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

QA Review
DEPARTMENT OF HEALTH AND HUMAN
SERVICES HEALTH CARE FINANCING
ADMINISTRATION
SURVEYOR NOTES WORKSHEET
Facility Name:
Surveyor Name:
Provider Number: Surveyor Number: Discipline:
Observation Dates: From
to
Part 1 -complete after Phase 2 Sampling meeting:
I. List the committee members or attach a list provided by facility:
Name:
Department/Title:
ll. Review the facility ·l- plan or written description of the Committee’s process for identifying quality deficiencies. Recap the
methods.
Ill.
Interviews with administrative staff and QNA Committee members:
Person interviewed:
Can list the
members of the
committee:
Can state how
often the
committee
meets?
Can state methods of
identifying issues in the
facility which require
QA/A activities?
Verbalizes methods to
respond to identified
quality deficiencies and
that evaluates the
effectiveness of that
response?
Y-N Y-N Y-N Y-N
Y-N Y-N Y-N Y-N
Y-N Y-N Y-N Y-N
Y-N Y-N Y-N Y-N
FORM HCFA-807 (7-951
5.58