Nursing Home COVID-19 Preparedness & Response Fiscal Survey

We are seeking to gauge the additional costs nursing homes are facing due to the COVID-19 emergency and to collect current indicators of the severity of the existing financial stress member organizations are enduring. This information will allow us to educate policymakers and more effectively advocate for needed financial relief. The information you provide will be kept strictly confidential and will be used only in the aggregate.

IF YOUR ORGANIZATION OPERATES MULTIPLE NURSING HOMES PLEASE COMPLETE A SEPARATE SURVEY FOR EACH.

Please complete and submit the survey at your earliest convenience, but no later than Friday, April 10th. If you have questions on the survey please contact Ken Allison at kallison@leadingageny.org

Question Title

* 1. Respondent Contact Information

Respondent's Name

Facility Name

Facility PFI

City/Town

If affiliated with hospital enter hospital name:

Respondent's Email Address

Respondent's Phone Number

Question Title

* 2. Please enter the approximate proportion of your total resident care days that were paid by Medicaid and Medicaid managed care payers in 2019 (as a percent):

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* 3. Days Cash on Hand (COH)

Days COH at the end of 2019:

Days COH currently:

Projected COH 45 days from now:

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* 4. Days in Accounts Receivable (AR)

Days AR at the end of 2019:

Days AR currently:

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* 5. Please enter your facility's 2019 operating margin as a percentage (operating income divided by operating revenue). Hospital-based homes should enter their sponsoring hospital's operating margin if nursing-home specific margin is unavailable.

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* 6. Please enter the estimated ADDITIONAL staffing costs related to COVID-19 that your facility has endured between Jan. 1 and March 31, 2020.

Please include costs related to:
- maintaining current or higher staffing levels (including overtime)
- staffing pattern disruptions/new staffing patterns due to any COVID-19 unit re-configurations
- back-filling for unavailable staff
- paid leave for quarantined staff
- increased housekeeping/cleaning staff
- replacements for staff in training
- consultants and trainers
- increased contract staff
- staff hours for pandemic planning
- child care and other staff benefit cost increases

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* 7. Please enter the estimated ADDITIONAL equipment and material costs related to COVID-19 that your facility has endured between Jan. 1 and March 31, 2020.

Please include purchase costs of additional materials including PPE, cleaning and disinfecting supplies, etc.

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* 8. If your facility encountered revenue loss/cost increases from the items below, please indicate the estimated impact between Jan 1 and March 31, 2020:

a. Decrease in Medicaid rate (July 2019 rate compared to Jan. 2019 rate), if any

b. Uncompensated increase in collective bargaining agreement costs, if any

c. If your census has declined since Jan. 1., what is the estimated revenue impact of that decline?

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* 9. If your facility is encountering additional costs related to the emergency that are not captured above, please enter a description of the cost, the amount and the time-frame (ex. monthly starting March 1, weekly starting March 15) on the lines below:

Description, amount and time-frame of additional cost #1

Description, amount and time-frame of additional cost #2

Description, amount and time-frame of additional cost #3

Description, amount and time-frame of additional cost #4

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* 10. If your facility is encountering new costs or decreased revenue in addition to those identified above (whether COVID-related or not), please specify the cause and provide an estimated impact for the period Jan 1 through Mar 31. Please indicate the time-frame during which the situation was impacting, or is expected to be impacting, your facility.

Nursing Home COVID-19 Preparedness & Response Fiscal Survey

Question Title

* 1. Respondent Contact Information

Question Title

* 2. Please enter the approximate proportion of your total resident care days that were paid by Medicaid and Medicaid managed care payers in 2019 (as a percent):

Question Title

* 3. Days Cash on Hand (COH)

Question Title

* 4. Days in Accounts Receivable (AR)

Question Title

* 5. Please enter your facility's 2019 operating margin as a percentage (operating income divided by operating revenue). Hospital-based homes should enter their sponsoring hospital's operating margin if nursing-home specific margin is unavailable.

Question Title

Question Title

* 7. Please enter the estimated ADDITIONAL equipment and material costs related to COVID-19 that your facility has endured between Jan. 1 and March 31, 2020.Please include purchase costs of additional materials including PPE, cleaning and disinfecting supplies, etc.

Question Title

* 8. If your facility encountered revenue loss/cost increases from the items below, please indicate the estimated impact between Jan 1 and March 31, 2020:

Question Title

* 9. If your facility is encountering additional costs related to the emergency that are not captured above, please enter a description of the cost, the amount and the time-frame (ex. monthly starting March 1, weekly starting March 15) on the lines below:

Question Title

* 7. Please enter the estimated ADDITIONAL equipment and material costs related to COVID-19 that your facility has endured between Jan. 1 and March 31, 2020.

Please include purchase costs of additional materials including PPE, cleaning and disinfecting supplies, etc.