Nursing Home Medicare/Medicaid Compliance Form
This Nursing Home Medicare/Medicaid Compliance Form serves as a comprehensive tool to assess and document compliance with Medicare and Medicaid regulations. Please complete all sections accurately to ensure adherence to legal standards and provide high-quality care to residents.
Facility Name: | [Your Company Name] |
Facility Address: | [Your Company Address] |
Facility ID Number: | [000-0000] |
Date of Evaluation: | [Month, Day, Year] |
Section 1: General Information |
Administrator's Name: | |
Director of Nursing's Name: | |
Medicare/Medicaid Certification Date: | |
Section 2: Compliance Checklist
Please check the appropriate box for each item to indicate compliance.
A. Patient Rights
Resident Rights
Advance Directives
Freedom from Abuse and Neglect
B. Quality of Care
Physician Services
Nursing Services
Rehabilitation Services
C. Quality of Life
Activities Program
Dining Services
Environment
Section 3: Summary and Recommendations |
Summary of Compliance Status: | |
Recommendations for Improvement: | |
Section 4: Certification
I certify that, to the best of my knowledge, the information provided in this Medicare/Medicaid Compliance Form is accurate and complete.
[Month, Day, Year]
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