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

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RESIDENT REVIEW WORKSHEET (continued) Tag/Concerns Source* <strong>Survey</strong>or Notes (including date/time) *Source: O=Observation RR=Record Review, I=Interview Form CMS-805(7-95) 5.64
QUALITY OF CARE Use probes regarding Anticoagulants, blood glucose, pain, falls, smoking, change of condition, pressure ulcers & abuse investigation to guide information gathering. Compare any negative answers to the intent of the regulation. Deficiencies should be cited only if the intent of the regulation is not met. Missing standard components addressed only under “standards not in compliance” section of FQR Score. F309 Anticoagulants: The lab work for residents on Coumadin is completed as ordered? Documentation of Physician notification and assessment complete for abnormal INR/PT results? F309 Blood Glucose: Are Blood Glucose levels obtained as ordered? Is assessment of resident with abnormal levels present? F309 Pain Pain assessment, interventions and follow-up documentation are clearly evident? F323 Falls: Post falls assessment completed and appropriate? Interventions on plan of care are evident on physical review of resident? Care plan appropriate to falls? F323 Smoking: Are smoking safety assessments completed on all residents who smoke? When observing the resident that smoke is it evident that the safety interventions identified are in place? F309/F157 Change of Condition: Timely assessment and physician notification is evident on any acute change of condition episodes. F314 Skin/Pressure Ulcers: Residents with pressure ulcers have had timely accurate assessment of wound? When resident with pressure ulcers are observed are all interventions identified on the care plan observed to be in place? F225 Verification of Investigation: All incidents are thoroughly investigated and documentation includes evidence of determining causal factors and recommendations to prevent reoccurrence? Recommendations to prevent reoccurrence identified o the investigations are observed on visual checks of resident or environment. 5.65
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Facility Self-Assessment (Mock Surv
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LONG-TERM CARE SURVEY MANUAL PREPAR
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Self-Assessment/Mock Survey Today,
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483.60 PHARMACY F-425 Pharmacy Serv
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F-155 Refusal of Treatment. The res
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deny or withdraw consent at any tim
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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 and 60: FIRE DRILL GRID JAN FEB MAR APR MAY
Page 61 and 62: SURVEYOR NOTES WORKSHEET Part 2 - c
Page 65: RESIDENT REVIEW WORKSHEET (continue
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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