Facility Information

Nursing Home Name:

Address:

Phone Number:

Email:

Website:

Audit Information

Date of Audit:

Auditor Name:

Auditor Position:

Federal Regulations

Are all federal regulations outlined in the Code of Federal Regulations (CFR) Title 42, Chapter IV, Subchapter G, Part 483 being met?

• Yes

• No

If No, provide details:

State Regulations

Are all state regulations outlined in [State] Administrative Code, Chapter [Chapter Number], being met?

• Yes

• No

If No, provide details:

Staffing

Is the facility adequately staffed to provide appropriate care to residents?

• Yes

• No

If No, provide details:

Quality of Care

Is the quality of care provided to residents in compliance with established standards?

• Yes

• No

If No, provide details:

Medical Services

Are medical services, including physician visits and medication management, provided according to residents' needs?

• Yes

• No

If No, provide details:

Cleanliness

Is the facility clean and well-maintained?

• Yes

• No

If No, provide details:

Safety Measures

Are safety measures, such as fall prevention and emergency preparedness, in place and effective?

• Yes

• No

If No, provide details:

Accessibility

Is the facility accessible to residents with mobility impairments?

• Yes

• No

If No, provide details:

Privacy and Dignity

Are residents' privacy and dignity respected?

• Yes

• No

If No, provide details:

Freedom from Abuse and Neglect

Are residents free from abuse and neglect?

• Yes

• No

If No, provide details:

Informed Consent

Are residents provided with adequate information to make informed decisions about their care?

• Yes

• No

If No, provide details:

Medical Records

Are residents' medical records accurate, complete, and up-to-date?

• Yes

• No

If No, provide details:

Documentation of Care

Is documentation of care provided to residents completed in a timely and thorough manner?

• Yes

• No

If No, provide details:

Training Programs

Are staff members adequately trained to perform their duties?

• Yes

• No

If No, provide details:

Continuing Education

Are staff members provided with opportunities for continuing education and professional development?

• Yes

• No

If No, provide details:

Quality Assurance Programs

Does the facility have quality assurance programs in place to monitor and improve the quality of care?

• Yes

• No

If No, provide details:

Incident Reporting and Analysis

Are incidents reported and analyzed to prevent future occurrences?

• Yes

• No

If No, provide details:

Recommendations

Follow-Up Action Plan

(Outline steps to be taken to address deficiencies identified during the audit)

Audit Summary

Overall Compliance Rating:

• Satisfactory

• Partially Satisfactory

• Unsatisfactory