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
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES Facility Name: Observation Dates: From --------- To ------ SURVEYOR NOTES WORKSHEET Surveyor Provider Name: Number: Surveyor Number: Discipline: TAG/CONCERNS DOCUMENTATION Form CMS-807 (7/95) 5.46
ADMINISTRATION CHECKLIST Area Yes No Comments Past survey reports displayed Medicare/Medicaid benefit information displayed Resident Trust Fund Balanced Surety Bond equals one and one half times the total amount of the average resident fund balance Ombudsman information posted Private access to a telephone available for residents Administrator licensure current Contract book current Safety Committee meetings held regularly Disclosure of ownership Bed Reconciliation form Waiver(s) available if applicable Daily Nursing staffing posted and current 5.47
- 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 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: FIRST IMPRESSIONS CHECKLIST Item to
- 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: DEPARTMENT OF HEALTH AND HUMAN SERV
- 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
DEPARTMENT OF HEALTH AND HUMAN<br />
SERVICES CENTERS FOR MEDICARE &<br />
MEDICAID SERVICES<br />
<strong>Facility</strong> Name:<br />
Observation Dates: From ---------<br />
To ------<br />
SURVEYOR NOTES WORKSHEET<br />
<strong>Survey</strong>or Provider Name: Number:<br />
<strong>Survey</strong>or Number:<br />
Discipline:<br />
TAG/CONCERNS<br />
DOCUMENTATION<br />
Form CMS-807 (7/95)<br />
5.46
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