______________________ Medicaid Days ; # ____________________ Resident Days;


7. For each classification below, show the number of employees scheduled to work
for


each shift.

Positions



1
st

Shift

2
nd

Shift


3
rd

Shift


Ave. Turnover




Employed/Contracted

Employed/Contracted

Employed/Contracted

Past Three Years




Full Time / Part Time Full Time / Part Time Full Time / Part T
ime

Physicians


_________________

__________________

__________________

_______________

Dentists



_________________

__________________

__________________

_______________

Registered Nurses


_________________

__________________

__________________

__________
_____

LPN



_________________

__________________

__________________

_______________

Nurses Aides


_________________

__________________

__________________

_______________

MD ‘on call’


_________________

__________________

__________________

_______________

Licensed Care Givers

_________________

__________________

__________________

_______________

EMT’s



_________________

__________________

__________________

_______________

Paramedics


_________________

__________________

__________________

______________
_

Phys Therapists


_________________

__________________

__________________

_______________

Dieticians


_________________

__________________

__________________

_______________

Beau
ticians/Barber

________________
_

_________________

__________________

_______
________

Admin Personnel


_________________

__________________

__________________

_______________

Mainte
nance/Security

________________
_

_________________

__________________

_______________

Social Workers


_________________

__________________

_____________
_____

_______________

Others: Describe;
________________________________________________________________________________________________________________


Total # of Employees ___________________ Total # of Volunteers ____________________


8. Respond f
or each position listed below:


Position


Name



Full/Part
-
time

Yrs at this facility

Yrs experience

Director of

Nursing


_________________________

____________

_______________


____________


Medical

Director


_________________________

____________

________
_______


____________


Administrator

_________________________

____________


_______________


____________


9. a. If skilled or Intermediate Care is provided, is there RN coverage 8 consecutive hours


per day, 7 days per week?



( ) Yes

(

) No


LTC
-
APP (
04 2012
)


Page
10


If no, has waiver been obtained?


( ) Yes

( ) No


b. If you do not provide RN’s 24 hours per day, explain your on
-
call system for RN’s when off duty?



10. Do you have an auxiliary electrical supply and emergency lighting system?








( ) Yes

( ) No

11. a. Is basic emergency resuscitation equipment located on each floor?









( ) Yes

( ) No



b. Do you require all employees to have current certification in CPR?









( ) Yes

( ) No

12. Minimum t
wo exits located remotely from each other, on each floor and fire


division?









( ) Yes

( ) No





Signed: __________________________________________________________________________




Name (Please Print):____________________________
____________________________________


Title:______________________________________________________


Date:______________________________________________________



(2)

Whoever is engaged in the business of insurance whose activities affect interstate commerce an
d


knowingly, with the intent to deceive, makes any false material statement or report or willfully and


materially overvalues any land, property or security
-

-


(C)

in connection with any financial reports or documents presented to any insurance
regulatory official or agency or an agent or examiner appointed by such official or agency
to examine the affairs of such person, and

(D)

for the purpose of influencing the actions of such official or agency or such an appointed
agent or examiner,



shal
l be punished as provided in paragraph (2).


(3)

The punishment for an offense under paragraph (1) is a fine as established under this title or
imprisonment for not more than 10 years, or both, except that the term of imprisonment shall be
not more than 15 yea
rs if the statement or report or over valuing of land, property, or security
jeopardized the safety and soundness of an insurer and was a significant cause of such insurer
being placed in conservation, rehabilitation, or liquidation by an appropriate court
.