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

More documents

Recommendations

Info

MONTHLY SANITATION/INFECTION CONTROL REVIEW DATE: FACILITY: REVIEWER: AREAS OF OBSERVATION POINTS COMMENTS 1. FIRST IMPRESSION of dietary cleanliness from dietary entrance is favorable. 8 4 0 2. Floor is clear of trash and food particles. 4 2 0 3. Walls are free of splatters, damage, peeling paint, paper clutter, etc. Papers are all in covers on clean bulletin board(s). 4 2 0 4. Ceiling is in good repair and appears clean, with clean, unbroken light fixtures - all bulbs working/bulbs covered. 4 2 0 5. Hood is free of grease, operational, lights work, extinguisher nozzles free of grease/dust, filters clean. 4 2 0 6. In dry storage, food is off floor by 6”, on sanitizable shelves, 18” from ceiling, all food is in enclosed clean containers if opened. Food is neatly arranged/dated and FIFO. No empty 4 2 0 boxes and damaged products are grouped for return. 7. In refrigerated/freezer storage, food is neatly arranged on clean shelving. Thermometers register less than 41 degrees F. 4 2 0 or 0 degrees F. for freezer. 8. All opened food is labeled/dated, and covered. 4 2 0 9. There are no smudges, fingerprints, dried food particles on refrig./freezer outside surfaces. 2 1 0 10. Nonfood and chemicals are stored away from food. 3 1 0 11. Walk-in, floors dry, clean fans, covered lighting. 2 1 0 12. Inside and outside of all cooking equipment is clean. 4 2 0 13. All work surfaces, under shelves and legs are free of food/dirt/dust/grease build-up. 3 1 0 14. All surfaces are free of rust. 2 1 0 15. Prep. equipment/dishes/utensils are effectively sanitized and properly stored. 4 2 0 16. Food transport prevents contamination. 3 1 0 17. Sewage and plumbing meet state or local law. 3 1 0 18. All refuse containers are covered/clean/adequate. 3 1 0 19. Frozen foods are thawed properly. 3 1 0 20. Safe water source with sufficient hot/cold water under pressure. 3 1 0 21. The can opener is clean/blade not badly worn 3 1 0 22. There are sufficient cleaning cloths in good condition. 2 1 0 23. The pot/pan sink is used properly. 3 1 0 24. Hairnets are on/dress appropriate/no nail polish. 3 1 0 25. All carts are clean – including wheels. 2 1 0 26. Manager’s office is free of clutter/organized. 3 1 0 27. Only NSF approved food storage containers are used for leftovers, opened items, etc. 3 1 0 28. Slicer and mixer bowl are covered when unused. 2 1 0 29. There is no sign of pest infestation. 3 1 0 30. All equipment is working properly. 3 1 0 31. Mops are hung-up, brooms, etc. stored properly. 2 1 0 CIRCLE POINTS ACCORDING TO FINDINGS. COMMENT ON ALL COLUMN 3 FINDINGS. Column 1 = Excellent; Column 2 = Improvements needed; Column 3 = Unacceptable RECORD THE SUM OF ALL POINTS CIRCLED _______________ (THERE ARE 100 POSSIBLE POINTS.) A SCORE OF LESS THAN 75 REQUIRES FOLLOW-UP BY ADMINISTRATOR & MANAGER WITHIN 7 DAYS. 5.84
Date: Person assigned: Specific area to monitor: Time meal starts: B_________ L MEAL AUDIT TOOL D Meals are posted and served per menu. Alternate is posted. Residents are served in a timely manner. Correct diets are served to the residents according to their meal card. Staff are assisting residents with meals as needed and not talking over residents to other staff. Meal started on time. Staff washed hands before passing trays and as needed during meal service. Residents are appropriately groomed and ready for meal service. Breakfast Lunch Dinner 5.85
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 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 and 80: MED PASS TECHNIQUE Resident Name/Ro
Page 83 and 84: DIETARY 5.81
Page 85: MONTHLY MEAL QUALITY REVIEW DATE: F
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
show all

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

You also want an ePaper? Increase the reach of your titles

Delete template?

Save as template?