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

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Task 6: Determination of Compliance: Compliance with 42 CFR 483.35(d)(1)(2), F364, Food o The facility is compliant with this requirement when each resident receives food prepared by methods that conserve nutritive value, palatable, attractive and at the proper temperatures. If not, cite F364. Compliance with 42 CFR 483.35(b), F362, Dietary services, sufficient staff o The facility is compliant with this requirement if they have sufficient staff to prepare and serve palatable and attractive, nutritionally adequate meals at proper temperatures. If not, cite F362. NOTE: If serving food is a function of the nursing service rather than dietary, refer to 42 CFR 483.30(a), F353. Compliance with 42 CFR 483.15(h)(1), F252, Environment 5.72
NON-STERILE DRESSING CHANGE <strong>Facility</strong>: Nurse: Date: Objective: To prevent cross contamination and maintain standard infection control techniques. Item # Procedure Met Not Met Comments 1 Check treatment order 2 Gather necessary equipment: - Plastic bag - Bed protector - Clean towel or towel paper for clean field - Dressing supplies - Cleaning solution – check expiration date - Medication ordered of treatment, if any - Gloves 3 Inform resident of procedure; provide privacy, position resident; place bed protector on bed 4 Wash hands; put on gloves 5 Remove dirty dressing and place in plastic bag 6 Remove gloves and place in plastic bag 7 Wash hands 8 Set up clean field; prepare supplies (open dressings, etc.) 9 Put on gloves Perform treatment (wound can be measured 10 at this time) a. Clean from inner edge of wound out b. Perform treatment according to orders and apply dressing c. Discard all waste in plastic bag 11 Remove gloves and place in plastic bag 12 Wash hands 13 Reposition resident for comfort Record treatment and return supplies to 14 proper areas General Comments: 5.73
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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
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F-252 Environment. The facility mus
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F-285 Pre-Admission Screening for M
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F-320 Adjustment Difficulty. The fa
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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 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: esidents with vision or swallowing
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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