2016 ALF Survey Facility Name*Contact Name* First Last Title or position of person completing:*Email* Date Facility licensed and in operation for:Less than a year1-6 years6 years +How many licensed beds does this facility have?6 or less7-2021-4041-6970-99100+What type of license does your facility have?StandardECCLNSLMHWhat region of the designated PSA's of Florida (1 thru 11) and/or county is the facility located?PSACountyDo you contract with one or more of the LTC SMMC plan providers for one or more residents in this facility? Yes No (NOT A LTC - SMMC PROVIDER) If YES, how many contracted SMMC residents do you currently service in this facility?Are you satisfied with the service and communication you currently have with the administration & case managers assigned to residents participating in the LTC SMMC Program in your facility? Yes No CommentsHow many residents enrolled in a LTC SMMC plan have transitioned from a skilled nursing facility into your ALF within the last 12 months?As of August 31, 2016 had you been paid in full by ALL plan providers for ALL resident services billed through June 30, 2016 for this facility? Yes No If NO: Please select the value below closest to the total outstanding amount owed as of June 30, 2016 billing?$900-$1999$2000-$3499$3500-$5499$5500 or moreWhat has been the longest delay for reimbursement from any plan you are contracted with?(days/ months)What minimum amount of monthly reimbursement do you estimate would meet or cover reasonable costs for resident care (ADL's) under the existing program?Have reimbursement issues, such as late pay, non-pay or low reimbursement rates caused you to consider terminating your provider status, limiting or refusing new admissions of SMMC recipients into this facility? Yes No Do you currently have residents in this facility who have been on the WAITLIST for a period of 6 months of more and currently pay the facility less than $1800 per month? Yes No If YES, which closest represents the number of residents in this facility who are currently on the waitlist and have been for a period of 6 months or more.1-45-1011-1718-2526 or moreDo you have residents currently waiting to be served by LTC Medicaid that are no longer able to pay the private pay monthly fee to the ALF and have been advised to move into a nursing home? Yes No If Yes, who advised them?Have ALF residents who are or were in your ALF waiting for services through SMMC been advised they may transition back to the ALF after a 60 to 90 day stay in a nursing home? Yes No NON PROVIDERS: If the LTC-SMMC reimbursement rates were at least $1500 monthly with guaranteed timely payments (30-45 days), would you opt to provide services through SMMC to recipents enrolled who meet ALF level of care? Yes No Please select below the selection (6 options) which falls closest to the average monthly fee/rate collected for the residents in this facility. This is the per residents rate including all private pay funds and LTC funds that make up the total monthly rate for room/board and services combined. If you have varying single & double occupancy rates or any other factors that equal at least 30% of the facilities total income, please select both rate categories that apply.$1700-$2299$2300-$2799$2800-$3299$3300-$3899$3900-$4299$4300 and upHas your facility been charged by any referral or placement service provider for a resident move in during the past 24 months? Yes No If yes, which amount closest reflects the total paid to all outside referral sources, (online, web and local provider) for resident move ins to this ALF within the last 12 month period?Less than $8,000$8,000-$11,999$12,000-$16,999$17,000-$21,999Over $22,000Has the expense of the increased leads coming from referral/ placement sources caused you to consider, or have to already incorporate new or increased "admission or other move in fees" to help offset the impact to the facility operations budget associated with referral fees? Yes No Have you encountered more than one placement/ referral provider contacting or invoicing your facility to collect or receive payment for one individual resident move in (the same client)? Yes No Have you encountered a placement/ referral provider making contact with a resident within your ALF with the intent of arranging a move to another facility within less than 9-12 months of the initial move in date? Yes No When you make initial calls to families based on the leads generated by online/ web based referral providers, do you encounter contacts who claim that they are not aware of signing up for a placement service and/or complaints that they are receiving multiple unsolicited call from facilities?NeverRarelySometimesOftenPlease use space for any additional comments you would like to share:Your time and reply is greatly appreciated... Thank You!