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

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ACTIVITIES CHART AUDIT TOOL Area of Review <strong>Assessment</strong> Timely, within 14 days Thorough Complete Care Plan Modified as needed Goals discontinued appropriately MDS Section F Progress Notes Quarterly Evidence assessment reviewed Reassessments Significant change Annual Activity Participation Record Maintained Separate record each resident Resident ID In-Room Activities 3x a week for those unable to leave their room 1x per week for those who refuse group activities Therapeutic goals documented Discharge Summary Completed / Interdisciplinary 5.104
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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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Facility: PHYSICAL PLANT ROUNDS - I
Page 55 and 56: PHYSICAL PLANT ROUNDS - INITIAL TOU
Page 57 and 58: PHYSICAL PLANT ROUNDS - INITIAL TOU
Page 59 and 60: FIRE DRILL GRID JAN FEB MAR APR MAY
Page 61 and 62: SURVEYOR NOTES WORKSHEET Part 2 - c
Page 63 and 64: DEPARTMENT OF HEALTH AND HUMAN SERV
Page 65 and 66: RESIDENT REVIEW WORKSHEET (continue
Page 67 and 68: QUALITY OF CARE Use probes regardin
Page 69 and 70: INVESTIGATIVE PROTOCOL HYDRATION Ob
Page 71 and 72: developed a care plan that includes
Page 73 and 74: esidents with vision or swallowing
Page 75 and 76: NON-STERILE DRESSING CHANGE Facilit
Page 77 and 78: CHART AUDIT TOOL FOCUS REVIEW RELAT
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
Page 89 and 90: KITCHEN/FOOD SERVICE OBSERVATION Ta
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 and 104: GROUP INTERVIEW 11. COUNCIL: (F243)
Page 105: Abuse Neglect Call lights Care need
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Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help

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