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
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Process – <strong>Survey</strong> Tasks<br />
<strong>Survey</strong> Task Responsible Action Item Reference<br />
Four: (continued) <strong>Nursing</strong> Team Observe Medication Pass<br />
Task 5-E Medication Pass, Pages P-59 to P-<br />
Day Two<br />
60<br />
Morning<br />
Observe Treatments<br />
CMS-677 Medication Pass Worksheet<br />
Treatment Observation Sheet<br />
Adm<br />
Review <strong>Facility</strong> quality Assurance Program<br />
Task 5-F LTC Manual<br />
Determine if committee has method to identify, respond and evaluate<br />
identified problems.<br />
Wandering and At<br />
Risk for Elopement Policies<br />
Review 3 months minutes/Actions Plans and Follow-Up.<br />
Interview 1 CNA, 1 Nurse and 1 Department Head regarding QA Program<br />
knowledge<br />
Safety Committee<br />
Meeting Minutes<br />
Adm<br />
Conduct Resident Group Interviews. Review<br />
CMS-806B Group Interview<br />
Activity and Grievance programs.<br />
Adm<br />
Resident Trust Fund – Internal Audit Criteria<br />
<strong>Facility</strong> Petty Cash – Internal Audit Criteria<br />
Five:<br />
Information<br />
Gathering<br />
Team<br />
Conduct comprehensive reviews. Record any concerns on Exhibit<br />
Worksheets. Begin focused reviews. Record any concerns on Exhibit<br />
Worksheet<br />
<strong>Survey</strong> Manual, Exhibit 93, Pages 1-4<br />
<strong>Survey</strong> Manual, Exhibit 95<br />
Day One<br />
All Day<br />
Team<br />
Kitchen Observation<br />
Meal Observation<br />
CMS-804 Kitchen/Food Observation<br />
12:00 noon<br />
Team lunch to<br />
review morning<br />
findings<br />
Focused Review: Weight Loss/Hydration<br />
5.33