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

1. Resident Rights

• Information on rights provided to residents upon admission.

• Posting of residents' rights in a visible location.

• Assurance of residents' rights during care delivery.

• Documentation of residents' rights training for staff.

2. Advance Directives

• Policy in place for advance directives.

• Documentation of advance directive discussions with residents.

• Compliance with resident wishes regarding advance directives.

3. Freedom from Abuse and Neglect

• Policy to prevent abuse and neglect.

• Procedures for reporting and investigating allegations of abuse or neglect.

• Documentation of abuse/neglect investigations and actions taken.

B. Quality of Care

1. Physician Services

• Arrangements for physician services.

• Physician visits as required by regulations.

• Documentation of physician orders and visits.

2. Nursing Services

• Skilled nursing services provided as needed.

• Nursing care plans developed and implemented.

• Documentation of nursing assessments and interventions.

3. Rehabilitation Services

• Availability of rehabilitation services.

• Rehabilitation goals established and monitored.

• Documentation of rehabilitation services provided.

C. Quality of Life

1. Activities Program

• Activities program tailored to resident preferences.

• Provision of individual and group activities.

• Documentation of resident participation in activities.

2. Dining Services

• Nutritious and appetizing meals provided.

• Accommodation of special dietary needs.

• Documentation of dietary assessments and interventions.

3. Environment

• Clean and well-maintained facility.

• Safe and comfortable living spaces.

• Compliance with regulations regarding resident accommodations.

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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