POS Mental Reference Report
Line
Line Descriptions
Value
Type
POS Field
10G053
FLORIDA MENTOR
LANTANA, FL 33462
A
Subtype of provider
Long Term
PROV0085
00010
Category of Provider/Supplier
ICF - Mentally Retarded'
PROV0075
00020
Change of Ownership Counter
00
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
490
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
12/07/2006
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
031261400
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
02/09/1983
PROV1565
00160
Date of Prior Change in Ownership
DATE
PROV1615
00170
Prior Intermediary Number
CODE
PROV1620
00180
Provider Number
CODE
10G053
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
LAN
PROV2710
00250
Provider Telephone Number
5615330555
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
Other
PROV2885
00310
Provider Zip Code
33462
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12099
FIPCNTY
00340
SSA MSA Code
637
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Beds - Total
BEDS
24
PROV0740
00400
Beds - Total Certified
BEDS
24
PROV0755
00410
Compliance - Life Safety Code
CMPL
PROV0240
00480
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
5.00
PROV0955
00580
Program Participation - Medicare/Medicaid
Medicaid Only
PROV1670
00680
Region Override #1 for Number of Beds
PROV1545
00760
Registered Nurses
FTES
2.00
PROV1145
00790
Waiver of beds per room requirement recommended
PROV0225
01740
Waiver of patient room size recommended
PROV0270
01750
Long Term Care cross reference provider number
PROV0640
01930
Long Term Facility is hospital based
PROV1675
02520
Related Provider Number
CODE
PROV1755
02560
Date that payment suspension was recinded
DATE
PROV1825
02570
Admission Suspension Date for New Admissions
DATE
PROV0030
03780
Beds - Intermediate Care Facility
BEDS
24
PROV0945
03790
Direct Care Personnel
FTES
50.00
PROV0780
03800
Long Term Care Agreement Start Date
DATE
04/01/2007
PROV0620
03810
Long Term Care Agreement End Date
DATE
03/31/2008
PROV0625
03820
Long Term Care Agreement Extension Date
DATE
PROV0630
03830
Prior Admission Suspension Date
DATE
PROV1610
03840
Prior Long Tern Care Agreement End Date
DATE
03/31/2007
PROV1630
03850
Prior Long Term Care Agreement Extension Date
DATE
PROV1635
03860
Prior Resend Admission Suspension Date
DATE
PROV1640
03870
Total number of employees
FTES
6800
PROV2850
03880
10G054
GREEN TREE COURT CLUSTER
BARTOW, FL 33830
A
Subtype of provider
Long Term
PROV0085
00010
Category of Provider/Supplier
ICF - Mentally Retarded'
PROV0075
00020
Change of Ownership Counter
00
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
520
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
03/19/2007
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
028028300
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
02/16/1983
PROV1565
00160
Date of Prior Change in Ownership
DATE
PROV1615
00170
Prior Intermediary Number
CODE
PROV1620
00180
Provider Number
CODE
10G054
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
TAM
PROV2710
00250
Provider Telephone Number
8635330837
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
Private Non Profit
PROV2885
00310
Provider Zip Code
33830
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12105
FIPCNTY
00340
SSA MSA Code
290
SSAMSACD
00350
SSA MSA Size Code
D
SSAMSASZ
00360
Beds - Total
BEDS
24
PROV0740
00400
Beds - Total Certified
BEDS
24
PROV0755
00410
Compliance - Life Safety Code
CMPL
PROV0240
00480
Fiscal Year Ending Month/Day
0630
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
13.00
PROV0955
00580
Program Participation - Medicare/Medicaid
Medicaid Only
PROV1670
00680
Region Override #1 for Number of Beds
PROV1545
00760
Registered Nurses
FTES
2.00
PROV1145
00790
Waiver of beds per room requirement recommended
PROV0225
01740
Waiver of patient room size recommended
PROV0270
01750
Long Term Care cross reference provider number
PROV0640
01930
Long Term Facility is hospital based
PROV1675
02520
Related Provider Number
CODE
PROV1755
02560
Date that payment suspension was recinded
DATE
PROV1825
02570
Admission Suspension Date for New Admissions
DATE
PROV0030
03780
Beds - Intermediate Care Facility
BEDS
24
PROV0945
03790
Direct Care Personnel
FTES
39.00
PROV0780
03800
Long Term Care Agreement Start Date
DATE
05/01/2007
PROV0620
03810
Long Term Care Agreement End Date
DATE
06/30/2008
PROV0625
03820
Long Term Care Agreement Extension Date
DATE
PROV0630
03830
Prior Admission Suspension Date
DATE
PROV1610
03840
Prior Long Tern Care Agreement End Date
DATE
06/30/2007
PROV1630
03850
Prior Long Term Care Agreement Extension Date
DATE
PROV1635
03860
Prior Resend Admission Suspension Date
DATE
PROV1640
03870
Total number of employees
FTES
6600
PROV2850
03880
10G055
GULF COAST CENTER FACILITY II
FORT MYERS, FL 33905
A
Subtype of provider
Long Term
PROV0085
00010
Category of Provider/Supplier
ICF - Mentally Retarded'
PROV0075
00020
Change of Ownership Counter
00
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
350
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
09/11/2007
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
028008900
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
05/05/1980
PROV1565
00160
Date of Prior Change in Ownership
DATE
PROV1615
00170
Prior Intermediary Number
CODE
PROV1620
00180
Provider Number
CODE
10G055
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
FTM
PROV2710
00250
Provider Telephone Number
2396942151
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
State
PROV2885
00310
Provider Zip Code
33905
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12071
FIPCNTY
00340
SSA MSA Code
197
SSAMSACD
00350
SSA MSA Size Code
E
SSAMSASZ
00360
Beds - Total
BEDS
53
PROV0740
00400
Beds - Total Certified
BEDS
53
PROV0755
00410
Compliance - Life Safety Code
CMPL
PROV0240
00480
Fiscal Year Ending Month/Day
0630
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
3.00
PROV0955
00580
Program Participation - Medicare/Medicaid
Medicaid Only
PROV1670
00680
Region Override #1 for Number of Beds
PROV1545
00760
Registered Nurses
FTES
3.00
PROV1145
00790
Waiver of beds per room requirement recommended
PROV0225
01740
Waiver of patient room size recommended
PROV0270
01750
Long Term Care cross reference provider number
PROV0640
01930
Long Term Facility is hospital based
PROV1675
02520
Related Provider Number
CODE
PROV1755
02560
Date that payment suspension was recinded
DATE
PROV1825
02570
Admission Suspension Date for New Admissions
DATE
PROV0030
03780
Beds - Intermediate Care Facility
BEDS
53
PROV0945
03790
Direct Care Personnel
FTES
59.00
PROV0780
03800
Long Term Care Agreement Start Date
DATE
01/01/2008
PROV0620
03810
Long Term Care Agreement End Date
DATE
12/31/2008
PROV0625
03820
Long Term Care Agreement Extension Date
DATE
PROV0630
03830
Prior Admission Suspension Date
DATE
PROV1610
03840
Prior Long Tern Care Agreement End Date
DATE
12/31/2007
PROV1630
03850
Prior Long Term Care Agreement Extension Date
DATE
PROV1635
03860
Prior Resend Admission Suspension Date
DATE
PROV1640
03870
Total number of employees
FTES
6500
PROV2850
03880
10G056
LAKEVIEW COURT
ORLANDO, FL 32810
A
Subtype of provider
Long Term
PROV0085
00010
Category of Provider/Supplier
ICF - Mentally Retarded'
PROV0075
00020
Change of Ownership Counter
00
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040
Provider has Correction Plan for Deficiencies
Compliance Based on Acceptable POC
PROV0220
00060
Provider in Compliance with Correction Plan
In Compliance
PROV2715
00070
Provider County
470
PROV2695
00080
Old Provider Number for this Provider
CODE
PROV0300
00090
Current FMS Survey Date
DATE
PROV0500
00100
Official Survey Date
DATE
11/01/2007
PROV2740
00110
Eligibility for Medicare/Mediciad
Yes
PROV0455
00120
Intermediary/Carrier Servicing Provider
PROV0605
00140
Medicare/Medicaid Vendor Number
CODE
028565000
PROV0655
00150
Date Approved for Medicare/Medicaid
DATE
02/01/1993
PROV1565
00160
Date of Prior Change in Ownership
DATE
PROV1615
00170
Prior Intermediary Number
CODE
PROV1620
00180
Provider Number
CODE
10G056
PROV1680
00190
Current Status of Record
Accepted
PROV1720
00200
CMS Regional Office for Provider
Atlanta
PROV1725
00210
Skeleton Record Indicator
PROV2045
00220
Provider State
FL
PROV3230
00230
SSA State Code
10
PROV2700
00240
State Region Code (in selected states)
ORL
PROV2710
00250
Provider Telephone Number
4076608600
PROV1605
00270
Termination Reason Code
Active
PROV4770
00280
Termination Date/Expriation Date
DATE
PROV4500
00290
Type of Action for Transmittal
Recertification
PROV2880
00300
Type of Control for Provider
Private Non Profit
PROV2885
00310
Provider Zip Code
32810
PROV2905
00320
Provider FIPS State
12
FIPSTATE
00330
Provider FIPS County
12095
FIPCNTY
00340
SSA MSA Code
431
SSAMSACD
00350
SSA MSA Size Code
C
SSAMSASZ
00360
Beds - Total
BEDS
64
PROV0740
00400
Beds - Total Certified
BEDS
64
PROV0755
00410
Compliance - Life Safety Code
CMPL
PROV0240
00480
Fiscal Year Ending Month/Day
1231
PROV0485
00570
Licensed Practical/Vocational Nurses
FTES
8.67
PROV0955
00580
Program Participation - Medicare/Medicaid
Medicaid Only
PROV1670
00680
Region Override #1 for Number of Beds
PROV1545
00760
Registered Nurses
FTES
1.19
PROV1145
00790
Waiver of beds per room requirement recommended
PROV0225
01740
Waiver of patient room size recommended
PROV0270
01750
Long Term Care cross reference provider number
PROV0640
01930
Long Term Facility is hospital based
PROV1675
02520
Related Provider Number
CODE
PROV1755
02560
Date that payment suspension was recinded
DATE
PROV1825
02570
Admission Suspension Date for New Admissions
DATE
PROV0030
03780
Beds - Intermediate Care Facility
BEDS
64
PROV0945
03790
Direct Care Personnel
FTES
56.23
PROV0780
03800
Long Term Care Agreement Start Date
DATE
03/01/2008
PROV0620
03810
Long Term Care Agreement End Date
DATE
02/28/2009
PROV0625
03820
Long Term Care Agreement Extension Date
DATE
PROV0630
03830
Prior Admission Suspension Date
DATE
PROV1610
03840
Prior Long Tern Care Agreement End Date
DATE
02/28/2008
PROV1630
03850
Prior Long Term Care Agreement Extension Date
DATE
PROV1635
03860
Prior Resend Admission Suspension Date
DATE
PROV1640
03870
Total number of employees
FTES
8754
PROV2850
03880
10G057
HILLSBOROUGH CO DEVELOPMENTAL
TAMPA, FL 33613
A
Subtype of provider
Long Term
PROV0085
00010
Category of Provider/Supplier
ICF - Mentally Retarded'
PROV0075
00020
Change of Ownership Counter
00
PROV0095
00030
Change of Ownership Date
DATE
PROV0100
00040