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

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CONTRACT BOOK CHECKLIST Contract License Insurance Comments Activities Consultant Audiologist Background Check Barber/Beauty Biohazardous Waste Blood Products Cable TV CLIA Waiver N/A N/A Dentist Dialysis (all providers) Electrical E.T. Nurse (Wound Nurse) Facility Insurance N/A N/A Fire Alarm P/M Hospice (all providers) N/A Laboratory Landscaping N/A Medical Director Medical Records Consultant Mobile x-ray Modified Barium Study Nursing Agency (supplemental staffing) Optometrist Oxygen Pest Control Pharmacy Pharmacy Consultant Podiatrist Psychiatrist Psychologist RT Agreement N/A N/A Radon Testing N/A N/A Dietitian Consultant Social Services Consultant Sprinkler System P/M Surety Bond N/A N/A Therapy PT Therapy OT Therapy SLP Therapy RT Transfer Agreement N/A Utilization Review N/A N/A 5.48
Instructions: 1. Complete review on charts indicated in columns across 2. Indicate with a √ if complete 3. Utilize “I” for incomplete 4. Utilize “N/A” for not applicable 5. D/H = department head Criteria Requirement R.N. R.N. L.P.N. L.P.N. C.N.A. C.N.A. D/H D/H HRLY HRLY Comments Hiring Information Pre-Employment References Credentials/License Verified Orientation Checklist for General Orientation Checklist for Dept. Orientation Signature Resident Rights Standards of Conduct Employee Handbook > Facility Policies Fire & Disaster Plan State Specific: Abuse & Neglect Separate Personnel Medical File: TB Testing Records (keep in a HepB separate Consents/documentation location from personnel file and with very Criminal Background checks I-9 Information limited access) EDL checked Other Family Care Registry C.N.A. Registry OIG Drug testing PERSONNEL FILE CHECK LIST 5.49
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 47 and 48: FIRST IMPRESSIONS CHECKLIST Item to
Page 49: ADMINISTRATION CHECKLIST Area Yes N
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 95 and 96: RESIDENT INTERVIEW 6. STAFF: (F223,
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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