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

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Process – Survey Tasks Survey Task Responsible Action Item Reference One: Team Review QI Profile, Facility Characteristics Report, OSCAR Data, Survey Survey Manual: Appendix P Survey Preparation History of facility Pages P-5 to P-11 Before FQR Phase One – Sample selection from 6 month QI Profile and Resident Level QI Summary. Select one half of sample size that Table 1 (p-23) would indicate. Pre-identify any possible focus areas (flagged indicators, sentinel events, above 75 th ) Make copies of all Exhibit Worksheets Two: Entrance Conference Day One Team Conduct entrance conference with Administrator and Department Heads. Request materials (Survey Readiness Book). Identify facility personnel to assist with tour. Survey Manual: Appendix P Pages P-11 to P-15 CMS-805 Resident Review Worksheet CMS-803 General Observation of Facility First Impressions Checklist Three: Initial Tour Team Validate that residents pre-selected in Task One are still present. Identify possible other residents to add to the Phase One sample. Survey Manual: Appendix P Pages P17 to P-23 Day One Identify other issues that may require investigation (i.e. restraint use, hydration, grooming, elopements, reportable events, falls) Four: Sample Selection Team Finalize Phase One sample. Pull records and begin comprehensive/focused reviews. Survey Manual: Appendix P Pages P-17 to P-23 Day One Day Two Morning Team Discuss focused areas based on results of comprehensive reviews and day one observations. Survey Manual, Pages P-7 to P-21 CMS-805 Resident Review Worksheet Select Phase Two Sample. Conduct focused reviews. Complete focused reviews (if not completed on day one) 5.32
Process – Survey Tasks Survey Task Responsible Action Item Reference Four: (continued) Nursing Team Observe Medication Pass Task 5-E Medication Pass, Pages P-59 to P- Day Two 60 Morning Observe Treatments CMS-677 Medication Pass Worksheet Treatment Observation Sheet Adm Review Facility quality Assurance Program Task 5-F LTC Manual Determine if committee has method to identify, respond and evaluate identified problems. Wandering and At Risk for Elopement Policies Review 3 months minutes/Actions Plans and Follow-Up. Interview 1 CNA, 1 Nurse and 1 Department Head regarding QA Program knowledge Safety Committee Meeting Minutes Adm Conduct Resident Group Interviews. Review CMS-806B Group Interview Activity and Grievance programs. Adm Resident Trust Fund – Internal Audit Criteria Facility Petty Cash – Internal Audit Criteria Five: Information Gathering Team Conduct comprehensive reviews. Record any concerns on Exhibit Worksheets. Begin focused reviews. Record any concerns on Exhibit Worksheet Survey Manual, Exhibit 93, Pages 1-4 Survey Manual, Exhibit 95 Day One All Day Team Kitchen Observation Meal Observation CMS-804 Kitchen/Food Observation 12:00 noon Team lunch to review morning findings Focused Review: Weight Loss/Hydration 5.33
Page 1 and 2: Facility Self-Assessment (Mock Surv
Page 3 and 4: LONG-TERM CARE SURVEY MANUAL PREPAR
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: QUALITY INDICATOR REPORT RESULTS QI
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 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 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 93 and 94:
DEPARTMENT OF HEALTH AND HUMAN SERV
Page 95 and 96:
RESIDENT INTERVIEW 6. STAFF: (F223,
Page 97 and 98:
DEPARTMENT OF HEALTH AND HUMAN SERV
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
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Facility Self-Assessment (Mock Survey) Tool - Nursing Home Help

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