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

Process – Survey Tasks
Survey Task Responsible Action Item Reference
Five: (continued)
End of Day
Team
Conduct Individual resident Interviews x 2
Team conference to
CMS-806A Resident Interview
review findings to
Observe non-interviewable resident x 2
plan Day Two
CMS-806A Observation of non-
Mean Observation
interviewable resident
Environment Review
Abuse Prevention
CMS-806C Family Interview
Review smokers for Smoking Standard Compliance
Review the criteria in the RCC Addendum, if applicable
CMS-803 General Observations of
facility
Smoking Policy
Six:
Determine
Deficiencies
Day Two Afternoon
Seven:
Exit Conference
Day Two Afternoon
Team
Team
Decide which F-Tags and Standards are not in place.
Review Findings with facility team.
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