Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help
Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help
LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT SECTION 5 - FACILITY SELF-ASSESSMENT (MOCK SURVEY TOOLS) Facility Self-Assessment - Mock surveys are an opportunity to look at systems, procedures and processes of care and to identify potential survey-risk areas. Mock surveys should be performed on a scheduled basis and shared with nursing home staff. The most important part of the survey process is what you do after it is over with the results. F-tags are used in this section. Be advised that CMS makes revisions to the F-tags on a regular basis. SECTION PAGE # Article: Mock Survey: An Important Component 5. 2 Survey Preparation Self-Assessment/Mock Survey 5.3 Guide to F-Tag Numbers 5.4-5.5 “F” Tag Deficiencies 5.6-5.30 Quality Indicator Report Results 5.31 Process-Survey Tasks 5.32-5.34 Meal Monitor Assignment and Times 5.35 Mock Survey Assignments 5.36 Survey Scope & Severity Grid 5.37-5.38 Resident Review Worksheet 5.39-5.42 General Observations of the Faculty 5.43-5.44 First Impressions Checklist 5.45 Surveyor Notes Worksheet 5.46 Administration Checklist 5.47 Contract Book Checklist 5.48 Personnel File Checklist 5.49 Environment 5.50 Physical Plant Rounds-Initial Tour 5.51-5.56 File Drill Grid 5.57 QA Review: Surveyor Notes Worksheet 5.58-5.59 Nursing 5.60 Resident Review Worksheet 5.61-5.64 Quality of Care 5.65 MDS Audit Tool 5.66 Investigative Protocol Hydration 5.67-5.72 Non-Sterile Dressing Change 5.73 Discharge Records Review 5.74 Chart Audit Tool 5.75-5.76 Med Pass Technique 5.77 CMS-677 Medication Pass Worksheet 5.78-5.80 Dietary 5.81 Dietary Observations 5.82 Monthly Meal Quality Review 5.83 Monthly Sanitation/Infection Control Review 5.84 Meal Audit Tool 5.85 Kitchen/Food Service Observation 5.86-5.87 Updated March 2013
LONG-TERM CARE SURVEY MANUAL PREPARED BY MU NHA CONSULTANT Social Services 5.88 Social Services Audit 5.89 Quality of Life Assessment Observation of 5.90 Non-Interviewable Resident Quality of Life Assessment Resident Interview 5.91 Resident Interview 5.92-5.94 Quality of Life Assessment Family Interview 5.95-5.97 Quality of Life Assessment Group Interview 5.98-5.101 Resident Council Meeting Audit 5.102-5.103 Activities Chart Audit Tool 5.104 Updated March 2013
- Page 1: Facility Self-Assessment (Mock Surv
- Page 5 and 6: Self-Assessment/Mock Survey Today,
- Page 7 and 8: 483.60 PHARMACY F-425 Pharmacy Serv
- Page 9 and 10: F-155 Refusal of Treatment. The res
- Page 11 and 12: deny or withdraw consent at any tim
- Page 13 and 14: F-223 Abuse. The resident has the r
- Page 15 and 16: F-252 Environment. The facility mus
- Page 17 and 18: F-285 Pre-Admission Screening for M
- Page 19 and 20: F-320 Adjustment Difficulty. The fa
- Page 21 and 22: F-353 Nursing Services/Sufficient S
- Page 23 and 24: F-364 Food. Each resident receives
- Page 25 and 26: F-390 Doctor Delegation of Tasks Pe
- Page 27 and 28: F-454 Physical Environment. The fac
- Page 29 and 30: F-494 Required Training NA. The fac
- Page 31 and 32: F-512 Transportation To/From. The f
- Page 33 and 34: QUALITY INDICATOR REPORT RESULTS QI
- Page 35 and 36: Process - Survey Tasks Survey Task
- Page 37 and 38: MEAL MONITOR ASSIGNMENT AND TIMES D
- Page 39 and 40: SURVEY SCOPE & SEVERITY GRID Append
- Page 41 and 42: DEPARTMENT OF HEALTH AND HUMAN SERV
- Page 43 and 44: RESIDENT REVIEW WORKSHEET (continue
- Page 45 and 46: DEPARTMENT OF HEALTH AND HUMAN SERV
- Page 47 and 48: FIRST IMPRESSIONS CHECKLIST Item to
- Page 49 and 50: ADMINISTRATION CHECKLIST Area Yes N
- Page 51 and 52: Instructions: 1. Complete review on
LONG-TERM CARE SURVEY MANUAL<br />
PREPARED BY MU NHA CONSULTANT<br />
SECTION 5 - FACILITY SELF-ASSESSMENT (MOCK SURVEY TOOLS)<br />
<strong>Facility</strong> <strong>Self</strong>-<strong>Assessment</strong> - <strong>Mock</strong> surveys are an opportunity to look at systems, procedures and<br />
processes of care and to identify potential survey-risk areas. <strong>Mock</strong> surveys should be performed<br />
on a scheduled basis and shared with nursing home staff. The most important part of the survey<br />
process is what you do after it is over with the results. F-tags are used in this section. Be advised<br />
that CMS makes revisions to the F-tags on a regular basis.<br />
SECTION PAGE #<br />
Article: <strong>Mock</strong> <strong>Survey</strong>: An Important Component 5. 2<br />
<strong>Survey</strong> Preparation<br />
<strong>Self</strong>-<strong>Assessment</strong>/<strong>Mock</strong> <strong>Survey</strong> 5.3<br />
Guide to F-Tag Numbers 5.4-5.5<br />
“F” Tag Deficiencies 5.6-5.30<br />
Quality Indicator Report Results 5.31<br />
Process-<strong>Survey</strong> Tasks 5.32-5.34<br />
Meal Monitor Assignment and Times 5.35<br />
<strong>Mock</strong> <strong>Survey</strong> Assignments 5.36<br />
<strong>Survey</strong> Scope & Severity Grid 5.37-5.38<br />
Resident Review Worksheet 5.39-5.42<br />
General Observations of the Faculty 5.43-5.44<br />
First Impressions Checklist 5.45<br />
<strong>Survey</strong>or Notes Worksheet 5.46<br />
Administration Checklist 5.47<br />
Contract Book Checklist 5.48<br />
Personnel File Checklist 5.49<br />
Environment 5.50<br />
Physical Plant Rounds-Initial Tour 5.51-5.56<br />
File Drill Grid 5.57<br />
QA Review: <strong>Survey</strong>or Notes Worksheet 5.58-5.59<br />
<strong>Nursing</strong> 5.60<br />
Resident Review Worksheet 5.61-5.64<br />
Quality of Care 5.65<br />
MDS Audit <strong>Tool</strong> 5.66<br />
Investigative Protocol Hydration 5.67-5.72<br />
Non-Sterile Dressing Change 5.73<br />
Discharge Records Review 5.74<br />
Chart Audit <strong>Tool</strong> 5.75-5.76<br />
Med Pass Technique 5.77<br />
CMS-677 Medication Pass Worksheet 5.78-5.80<br />
Dietary 5.81<br />
Dietary Observations 5.82<br />
Monthly Meal Quality Review 5.83<br />
Monthly Sanitation/Infection Control Review 5.84<br />
Meal Audit <strong>Tool</strong> 5.85<br />
Kitchen/Food Service Observation 5.86-5.87<br />
Updated March 2013
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