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

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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
SURVEYOR NOTES WORKSHEET Part 2 - complete if/when deficient practice/s have been identified as Pattern or Widespread: Interviews with: Committee member name: Knows quality deficiencies the facility identified? Identifies some systems that have been developed & implemented to address those deficiencies? Can identify areas that have been evaluated or will be evaluated for the effectiveness of the planned intervention? Describe a sample of the quality deficiencies they have identified and dealt with. Y-N Y-N Y-N Y-N Y-N Y-N Y-N Y-N Y-N Y-N Y- N Y-N Direct care staff name: Knows how the QNA Committee functions? Knows what the QNA process is? Knows how to access the QNA process & Committee? Identifies if the QNA Committee is responsive to the concerns submitted to it? Verbalizes specific plans for care described by the QNA Committee Comments: 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 {7-95) 5.59
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 and 50: ADMINISTRATION CHECKLIST Area Yes N
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: FIRE DRILL GRID JAN FEB MAR APR MAY
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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