VIRGINIA DEPARTMENT OF HEALTH

Application for a Certificate of Public Need – (name of project): ______

COPN Request No. VA - ______Date Prepared: ______Applicant’s Page no. ____

Table III-C

FACILITY STAFFING

(FTEs for employed personnel and hours for contract/consultant personnel)

Job
Title / Current
Average / Current
Hourly / Existing
Nursing Home / Proposed
Nursing Home
2nd Year After Completion / Existing
Assisted
Living / Proposed
Assisted Living
2nd Year After Completion / Existing
Total Facility / Proposed
Total Facility
2nd Year After Completion /
/ Annual Salary / Consult.
Fee / FTEs / Annual Consult. Hours / FTEs / Annual Consult. Hours / FTEs / Annual Consult. Hours / FTEs / Annual Consult. Hours / FTEs / Annual Consult. Hours / FTEs / Annual Consult. Hours /
Nursing Services
Medical director
Director of nursing
Staff development coordinator
Registered nurse
Ventilator nurse
Licensed practical nurse
Certified nurse assistant
Cert. resp. care tech./reg. resp. thera.
Ward clerk
Other nursing service (______)
Other nursing service (______)
Total Nursing Services
Ancillary Patient Care
Physical therapist
Physical therapy assistant
Physical therapy aide
Rehabilitation aide
Occupational therapist
Recreational therapist
Speech therapist
Audiologist
Oxygen therapist
Tube feeding therapist
Therapy asst., aide (excl. PT)
Laboratory technician
Pharmacist
Other ancillary care (______)
Other ancillary care (______)
Total Ancillary Services
Social Work Services
Social services director
Social services assistant
MSW consultant
BSW consultant
Other social service (______)
Total Social Work Services
Activity Services
Activity director
Activity assistant
Activity consultant
Other activity service (______)
Total Activity Services
Dietary Services
Licensed dietitian
Food service supervisor
Cook
Dietary aide
Other dietary service (______)
Total Dietary Services
Housekeeping & Laundry
Housekeeping supervisor
Laundry supervisor
Housekeeping aide
Laundry aide
Other hskp., laundry (______)
Total Housekeep. & Laundry
Maintenance
Maintenance supervisor
Maintenance assistant
Janitor
Other maintenance (______)
Total Maintenance
Administration
Administrator
Assistant administrator
Administration secretary
Admissions coordinator
Business office dir./bookkeeper
Supply clerk
Other administration (______)
Other administration (______)
Total Administration
Other (______)
Other (______)
Other (______)
Other (______)
Total Personnel

Long-Term Care Facilities (updated April 2006) Table III-C, page 3 of 3