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Veteran’s Health Administration (VHA) Community Nursing Home (CNH) Medicare Star Rating Waiver Template Nursing Home Eligibility for CNH Program
| Eligibility |
| Nursing Home Compare Score |
| Eligible without waiver |
| 3-5 Overall Stars |
2 Overall Stars AND 4-5 Quality Measures Stars
| Eligible with waiver |
| 2 Overall Stars AND 1-3 Quality Measures Stars |
1 Overall Star
Submission Instructions To pursue a waiver, VA Medical Centers’ (VAMC) CNH Points of Contact must take the following steps:
1. Collect information required to fill out waiver, and then prepare the waiver.
1. Submit to VAMC Director or designee for review, approval, and signature.
1. Submit to Network Director or designee for review, approval, and signature.
1. Upload to CNH SharePoint Online document library for CNH Medicare Star Rating Waivers in VAMC-specific folder
3. Use the following naming convention for the waiver form: VISN_Station Number_CNH Name_Date Approved by Network Director [YY.MM.DD]_Waiver
3. Use the following naming convention for waiver resolutions: VISN_Station Number_CNH Name_Date Approved by Network Director [YY.MM.DD]_Waiver Resolution
To find more information on use of the VHA CNH Medicare Star Rating Waiver, please see the CNH Assessment subsection [list subsection number] of the Geriatrics and Extended Care section in the Specialty Programs chapter of the Office of Community Care Field Guidebook [Link to FGB].
Demographic Information
| VHA Identifying Information |
| Input |
| Date of Waiver Submission: |
| Click or tap to enter a date. |
| Duration of Waiver: |
| Click or tap here to enter text. |
| VAMC CNH Point of Contact: |
| Click or tap here to enter text. |
| CNH Identifying Information |
| Input |
| Name of CNH: |
| Click or tap here to enter text. |
| Medicare Nursing Home Compare Profile |
| Click or tap here to enter text. |
Medicare Nursing Home Compare Scores and Other Information
| Overall Rating: |
| Choose an item. |
| Health Inspection Rating: |
| Choose an item. |
| Date of Health Inspection: |
| Click or tap to enter a date. |
| Staffing Rating: |
| Choose an item. |
| Quality Measures Rating: |
| Choose an item. |
| Average Number of Residents per Day: |
| Click or tap here to enter text. |
| Number of Certified Beds: |
| Click or tap here to enter text. |
| Occupancy Rate: |
| Click or tap here to enter text. |
| Percentage of Residents Paid by Medicaid: |
| Click or tap here to enter text. |
| Percentage of Residents Classified as Long Stay: |
| Click or tap here to enter text. |
| In what areas of care does the home excel or provide good service? |
| Click or tap here to enter text. |
| In the latest quality of resident care results, please select any of the following measures in which the nursing home performed the same or better than the state rate: |
| ☐ Percentage of short-stay residents who improved in their ability to move around on their own |
☐ Percentage of short-stay residents who got antipsychotic medication for the first time.
☐ Percentage of SNF residents with pressure ulcers that are new or worsened.
☐ Percentage of long-stay high-risk residents with pressure ulcers.
☐ Percentage of SNF residents who experience one or more falls with major injury during their SNF stay.
☐ Percentage of long stay experiencing one or more falls with major injury.
☐ Percentage of long-stay residents who were physically restrained.
| Aspects Needing Improvement |
| Input |
| If the CNH experienced a poor survey, were the deficiencies found in the care of only one or two residents? |
| Choose an item. |
| If the CNH was cited in the latest State Survey with a health care deficiency rated “G” or higher, was the deficiency resolved quickly? |
| Choose an item. |
| Does the CNH leadership have a plan to improve its Star Ratings? Briefly describe the plans. |
| Click or tap here to enter text. |
Summary of Reasons to Use This CNH
| For existing CNHs, what are the findings from VA staff visits in terms of the quality of care delivered and the quality of life available to Veterans? |
| Click or tap here to enter text. |
| Please list the CNH Assessment Team/Oversight Committee’s summary of reasons for continuing or initiating a contract with this CNH: |
| Click or tap here to enter text. |
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