Free CON REPORT OUTLINE - Indiana

ANNUAL REPORT OF COMPREHENSIVE LONG TERM CARE FACILITY
State Form 50834 (2-02) INDIANA STATE DEPARTMENT OF HEALTH

Year: ___________ I. Facility Identification Facility Name Street Address City County Administrator Name Former Name of Facility Person Completing Form Open the entire year (yes/no) Owner's Name Owner's Address Type of Ownership (check one below) For Profit Individual For Profit Partnership For Profit Corp Nonprofit Church Nonprofit Corp State County Zip Code Township

Type of Specialized Units Number of Beds HIV Alzheimer's Head Trauma Unit Pediatric Unit Ventilator Unit Census December 31st

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ISDH II. DATE

ANNUAL REPORT of Comprehensive Long Term Care Facility Comprehensive Beds TOTAL LICENSED BEDS CERTIFIED BEDS

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January 1st December 31st III.

NON -CERTIFIED BEDS

Addition/Removal of Comprehensive Beds Certified Beds # of Beds Month Changed Non-Certified

Added Beds

Removed Beds # of Beds Month Changed IV. Comprehensive Resident Days by Source of Reimbursement for calendar year CERTIFIED NON-CERTIFIED TOTAL

PAYMENT Private Pay Medicare Medicaid Other Total V.

Comprehensive Resident Days by Age for calendar year > 65 Years 65-74 Years 75-84 Years 85+ Years Total

Certification Certified Non-certified Total

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ISDH VI.

ANNUAL REPORT of Comprehensive Long Term Care Facility

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Comprehensive Residents by Age and Sex (Census as of December 31, 2000) Male Residents Female Residents Total Residents

Age Group 0-19 Years 20-39 Years 40-64 Years 65-75 Years 75-84 Years 85 + Years Total VII.

Annual Admissions to Comprehensive Care Facility Total Residents

Source of Referrals Independent / Self Care Family Hospital Mental Health Center Home Health Agency Another Nursing Home Other Total VIII.

Annual Discharges from Comprehensive Care Facility Total Residents

Discharged to Independent Self Care Family Hospital Mental Health Another Nursing Home Death Other Total Discharges Comments

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