Form HFS 2022 Compliance Report for Skilled Nursing, Intermediate Care and Other 24-hour Facilities (Civil Rights Act Title Vi) - Illinois

Form HFS2022 or the "Compliance Report For Skilled Nursing, Intermediate Care And Other 24-hour Facilities (civil Rights Act Title Vi)" is a form issued by the Illinois Department of Healthcare and Family Services.

The form was last revised in December 1, 2006 and is available for digital filing. Download an up-to-date Form HFS2022 in PDF-format down below or look it up on the Illinois Department of Healthcare and Family Services Forms website.

ADVERTISEMENT
State of Illinois
Department of Healthcare and Family Services
COMPLIANCE REPORT FOR SKILLED NURSING, INTERMEDIATE CARE
AND OTHER 24-HOUR FACILITIES (Civil Rights Act Title VI)
If any of the questions below require an explanation, use PART IV REMARKS and identifying comments by Item Number.
I. IDENTIFYING INFORMATION
Name of Facility
Street Address
City, County, State and Zip code
MEDICARE PROVIDER NO.
Phone Number
MEDICAID PROVIDER NO.
Bed Capacity
Licensed Bed Capacity
Medicare Beds Approved
Medicaid Beds Approved
Current Bed Capacity
Name, Address and Telephone Number of Owner of Facility
TYPE OF FACILITY
TYPE OF CONTROL
Skilled Nursing Facility
Religious
Intermediate Care Facility
Fraternal
Intermediate Care Facility for the Mentally Retarded
Other non-profit
Mental Health Facility
County
(Specify)
Other
Proprietary
Other (Specify)
II. RESIDENT ADMISSION AND DISTRIBUTION
Does your facility have a written policy of nondiscrimination that provides for
resident admission and service without regard to race, color, or national origin?
Yes
No
Is this policy displayed in areas of the facility accessible to employees, residents, and the public?
Yes
No
Describe briefly any amendments to your civil rights policy or any implementation efforts made since the last compliance report.
(Use PART IV REMARKS)
Has the community been notified of your policy to accept residents
and render services without regard to race, color or national origin?
Yes
No
If "yes" is checked enter date and
Letter
Other
Newspaper
Radio
(Specify)
check method of communication:
Is use of your facility limited to membership in a defined group? (i.e. fraternal
No
organization, religious denomination, employees of a corporation, etc.)
Yes
If "yes" explain and describe membership requirements. (Use PART IV REMARKS)
Estimate the number of residents of minority groups (African American, American Indian, Oriental and Hispanic) admitted
during the last year.
0
1-10
11-20
21-50
Over 50
Total number of minority group residents in today's census
HFS 2022 (R-12-06)
State of Illinois
Department of Healthcare and Family Services
COMPLIANCE REPORT FOR SKILLED NURSING, INTERMEDIATE CARE
AND OTHER 24-HOUR FACILITIES (Civil Rights Act Title VI)
If any of the questions below require an explanation, use PART IV REMARKS and identifying comments by Item Number.
I. IDENTIFYING INFORMATION
Name of Facility
Street Address
City, County, State and Zip code
MEDICARE PROVIDER NO.
Phone Number
MEDICAID PROVIDER NO.
Bed Capacity
Licensed Bed Capacity
Medicare Beds Approved
Medicaid Beds Approved
Current Bed Capacity
Name, Address and Telephone Number of Owner of Facility
TYPE OF FACILITY
TYPE OF CONTROL
Skilled Nursing Facility
Religious
Intermediate Care Facility
Fraternal
Intermediate Care Facility for the Mentally Retarded
Other non-profit
Mental Health Facility
County
(Specify)
Other
Proprietary
Other (Specify)
II. RESIDENT ADMISSION AND DISTRIBUTION
Does your facility have a written policy of nondiscrimination that provides for
resident admission and service without regard to race, color, or national origin?
Yes
No
Is this policy displayed in areas of the facility accessible to employees, residents, and the public?
Yes
No
Describe briefly any amendments to your civil rights policy or any implementation efforts made since the last compliance report.
(Use PART IV REMARKS)
Has the community been notified of your policy to accept residents
and render services without regard to race, color or national origin?
Yes
No
If "yes" is checked enter date and
Letter
Other
Newspaper
Radio
(Specify)
check method of communication:
Is use of your facility limited to membership in a defined group? (i.e. fraternal
No
organization, religious denomination, employees of a corporation, etc.)
Yes
If "yes" explain and describe membership requirements. (Use PART IV REMARKS)
Estimate the number of residents of minority groups (African American, American Indian, Oriental and Hispanic) admitted
during the last year.
0
1-10
11-20
21-50
Over 50
Total number of minority group residents in today's census
HFS 2022 (R-12-06)
II. RESIDENT ADMISSION AND DISTRIBUTION (continued)
Indicate below the number of minority group residents in today's census by type and room assignment according to the
following breakdown:
Type of Room Assignment
African American Oriental Hispanic
Number in single rooms or in room alone.
Number in semi-private or ward rooms having only minority persons.
Number in semi-private or ward rooms with one or more non-minority persons.
TOTAL
Indicate the number of residents in today's census whose charges made by your facility are paid in part or full by Medicare
or Medicaid.
Type of Aid
TOTAL
African
American
Oriental
Hispanic
Medicare
Medicaid
What is the approximate percentage of minority group population in the
geographic service area from which most of your residents are drawn?
III. SERVICE AND FACILITY UTILIZATION
Are all services and facilities used routinely by all persons without regard
to race, color, or national origin? (i.e. nursing care, social services,
No
occupational therapy, dining area, barber shop, beauty salons, etc.)
Yes
If "no" specify which are not.
Are services rendered in this facility without regard to race, color, or
No
national origin of either the resident or the person rendering the service?
Yes
If "no" specify which are not.
Estimate below the number of physicians and other licensed paramedical personnel not on your payroll that gave resident
service in this facility during the last month by race of the physician or person rendering the service.
Physicians and Other Non-Salaried Paramedical Personnel
TOTAL
African
American
Oriental
Hispanic
IV. REMARKS
I CERTIFY THAT THE INFORMATION GIVEN IS TRUE AND CORRECT TO THE BEST OF MY KNOWLEDGE AND BELIEF
(A willfully false statement is punishable by law: U.S. Code, Title 18, Sec. 1001).
Date
Signature of Authorized Official
Title
HFS 2022 (R-12-06)

Download Form HFS 2022 Compliance Report for Skilled Nursing, Intermediate Care and Other 24-hour Facilities (Civil Rights Act Title Vi) - Illinois

1091 times
Rate
4.3(4.3 / 5) 54 votes
ADVERTISEMENT
Page of 2