Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help

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RESIDENT COUNCIL MEETING AUDIT 1. Arrange for a Resident Council Meeting with interviewable residents. 2. Use probe questions to ascertain if issues are met/not met. 3. Circle potential deficiencies. 4. <strong>Facility</strong> staff should not be present at this meeting. TOPIC TAG# QUESTIONS/PROBES MET NOT MET Food F-364 How does the food taste? Quality F-367 Are you on a special diet? Snacks F-364 Are you served food you like to eat? Temps F-364 Are your hot foods hot? Temps F-364 Are your cold foods cold? Mealtime F-366 Have you ever refused to eat something? Did the facility offer you something else? Snacks F-368 Are you offered snacks in the evening? Privacy F-164 Do you like your privacy? Do you get it? Visitors F-172 Do you have a private place to meet with visitors? Phone F-174 Where do you make a phone call? Is it private? Possessions F-223 Has anyone taken anything of yours without permission? Mail F-170 Is your mail delivered when received? Is your mail delivered unopened? Privacy F-460 Do you have privacy when examined by a physician? Choice F-246 Tell me about your room and how you feel about it. Environment F-252 Do you enjoy spending time in your room? Individual Choice Transfer F-201 F-155 F-177 Choice F-246 F-242 F-465 F-253 F-252 Choice Physician Adv. Dir Activities F-248 F-246 Dignity Grievance F-165 F-166 F-256 Is there enough light for you? Is the temperature comfortable? Have you ever lived in a different room in the facility? Did you have a choice about room changes? Where was your other room? Is there anything you would like to change about your room? Have you asked the facility? Is it quiet or noisy? Does the staff try and make it homey? Can you choose how you spend the day? F-155 Have you refused a medication or treatment? What happened then? F-163 Who is your physician? Did you choose your physician yourself? F-156 Did you choose to do Advanced Directives? Are there activities on the weekends? How do you find out about activities? Is there some activities you would like to do F-246 Are you treated with respect? that Does is the not staff available know here? you as a person? Have Are they you willing talked with to listen anyone to you else? if you have a problem? Do they try to solve your problems? COMMENTS 5.102
Abuse Neglect Call lights Care needs met Medical Condition Finance Charges Trust Fund Ombudsman <strong>Survey</strong> Rights F-223 F-165 Has anyone physically harmed you? Has any staff member yelled or swore at you? Did you tell anyone? What happened? If you are unhappy with something, how do you let the facility know? Does the staff listen and respond to your requests? If they can’t honor your request, do they give you a reasonable explanation? F-241 Does the staff answer your call bell/light when you put it on? F-311 F-310 F-328 F-385 F-387 F-411 F-156 F-162 Do you get help when you need it? Does the staff encourage you to do as much as you can for yourself? How about your nursing care and treatment? Do you participate in meetings where your care plan is discussed? If not, does someone discuss your plan of care with you? Are you satisfied with the care provided by your physician? Can you see a doctor if you need to? Do you see the doctor here or at the office? How do you get to the doctor’s office? Does the facility help you make appointments and arrange transportation? Can you see the podiatrist, dentist, optometrist or other specialist if you need to? Do you know how to get in touch with the Medicaid & Medicare office about your bill? Does the facility explain charges to you? F-159 Can you get money from your trust fund when you need it? F-168 Do you know how to call the Ombudsman? F-169 Have you seen the facility’s survey results? F-151 Did you have an opportunity to vote in the last election? GENERAL COMMENTS: __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ __________________________________________________________________________________________________ 5.103
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Facility Self-Assessment (Mock Surv
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LONG-TERM CARE SURVEY MANUAL PREPAR
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Self-Assessment/Mock Survey Today,
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483.60 PHARMACY F-425 Pharmacy Serv
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F-155 Refusal of Treatment. The res
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deny or withdraw consent at any tim
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F-223 Abuse. The resident has the r
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F-252 Environment. The facility mus
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F-285 Pre-Admission Screening for M
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F-320 Adjustment Difficulty. The fa
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F-353 Nursing Services/Sufficient S
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F-364 Food. Each resident receives
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F-390 Doctor Delegation of Tasks Pe
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F-454 Physical Environment. The fac
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F-494 Required Training NA. The fac
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F-512 Transportation To/From. The f
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QUALITY INDICATOR REPORT RESULTS QI
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Process - Survey Tasks Survey Task
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MEAL MONITOR ASSIGNMENT AND TIMES D
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SURVEY SCOPE & SEVERITY GRID Append
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DEPARTMENT OF HEALTH AND HUMAN SERV
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RESIDENT REVIEW WORKSHEET (continue
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DEPARTMENT OF HEALTH AND HUMAN SERV
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FIRST IMPRESSIONS CHECKLIST Item to
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ADMINISTRATION CHECKLIST Area Yes N
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Instructions: 1. Complete review on
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Page 59 and 60: FIRE DRILL GRID JAN FEB MAR APR MAY
Page 61 and 62: SURVEYOR NOTES WORKSHEET Part 2 - c
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Page 65 and 66: RESIDENT REVIEW WORKSHEET (continue
Page 67 and 68: QUALITY OF CARE Use probes regardin
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Page 79 and 80: MED PASS TECHNIQUE Resident Name/Ro
Page 83 and 84: DIETARY 5.81
Page 85 and 86: MONTHLY MEAL QUALITY REVIEW DATE: F
Page 87 and 88: Date: Person assigned: Specific are
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Page 91 and 92: SOCIAL SERVICES AUDIT Date: Unit #:
Page 95 and 96: RESIDENT INTERVIEW 6. STAFF: (F223,
Page 99 and 100: FAMILY INTERVIEW 5. (For all the it
Page 101 and 102: GROUP INTERVIEW 3. ACTIVITIES: (F24
Page 103: GROUP INTERVIEW 11. COUNCIL: (F243)
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