Get Ca Cdph 612 2019-2026

The California Department of Public Health (CDPH) 612 form is essential for documenting patient census and direct care service hours in skilled nursing facilities. This guide provides a clear, step-by-step approach to help you complete the form accurately and effectively.

Follow the steps to complete the CA CDPH 612 form online.

1. Click ‘Get Form’ button to access the CA CDPH 612 document and open it for editing.
2. Enter the date of the patient day in MM/DD/YY format in the first field.
3. Input the total number of licensed skilled nursing beds available in your facility.
4. Fill in the CDPH license number assigned to your facility.
5. Provide the official name of your facility.
6. Enter the complete address of the facility.
7. Document the name of the facility administrator responsible for this data.
8. Indicate the name of the individual who is the Director of Nursing or their designee for the patient day.
9. Record the beginning patient census, including the total direct care service hours and calculate the scheduled direct care service hours per patient day (DHPPD) based on the beginning census count.
10. Log daily census changes at specified intervals (beginning of patient day, 8 hours in, and 16 hours in), and note any admissions, discharges, transfers, deaths, or other changes during the census period.
11. At the end of the patient day, complete the section for actual direct care service hours and actual/final DHPPD based on your records, ensuring that the totals are accurate.
12. Ensure the form is reviewed and signed by the Director of Nursing or their designee, confirming that all information provided is accurate and true.

Complete your CA CDPH 612 form online to ensure accurate reporting and compliance.