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

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CMS-677 MEDICATION PASS WORKSHEET 1. Observe 10 opportunities for error. If one or more errors are found, observe another five opportunities. 2. Record your observation for each opportunity for error on the Medication Pass Worksheet. 3. Compare your record with the Physician Orders. 4. Calculate and note error rate. (For calculation, see CMS-677) 5.78
DEPARTMENT OF HEALTH AND HUMAN SERVICES CENTERS FOR MEDICARE & MEDICAID SERVICES MEDICATION PASS WORKSHEET Provider Number <strong>Survey</strong>or Name Date Error Rate Instructions: 1. Observe Pass for 20-25 opportunities for error. If one or more errors is found observe another 20-25 opportunities for error. 2. Record your observation of each opportunity for error. 3. Compare your record with physician orders. 4. Calculate and note error rate Deficiency Formulas: Significant Error + Non-Significant Error 1. One or more Significant Errors = Deficiency X 100 ≥ 5% = Deficiency 2. Doses given + Doses ordered but not given Identifier Pour Pass Record Resident’s Full Name Drug Prescription Name, Dose and Form Observation of Administration Drug Order Written As (when different from observation) FORM CMS-677 (07/95) 5.79
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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
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F-364 Food. Each resident receives
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F-390 Doctor Delegation of Tasks Pe
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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 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: 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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