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

More documents

Recommendations

Info

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
Page 53 and 54:
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 81 and 82:
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 93 and 94:
Page 95 and 96:
RESIDENT INTERVIEW 6. STAFF: (F223,
Page 97 and 98:
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 and 106:
Abuse Neglect Call lights Care need
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?