1

Facility Information

Facility Information

Facility Name

2

Facility Information

Facility Information

Address

3

Facility Information

Facility Information

City

4

Facility Information

Facility Information

Postal Code

5

Facility Information

Facility Information

Telephone

6

Facility Information

Facility Information

FAX

7

Facility Information

Facility Information

Facility's website Address

8

Facility Information

Facility Information

Site ID #

9

Facility Information

Facility Information

Program Type 

10

Facility Information

Facility Information

Ownership Type

11

Facility Information

Facility Information

Legislation

12

Facility Information

Facility Information

Accreditation Body

13

Facility Information

Facility Information

Accreditation Date

14

Facility Information

Facility Information

Accreditation Expiry Date

15

Facility Information

Facility Information

Health Authority

16

Facility Information

Facility Information

Local Health Authoriy

17

Facility Information

Owner Information

Site ID #

18

Facility Information

Owner Information

Program Type 

19

Facility Information

Owner Information

Ownership Type

20

Facility Information

Owner Information

Legislation

21

Facility Information

Owner Information

Accreditation Body

22

Facility Information

Owner Information

Accreditation Date

23

Facility Information

Owner Information

Accreditation Expiry Date

24

Facility Information

Owner Information

Health Authority

25

Facility Information

Owner Information

Local Health Authority

26

Facility Information

Operator Information

Operator Name   

27

Facility Information

Operator Information

Address

28

Facility Information

Operator Information

City

29

Facility Information

Operator Information

Postal Code

30

Facility Information

Operator Information

Telephone

31

Facility Information

Operator Information

FAX

32

Facility Information

Operator Information

(Contact) Name

33

Facility Information

Operator Information

(Contact) Position

34

Facility Information

Operator Information

(Contact) Telephone

35

Facility Information

Operator Information

(Contact) E-mail Address

36

Facility Information

Preparer Contact Information

Name

37

Facility Information

Preparer Contact Information

Position

38

Facility Information

Preparer Contact Information

Telephone

39

Facility Information

Preparer Contact Information

E-mail Address

40

Facility Information

Preparer Contact Information

Fax

41

Facility Information

CFO or VP Finance Contact Information

Name

42

Facility Information

CFO or VP Finance Contact Information

Position

43

Facility Information

CFO or VP Finance Contact Information

Telephone

44

Facility Information

CFO or VP Finance Contact Information

E-mail Address

45

Facility Information

CFO or VP Finance Contact Information

Fax

46

Facility Information

Auditor's Contact Information

Audit Firm

47

Facility Information

Auditor's Contact Information

(Contact) Name

48

Facility Information

Auditor's Contact Information

(Contact) Position

49

Facility Information

Auditor's Contact Information

(Contact) Telephone

50

Facility Information

Auditor's Contact Information

(Contact) E-mail Address

51

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

In-Scope 3.36 HPRD Publicly Funded Beds

52

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

LTC Regular

53

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

LTC Temp

54

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Other ~ specify

55

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Subtotal ~ in-scope 3.36 HPRD publicly funded beds

56

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Out of Scope Publicly Funded Beds

57

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Short Stay Beds

58

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• respite

59

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• end of life

60

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• convalescent

61

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• flex

62

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• other

63

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Subtotal ~ out-of-scope publicly funded beds

64

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Private Beds

65

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Private beds co-located with in-scope publicly funded beds

66

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Private beds located in separate wing/unit

67

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Subtotal ~ private beds

68

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Total Beds

69

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

In-Scope 3.36 HPRD Publicly Funded Beds

70

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

LTC Regular

71

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

LTC Temp

72

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Other ~ specify

73

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Subtotal ~ in-scope 3.36 HPRD publicly funded beds

74

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Out of Scope Publicly Funded Beds

75

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Short Stay Beds

76

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

• respite

77

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

• end of life

78

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

• convalescent

79

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

• flex

80

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

In-Scope 3.36 HPRD Publicly Funded Beds

52Adjustment

• other

81

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

LTC Regular

53Adjustment

Subtotal ~ out-of-scope publicly funded beds

82

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

LTC Temp

54Adjustment

Private Beds

83

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Other ~ specify

55Adjustment

Private beds co-located with in-scope publicly funded beds

84

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Subtotal ~ in-scope 3.36 HPRD publicly funded beds

56Adjustment

Private beds located in separate wing/unit

85

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Out of Scope Publicly Funded Beds

57Adjustment

Subtotal ~ private beds

86

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1Short Stay Adjustment

Total Beds

5887

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• respite

59Revised

In-Scope 3.36 HPRD Publicly Funded Beds

88

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• end of life

60Revised

LTC Regular

89

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• convalescent

61Revised

LTC Temp

90

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• flex

62Revised

Other ~ specify

91

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

• other

63Revised

Subtotal ~ in-scope 3.36 HPRD publicly funded beds

92

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Subtotal ~ out-of-scope publicly funded beds

64Revised

Out of Scope Publicly Funded Beds

93

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1Private Revised

Short Stay Beds

6594

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Private beds co-located with in-scope publicly funded beds

66Revised

• respite

95

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

• end of life

96

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Private beds located in separate wing/unit

67Revised

• convalescent

97

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Subtotal ~ private beds

68Revised

• flex

98

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / At April 1

Total Beds

69Revised

• other

99

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

In-Scope 3.36 HPRD Publicly Funded Beds

70Revised

Subtotal ~ out-of-scope publicly funded beds

100

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / AdjustmentRevised

LTC RegularPrivate Beds

71101

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

LTC Temp

72Revised

Private beds co-located with in-scope publicly funded beds

102

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Other ~ specify

73Revised

Private beds located in separate wing/unit

103

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / AdjustmentRevised

Subtotal ~ in-scope 3.36 HPRD publicly funded private beds

74104

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Out of Scope Publicly Funded Beds

75

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Short Stay Beds

76

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

• respite

77

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

• end of life

78

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

• convalescent

79

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

• flex

80

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

• other

81

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Subtotal ~ out-of-scope publicly funded beds

82

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Private Beds

83

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Private beds co-located with in-scope publicly funded beds

84

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Private beds located in separate wing/unit

85

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Subtotal ~ private beds

86

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Adjustment

Total Beds

87

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

In-Scope 3.36 HPRD Publicly Funded Beds

88

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

LTC Regular

89

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

LTC Temp

90

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Other ~ specify

91

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Subtotal ~ in-scope 3.36 HPRD publicly funded beds

92

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Out of Scope Publicly Funded Beds

93

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Short Stay Beds

94

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

• respite

95

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

• end of life

96

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

• convalescent

97

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

• flex

98

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

• other

99

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Subtotal ~ out-of-scope publicly funded beds

100

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Private Beds

101

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Private beds co-located with in-scope publicly funded beds

102

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Private beds located in separate wing/unit

103

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Subtotal ~ private beds

104

# of beds & occupancy rate

Data Collection ~ Bed Inventory / # of beds in the facility / Budget / Revised

Total Beds

105

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / Approved Beds

Revised

Total Beds

105

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / Approved Beds

1. In- scope 3.36 HPRD publicly funded beds

106

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / Approved Beds

1. Out of scope publicly funded bed

107

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / Approved Beds

1. Private Beds

108

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / Approved Beds

Total beds and YTD occupied days

109

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / YTD Maximum Days

1. In- scope 3.36 HPRD publicly funded beds

110

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / YTD Maximum Days

1. Out of scope publicly funded bed

111

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / YTD Maximum Days

1. Private Beds

112

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / YTD Maximum Days

Total beds and YTD occupied days

113

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / YTD Occupied Days

1. In- scope 3.36 HPRD publicly funded beds

114

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / YTD Occupied Days

1. Out of scope publicly funded bed

115

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / YTD Occupied Days

1. Private Beds

116

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / YTD Occupied Days

Total beds and YTD occupied days

117

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / % Occupied

1. In- scope 3.36 HPRD publicly funded beds

118

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / % Occupied

1. Out of scope publicly funded bed

119

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / % Occupied

1. Private Beds

120

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / % Occupied

Total beds and YTD occupied days

121

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

1. In-scope 3.36 HPRD publicly funded beds - at April 1

122

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

1. In-scope 3.36 HPRD publicly funded beds - adjustments

123

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

Subtotal 

124

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

2. Out-of-scope publicly funded beds

Field Name to be confirmed

125

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

2. Out-of-scope publicly funded beds

Field Name to be confirmed

126

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

Subtotal

127

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

3. Private Beds

Field Name to be confirmed

128

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

3. Private Beds

Field Name to be confirmed

129

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

Subtotal

130

Data Collection - Details for YTD Maximum Days

Bed Type / # of Beds

Total

131

Data Collection - Details for YTD Maximum Days

Bed Type / Start

1. In-scope 3.36 HPRD publicly funded beds - at April 1

132

Data Collection - Details for YTD Maximum Days

Bed Type / Start

1. In-scope 3.36 HPRD publicly funded beds - adjustments

133

Data Collection - Details for YTD Maximum Days

Bed Type / Start

2. Out-of-scope publicly funded beds

134

Data Collection - Details for YTD Maximum Days

Bed Type / Start

2. Out-of-scope publicly funded beds

135

Data Collection - Details for YTD Maximum Days

Bed Type / Start

3. Private Beds

136

Data Collection - Details for YTD Maximum Days

Bed Type / Start

3. Private Beds

137

Data Collection - Details for YTD Maximum Days

Bed Type / End

1. In-scope 3.36 HPRD publicly funded beds - at April 1

138

Data Collection - Details for YTD Maximum Days

Bed Type / End

1. In-scope 3.36 HPRD publicly funded beds - adjustments

106139

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types Type / Approved BedsEnd

2. Out-of-scope publicly funded

beds

107140

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types Type / Approved Beds

1. Private Beds

108End

2. Out-of-scope publicly funded beds

141

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types / Approved Beds

Total beds and YTD occupied days

109Type / End

3. Private Beds

142

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types Type / YTD Maximum Days

1. In- scope 3.36 HPRD publicly funded beds

110End

3. Private Beds

143

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types / YTD Maximum Days

1. Out of scope publicly funded bed

111Type / # of days

1. In-scope 3.36 HPRD publicly funded beds - at April 1

144

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types / YTD Maximum Days

1. Private Beds

112Type / # of days

1. In-scope 3.36 HPRD publicly funded beds - adjustments

145

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types / YTD Maximum Days

Total beds and YTD occupied days

113Type / # of days

2. Out-of-scope publicly funded beds

146

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types / YTD Occupied Days

Type / # of days

2. Out-of-scope publicly funded beds

114147

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types / YTD Occupied Days

1. Out of scope publicly funded bed

115Type / # of days

3. Private Beds

148

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types / YTD Occupied DaysType / # of days

3. Private Beds

116149

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types / YTD Occupied Days

Total beds and YTD occupied days

117Type / YTD Maximum

1. In-scope 3.36 HPRD publicly funded beds - at April 1

150

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Types Type / % OccupiedYTD Maximum

1. In-scope 3.36 HPRD publicly funded beds - adjustments

118151

Data Collection - Year-to-Date (YTD) Resident Bed Details for YTD Maximum Days

Bed Type / YTD Maximum

Subtotal 

152

Data Collection - Details for YTD Maximum Days

Bed Types Type / % OccupiedYTD Maximum

2. Out-of-scope publicly funded

119

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / % Occupied

1. Private Beds

120

Data Collection - Year-to-Date (YTD) Resident Bed Days

Bed Types / % Occupied

Total beds and YTD occupied days

121

VIHA - staffing plan

122

123

124

125

126

127

128

129

130

131

132

133

134

135

136

137

138

139

140

141

142

143

144

145

146

147

148

149

150

151

152

153

154

155

156

157

158

159beds

Field Name to be confirmed

153

Data Collection - Details for YTD Maximum Days

Bed Type / YTD Maximum

2. Out-of-scope publicly funded beds

Field Name to be confirmed

154

Data Collection - Details for YTD Maximum Days

Bed Type / YTD Maximum

Subtotal

155

Data Collection - Details for YTD Maximum Days

Bed Type / YTD Maximum

3. Private Beds

Field Name to be confirmed

156

Data Collection - Details for YTD Maximum Days

Bed Type / YTD Maximum

3. Private Beds

Field Name to be confirmed

157

Data Collection - Details for YTD Maximum Days

Bed Type / YTD Maximum

Subtotal

158

Data Collection - Details for YTD Maximum Days

Bed Type / YTD Maximum

Total

159

Data Collection - Details for YTD Occupied Days

160

161

162

163

164

165

166

167

168

169

170

171

172

173

174

175

176

177

178

179

180

181

182

183

184

185

186

187

188

189

190

191

192

193

194

195

196

197

198

199

200

201

202

203

204

205

206

207

208

209

210

211

212

213

214

215

216

217

218

219

220

221

222

223

224

225

226

227

228

229

230

231

232

233

234

235

236