Free Instructions for Report of Hours Worked and Resident Census Forms-F-62022A - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62022A (Rev. 02/09)

STATE OF WISCONSIN Chapter 50.04(2)(d), Wis. Stats. DHS 132.62, Wis. Admin. Code

INSTRUCTIONS FOR REPORT OF HOURS WORKED AND RESIDENT CENSUS FORMS
Report of Hours Worked - Registered Nurse / Day (F-62023), Evening (F-62025), Night (F-62027) Report of Hours Worked - Licensed Practical Nurse / Day (F-62164), Evening (F-62165), Night (F-62166) Report of Hours Worked - Nurse Aide / Day (F-62024), Evening (F-62026), Night (F-62028) Report of Hours Worked - Other Direct Care Nurse Aide / Day (F-62440), Evening (F-62441), Night (F-62442) Resident Census (F-62030)
NOTE: DHS 132.45(1), Wis. Admin. Code, requires that the administrator or the administrator's designee provide information needed to document compliance with DHS 132, Wis. Admin. Code, and Chapter 50.04(2)(d), Wis. Stats., effective June 17, 1998. The administrator's or designee's signature will serve to attest that the information provided on these forms is accurate and correct. Failure to provide this information may affect your licensure status. Complete the attached forms and provide the information requested. Use BLACK INK or TYPE all responses. Return all materials to the Division of Quality Assurance surveyor. Personal information collected on these forms will be used to confirm that minimum staffing requirements have been met and will be used for no other purpose. If you have any questions on filling out these forms, please ask the surveyors while they are in the facility conducting the survey.
City License Number Date

Name - Facility SIGNATURE - Nursing Home Administrator or Designee

Report of Hours Worked - RN, LPN, NA, Other Direct Care NA (See forms listed above.)
Depending on your staff mix, multiple pages are required for each shift. If additional pages are needed to list all nursing staff, you may make additional copies; however, be sure to clearly indicate the shift on each copied page. The Director of Nurses' hours should be clearly identified, if included in the report. Report only paid hours. List each nursing staff member by name in the appropriate area (e.g., RN, LPN, NA, Other Direct Care NA) and indicate the number of total paid hours of resident care provided and recorded for the shift. If hours worked overlap into another shift, the number of hours worked on each shift is to be recorded for the appropriate shift and on the appropriate form. Actual hours worked are to be specified for each nursing staff listed. Express fractions as decimals rounded to the nearest .25, .50, or .75. Add columns vertically. If you have more than one page per shift, provide a subtotal on each page, add the subtotals together, and provide a grand total on the final page for that shift. Do NOT grand total RN, LPN, NA, Other Direct Care NA hours together. Services provided by volunteers may NOT be counted toward satisfaction of this requirement. The information should be provided for the two-week period from to

Following is an example to assist in completing the forms.
Time Allowed for Meal Break Meal Break (Check one.)

30 minutes
S Jones, Sue Smith, Ann Davis, Greg GRAND TOTAL 7.5 8 15.5 16 16 M 8 8 T 8 8 8 16 W 8 8 7.5 15.5 8 7.5 15.5 16 16 TH F S 8 8 S 8 8 M 8 4 8 20 8 16 T 8

Paid Time
W 8 8 8 16 8 TH

Unpaid Time
F S 8 8 8

8

16

Resident Census (F-62030)
The information requested is to be provided for all residents in your facility on the following date: Record the total number of residents in each care level in your facility on this date. Please note that a resident with any developmental disability diagnosis is to be counted on a separate line under each care level. Subtotals and totals should be provided where requested on the form. The far right-hand "total" should equal the total census.



Report care level changes that are "pending" at the currently established care level.