Long-Term Care Survey Alert

A copy of the actual working schedule for RN/LPNs for the survey period

Facility policies and procedures to prohibit and investigate allegations of abuse (also the name of the person designated by the administrator to answer questions about what the facility does to prevent abuse)

List of key facility personnel and their location

Meal times, dining locations and copies of all menus, including therapeutic diets that will be served during the course of the survey

Medication pass times, by unit

List of residents admitted during the past month and a list of residents transferred or discharged during the past 3 months (include the date of transfer/discharge and the locations)

Facility layout (floor plan)

A copy of the facility admission contract(s) for all residents (Medicare, Medicaid, other payment sources)

Evidence of the system used to monitor accidents and incidents; evidence of analysis of this data to prevent further accidents and incidents

Activity calendar and schedule

Resident council and president/representatives name and room number

Minutes from the last 3 months of the resident council meetings

The names of residents who communicate with non-oral communication devices, sign language, or who speak a language other than the dominant language of the facility

Procedures to provide water in the case of an emergency

List of employees hired within the past 4 months, with the dates of hire; proof of criminal background check, if required by state law and/or proper screening

Copy of CLIA waiver (if facility has waiver); copies of other waivers;

The team leader will also request that you complete the following forms:

CMS 671: LTC Facility

Application for Medicare and Medicaid

CMS 1513: Disclosure of Ownership

CMS 802: Resident Roster/Sample Matrix

CMS 672: Resident Census and Condition Report