TO: ALL NURSING HOME and ICF/MR ADMINISTRATORS
FROM: LESLIE CLEMENT, Bureau Chief
Bureau of Benefits and Reimbursement Policy
Each year, the Department gathers information from all Nursing Facilities (including those which are hospital-based) and Intermediate Care Facilities for the Mentally Retarded in order to determine wage data for select employees within the nursing home industry.* At this time, the Department is requiring that facilities respond according to the attached instructions and complete the attached certification. A survey form is also being provided to assist you in the completion of this request.
If your facility was certified for participation in the Medicaid program before March 15, 2002, you must respond by May 15, 2002. Otherwise, you are not required to participate this year. Please return the requested information as soon as possible to:
Myers and Stauffer LC
8555 West Hackamore Drive, Suite 100
Boise, ID 83709
If you have questions, please feel free to contact Michele Hanrahan at (208) 364-1817 or Myers and Stauffer at (800) 336-7721. Thank you for your participation in Idaho Medicaid.
* Per Idaho Code, Section 39-5606, and IDAPA 16.03.10202.03
MIR 2002-13 INFORMATION REQUEST INSTRUCTIONS
In compliance with Idaho Code, Section 39-5606, we are requesting the following information related to select staff at all nursing facilities (including those which are hospital-based) and Intermediate Care Facilities for the Mentally Retarded (ICFs/MR) as of March 15, 2002.
The following information is required (PRM 03.10202.03) to be submitted to Myers and Stauffer no later than May 15, 2002. Early submissions would be greatly appreciated.
1) EMPLOYEE NAME: This category will include only the name and/or identifier for each employee (e.g., I.D. number).
2) EMPLOYMENT CLASS: Include ONLY the specified classifications indicated below:
* Registered Nurses (indicate Director of Nursing)
* Licensed Practical Nurses
* Qualified Mental Retardation Professional (ICFs/MR only)
* Certified Nurse Aides
* Nurse Aides
* Therapy Technicians (ICFs/MR only)
3) WAGE PER HOUR: This category is to include the wage per hour only. If the individual is paid a salary, please convert it to an hourly wage (full time = 2,080 hours/year).
4) HOURS PER WEEK: This category requests the number of hours that the individual works in the AVERAGE WORK WEEK. Round figures to the nearest hour.
5) TIME FRAME: The wage data must be the rate paid as of March 15, 2002. Do not include personnel hired after this date.
6) FORMAT: A form has been included for your use in manually reporting this information. Should you elect to use an alternative format, the data is to be organized as follows:
Employee Name Employment Class Wage per Hour Avg. Hours per Week
John Doe Nurse Aide $7.00 32
ELECTRONIC FILES would be appreciated, as long as they can be presented in either an Excel or Lotus spreadsheet format. In addition, a printout of the file must be attached to the certification page.
No subtotals or summarizations are necessary, but PLEASE SORT BY EMPLOYMENT CLASS. Please note that a payroll schedule will not satisfy the requirements of this request.
7) CERTIFICATION: Included with this request is a cover sheet/certification page. This page must be completed, signed, and attached to the information requested above.
STATE OF IDAHO
DEPARTMENT OF HEALTH AND WELFARE
* * * * * * * * * * * * * * * * * *
* * *
PERSONNEL LISTING WITH WAGE DATA
REQUESTED TO COMPLY WITH
IDAHO CODE, SECTION 39-5606
(Medicaid Information Release 2002-13)
AS OF MARCH 15, 2002
(Name of Facility)
(City, State, Zip)
(Medicaid Provider Number)
I certify that, to the best of my knowledge, the information reflected herein is an accurate representation of the facts.
Print or Type Name