60 Essential Forms · 60 EssEntial Forms For long-tErm CarE DoCumEntation Form 1.1 Quality auditing form: Documentation Purpose: To perform a quick audit to ensure compliance with

Kathleen Martin, RN, MSN, MPA, LNHA

60 Essential

FormsFor Long-Term Care

Documentation

�60 Es s E n t i a l Fo r m s F o r lo n g-tE r m Ca r E Do C u m E n t a t i o n

Contents

Preface . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . vi

Section one: Audit forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .1

Form 1.1: Quality auditing form: Documentation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3

Form 1.2: MDS auditing form: Documentation for reimbursement . . . . . . . . . . . . . . . . . . . . . . . . . 6

Form 1.3: Resident care status survey tool . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 9

Form 1.4: New admission documentation audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 13

Form 1.5: Dysphagia audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 15

Form 1.6: Psychotropic audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17

Form 1.7: Nursing audit: Urinary catheter use . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 19

Form 1.8: Medical staff documentation audit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 21

Form 1.9: Safety rounds audit. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 23

Form 1.10: Kitchen/dietary audit . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 26

Section two: Documentation forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 29

Form 2.1: Admission data base assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 31

Form 2.2: Nursing care flow-sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 39

Form 2.3: Monthly psychoactive summary . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44

Form 2.4: Restraint elimination/reduction assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 47

Form 2.5: Restraint needs assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 49

Form 2.6: Interdisciplinary health education form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 52

Form 2.7: Fall risk assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 56

Form 2.8: 48-hour post-fall monitoring form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 58

Form 2.9: Incident/accident form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61

Form 2.10: Pain assessment for those with communication barriers/dementia . . . . . . . . . . . . . . 63

Form 2.11: Pain management tracking form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 65

Co n t E n t s

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Form 2.12: Pain management assessment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 66

Form 2.13: ADL/restorative nursing flow sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 69

Form 2.14: ADL data collection form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 72

Form 2.15: Cognitive/mood/behavioral data collection flow sheet . . . . . . . . . . . . . . . . . . . . . . . . 74

Form 2.16: Restorative nursing flow sheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 76

Form 2.17: Wandering assessment. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 78

Form 2.18: Product evaluation form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 81

Form 2.19: Transfer checklist (sub-acute to LTC units) . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83

Form 2.20: Infection control tracking form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85

Section three: Accountability reports . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 87

Guidelines for monthly reports (Forms 3.1, 3.2, 3.3, 3.4). . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89

Form 3.1: Sample monthly report: Director of nursing . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 90

Form 3.2: Sample monthly report: Assistant director of nursing . . . . . . . . . . . . . . . . . . . . . . . . . . 92

Form 3.3: Sample monthly report: Non-nursing manager. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 93

Form 3.4: Sample monthly report: Maintenance director . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94

Form 3.5: Task management sheet. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 95

Form 3.6: Utilization review/discharge meeting worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 97

Section four: Regulatory forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .99

Form 4.1: Gantt chart for regulatory planning . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 101

Form 4.2: Standing meeting/committee guidelines . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 104

Form 4.3: Root-cause analysis worksheet . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 108

Form 4.4: State department of health survey preparation. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 110

Section five: Performance improvement forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .113

CQI and PI form: Directions . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 116

Form 5.1: CQI and PI form. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117

Form 5.2: CQI and PI form: Pain management sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 118

Form 5.3: CQI and PI form: Fall reduction sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 119

Form 5.4: CQI and PI form: Transfers to hospital sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 120

Co n t E n t s


Form 5.5: CQI and PI form: Psychoactive drug use monitoring sample. . . . . . . . . . . . . . . . . . . . 121

Form 5.6: CQI and PI form: Restraint reduction sample . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 122

Form 5.7: CQI and PI form: Infection control and surveillance sample . . . . . . . . . . . . . . . . . . . . 123

Form 5.8: Pain management data collection form for performance improvement program . . . 124

Form 5.9: Interdisciplinary action committee (IAC) form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 126

Section six: Other forms . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .129

Credentialing and privileging physicians and nurse practitioners: Procedures . . . . . . . . . . . . . 131

Form 6.1: Request for application intake form: General appointment. . . . . . . . . . . . . . . . . . . . . 134

Form 6.2: Request for application intake form: Temporary appointment . . . . . . . . . . . . . . . . . . 135

Form 6.3: Credentialing cover letter: Initial appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 136

Form 6.4: Credentialing cover letter: Reappointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 137

Form 6.5: Credentialing checklist: Initial appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 138

Form 6.6: Credentialing checklist: Temporary appointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 139

Form 6.7: Credentialing checklist: Reappointment . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 140

Form 6.8: License verification. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 141

Form 6.9: Credentials phone verification form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 142

Form 6.10: Reappointment evaluation . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 143

Form 6.11: Temporary appointment form . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 145

SECTION ONE

Audit forms

• Form 1.1: Quality auditing form: Documentation • Form 1.2: MDS auditing form: Documentation for reimbursement • Form 1.3: Resident care status survey tool • Form 1.4: New admission documentation audit • Form 1.5: Dysphagia audit • Form 1.6: Psychotropic audit • Form 1.7: Nursing audit: Urinary catheter use • Form 1.8: Medical staff documentation audit • Form 1.9: Safety rounds audit • Form 1.10: Kitchen/dietary audit


Quality auditing form: DocumentationForm 1.1

Purpose: To perform a quick audit to ensure compliance with nursing documentation standards; for use with concurrent

records/resident status.

Directions: 1. Place a check mark in the appropriate column.

2. Make comments in the provided space.

3. Edit the form for your own use and facility needs.

Should be completed by: This form should be completed by a nurse and returned to the director of nursing or facility administrator.



Item/indicator Yes No Comment

Medical record:

1. Admission assessment is fully completed,

signed by RN (co-sign).

2. All other assessments done: pain, fall, skin, etc.

3. Treatment admin. records signed for?

4. Medication admin. records (MAR) signed?

5. Immunizations documented properly/done?

6. Weights charted monthly and/or per order?

7. Does the documentation support the MDS?

• Assessments?

• Progress notes?

• Other?

8. Does documentation support Medicare

requirements?

9. Is care plan accurate and up to date?

Measurable goals? Relevant problems?

10. Proper evaluation dates and follow-ups?

11. Proper signatures on care plan?

12. Care planning reflects MDS and other

assessments?

13. Evidence of teaching?

Special needs:

Thickened liquids/dysphagia:

14. Proper notation by the door (if permitted by

state); proper protocol followed?

15. Water at bedside?

Fall risks:

16. Fall risk evident?

17. Care planned?

Date of audit: ___________ Auditor (signature/title): ____________________

Resident name: __________________________________ Room/Unit #: ______________________________

Admissions date: ______________________________________________________________________________



Indicators/areas of focus CommentNoYes

Wounds:

18. Wound care protocol followed/proper forms completed?

19. Care planned?

Pain management:

20. Protocol/forms followed? (assessment and outcome)

21. Care planned?

22. MAR completed?

23. Initial and ongoing pain assessments done?

Equipment in room:

24. Respiratory, feeding pump equipment labeled/tagged?

25. IVs dated, labeled?

26. Wound dressings, IV site dated and signed?

Resident appearance:

27. Properly positioned? WC, bed?

28. Appears clean, appropriate dress?

29. Any complaints/concerns?

Other:

Area:

Comment:

__________________________________________________ ___________________________________ Signature/title Date


MDS auditing form: Documentation for reimbursementForm 1.2

Purpose: To audit key areas of the MDS for accurate documentation, ensuring proper reimbursement and compliance with

Medicare regulations and guidelines.

Directions: 1. UB-92 is helpful in auditing for MDS accuracy, as the bill must match with the MDS to ensure

proper reimbursement.

2. Place a check mark in the appropriate column and add comments as necessary.

Should be completed by: An MDS coordinator or an RN familiar with the MDS.


MDS auditing form: Documentation for reimbursement Form 1.2


Medical record number: _________________________

Resident name: _________________________

Admissions date: ___________________ Discharge date: ________________________

UB-92 bill:

1. Days billed correctly? Match resource

utilization group (RUG)?

2. Diagnosis codes? Accurate?

MDS:

3. MDS reflects the RUG areas billed?

4. UB-92 reflects the MDS?

5. Consistent claim data?

6. Illogical RUG jumps? (example: A “jump”

from a CC to RB level may be indicative

of a mistake)

MDS: Key areas:

7. Section E: Mood/depression: Capturing

when can?

8. Section G: ADLs?

9. ARD? Best date? Lookback date consistent?

10. Does ARD match UB-92 “service date”?

11. Section T: Left blank or inaccurate,

under/over-estimated?

12. MDS: Reason for assessment: modifier codes?

13. Rehab log: Sections K and P: Consistent/

true/matching times?

14. Section K/P (IV): Indicated?

15. Tube feed/supplies on UB-92 if applicable?

Chart/documentation:

16. Documentation supports the MDS?

1. Assessments?

2. Progress nurses’ notes?

3. Rehab notes?

4. Other?


MDS auditing form: Documentation for reimbursementForm 1.2


17. Documentation supports Medicare

requirements?

18. Care plan accurate and up to date?

19. Proper evaluation dates and follow-ups?

20. Proper signatures on care plan?

21. Care planning reflects MDS and assessments?

Other: _____________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________


Resident care status survey toolForm 1.3

Purpose: To help your facility prepare for surveys; to monitor resident care.

Directions: 1. Place a check mark in the appropriate column; be sure to note follow-up/comments.

2. Using the questions listed at the bottom of the form, interview the resident about his/her

perceived quality of care.

3. After the form is complete, forward it to the director of nursing.

Should be completed by: An LPN or RN should complete this form.

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Indicators/areas of focus Yes No Follow-up/action Comments/NA

Resident name: __________________________________ Room/Unit #: ________________________________

Date: __________________________________________ Auditor: ____________________________________

A. Resident rooms

1. Over-bed tables are clean and free of clutter?

2. Water is within reach? Cup is dated as per

policy/practice?

3. Call bell within reach/is working?

4. Bedside cabinet clean and orderly:

a. No medications at bedside?

b. No treatment supplies on bedside table?

5. Side rails are in prescribed position?

6. Supplies not designated for resident are not

found in the rooms?

7. Soiled linen/personal clothing not placed

on floor?

8. Oxygen sign is posted before entering

resident’s room (as applicable)?

B. Tube feedings

1. Pump is clean, free of dust and dried debris?

2. Tubing is dated and changed as per policy?

3. G-tube solution bottle is dated, labeled

per policy?

4. Head of bed is elevated 30-45 degrees?

5. Mouth care is evident?

C. Resident-specific care

1. Appearance is neat and clean?

2. Resident is properly dressed?

3. Correct footwear is on?

4. Nails are clean and trimmed?

5. Hair is neat and clean?

6. Men are shaved?

7. ID bracelet is intact/correct?

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Indicators/areas of focus Yes No Follow-up/action Comments/NA

Interview questions

Have you attended activities today, or have you in the past? ______________

What kind? __________________________________________________________________

Are you encouraged to attend? _________________

Do you experience any barriers to attending activities?___________________________________

If you have any pain, has it been managed to your satisfaction? (May elaborate on this):______________________________________________________________________________________________________________________________________________________________________________________

Meal selection: Do you enjoy your meals generally? ______________

8. Protective/assistive devices applied correctly.

9. Curtains are closed during personal care.

10. Foley catheters are properly positioned, dated

and labeled, and covered.

11. Is resident properly positioned in wheel chair/

bed?

12. Are IVs/dressings, other tubings dated and

initialed?

D. Nutrition

1. Before meal, hands are washed.

2. Bibs are on for meals and removed after.

3. Resident is positioned appropriate for meals/

eating.

4. Appropriate music is playing during meals.

E. Staff

1. All staff are wearing ID tags.

2. Staff knock before entering rooms.

3. Staff speak to residents in “customer

friendly” manner.



Do you receive what you like or order? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Are you offered snacks in the afternoon and evening? ________________________________________

Are you receiving your showers to your satisfaction? _________________

Do you know your shower schedule? ___________________

Do you know the name of your caregivers on most days?_____________________________

Do nursing staff respond to you in a timely manner?__________________

(Differentiate between nurses and CNAs)

Are nursing staff attentive to your needs? ____________________

Are medications on time?______________

Are nursing staff generally courteous and kind in their speaking tone/manner? _________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________

Elaborate on any area here:__________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________________


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New admission documentation auditForm 1.4

Purpose: To ensure that all of required information is in newly admitted residents’ records.

Directions: 1. Complete this form for all new residents within 24 hours of admission (or as per facility policy).

2. Place a check mark in the appropriate column.

3. This form may be monitored to meet your facility’s specific needs.

Should be completed by: A nurse manager or his/her designee should complete this form.

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New admission documentation auditForm 1.4

Yes No Comments

1. Admission assessments completed,

signed by RN?

2. Fall risk completed. If at risk, care analysis

plan initiated?

3. Pressure ulcer risk is completed? If at risk,

care plan initiated, pressure relieving

devices ordered

4. Self administration of medications form

completed?

5. Bowel and bladder assessment complete?

6. Immunizations documented?

7. Learning/teaching assessment completed?

8. Medicare certification initiated?

9. Interim care plan initiated?

10. Weight/height documented?

11. If diabetic, chart marked as such?

12. If resident has do-not-resuscitate order, chart

marked as such?

13. If resident has dyspahgia, chart marked as such?

14. Side-rail assessment completed?

Comments:

___________________________________________________________________________________________

___________________________________________________________________________________________

___________________________________________________________________________________________

Resident name: __________________________________ Admission date: _____________________

Room/Unit #: _____________________________________

Source: Steven Missaggia, RNC, DN.



Dysphagia auditForm 1.5

Purpose: To provide a focused audit of dysphagia, which tends to be problematic in long-term care facilities.

Directions: 1. This form should be completed weekly for any resident on thickened liquids/NPO.

2. Place a check mark in the appropriate column and provide comments as needed.

Should be completed by: Any staff nurse can complete this form.


Dysphagia auditForm 1.5

Yes No Comments

1. Water pitcher at bedside?

2. Medication administration record reflects

daily temperature?

3. Care plan reflects dysphagia?

4. Proper ID band on resident?

Resident’s name: _________________________________________________ Room/Unit #: ________________

Auditor: ________________________________________________________ Date: ______________________

Note: All deficiencies are to be corrected and reported to the nurse manager. Form should be forwarded to director

of nursing.

Comments:_____________________________________________________________________________________________________________________________________________________________________________________________________________________________________________




Psychotropic auditForm 1.6

Purpose: To provide a focused audit of psychotropic drug use, ensuring that regulations are met and quality care is provided.

Directions: 1. This form should be completed for every resident taking a psychotropic medication.

2. Place a check mark in the appropriate column and provide comments as needed.

Should be completed by: Any staff nurse can complete this form.


Psychotropic auditForm 1.6


Yes No Comments

1. Psychiatry consultation on chart?

2. Consultation reflects psychiatric diagnosis

for medication?

3. Care plan reflects nondrug interventions

for management by all disciplines?

4. Fall risk is reflected in care plan?

5. Behavior note is present in the medical record

by the 15th of the month?

6. Behavior note is inclusive of behaviors

monitored on “behavior monitor log”?

7. Behavior monitor logs accurately account

for residents’ behavior and continued use

of psychotropic medication?

8. If on PRN antianxiety, nondrug intervention

form is in medication admin record?

9. Coded correctly on MDS?

Resident name: _________________________________________________ Room/Unit #: _______________

Auditor: ________________________________________________________ Date: _____________________

Specific medication: __________________________________________________________________________



Nursing audit: Urinary catheter useForm 1.7

Purpose: Regulatory agencies discourage the use of urinary catheters, as it is felt that residents should be toileted regularly and remain as independent as possible. Auditing catheter use helps ensure survey success and helps prevent associated infections.

Directions: 1. Complete the form for each resident, checking the appropriate box and adding comments as necessary.

2. Sign and date the form, then forward it to the person who instructed you to perform the audit.

Should be completed by: This may be assigned to any clinical staff member by the director of nursing.


Nursing audit: urinary catheter useForm 1.7

Yes No Comments/NA

1. Is urinary-bedside bag labeled and dated?

2. Is there evidence that the bag and set-up have

been changed as per procedure?

3. Is there evidence that the catheter care

is provided?

4. Is catheter tubing secured at a level below

resident’s bladder?

5. Is tubing and drainage bag free from

touching floor?

6. Is a dignity-bag cover in use by the 15th

of the month?

7. Is there an MD order/diagnosis present?

Reason for catheter use?

8. Is a measuring container present with name

labeled on it?

Resident name: _________________________________________________ Room/Unit #: _______________

Auditor: ________________________________________________________ Date: _____________________

Plan of correction:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________



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Medical staff documentation auditForm 1.8

Purpose: Physicians have to comply with several documentation standards and prescribed policies related to medical record compliance. It is advantageous to audit such records to ensure that the record is complete for general information purposes, to monitor the physicians, and to monitor credentialing and privileging procedures.

Directions: 1. Complete the form for each resident, placing a check in the appropriate box.

2. Sign and date the form, then forward it to the person who instructed you to perform the audit.

Should be completed by: This may be assigned to any clinical staff member by the director of nursing.


Medical staff documentation auditForm 1.8

Resident: __________________________________________________________________________________

Physician name: ____________________________________________________________________________

Auditor: _________________________________________________ Date: ____________________________

Plan of correction:

_______________________________________________________________________________

_______________________________________________________________________________

_______________________________________________________________________________

Yes No Comments

1. Written medical evaluation and summary of

current medical diagnosis is complete?

2. Physician’s orders are available at time of

admission of resident (within 24 hours)?

3. An initial history and physical is done in a

timely manner (within 48 hours, including

weekends)?

4. Required periodic visits (30 days) are done

and reflected in the resident’s medical record

(i.e., progress notes)?

5. Progress notes reflect admission?

6. Verbal or phone orders are dated and

countersigned within the required period?

7. All consults are countersigned by attending phy-

sician (pharmacy, podiatry, psychiatry, etc.)?




Safety rounds auditForm 1.9

Purpose: This form is designed to assist the nursing, housekeeping, and maintenance departments survey the facility’s environment for hazards and ensure that regulatory compliance guidelines are in place.

Directions: For each item, place a check box in the appropriate column and add comments as necessary. When the form is complete, forward it to the director of nursing or other supervisor.

Should be completed by: The facility administrator determines who should complete this form. Nursing management can also use this form regularly to survey their units.



Area/indicator Yes/ No/ N/A Action/

satisfactory unsatisfactory comment

1. Items blocking fire exits?

2. Carts covered?

3. Carts/equipment on one side of halls/hall

way clear?

4. Equipment properly tagged/dated/checked?

5. Walls in satisfactory to good condition

(indicate area)?

6. MSDS books on units?

7. Evidence of ice chests disinfected?

8. Suction machine in dining room(s)

working, covered? Extension cord

present? Gloves present?

9. Medical waste containers empty/

appropriate level?

10. Treatment carts locked?

Rooms/location

11. Access to bed area without clutter, etc.?

12. Floors dry, clean?

13. Emergency call bell/light working in

bathroom?

14. Call light in working order?

15. Call bell in reach of resident?

16. Ceiling tiles in place?

17. Leaks in sinks, ceiling tiles?

18. Trash cans empty/appropriate level

(indicate area)?

19. TV working properly?

20. Staff performing proper body mechanics

when observed?



Area/indicator Yes/ No/ N/A Action/

satisfactory unsatisfactory comment

21. Equipment (oxygen, humidifier, tube

feeding pumps, etc) in room labeled as

per policy; clean?

22. Personal protective equipment used

properly?

23. Isolation equipment provided outside

isolation rooms?

24. Comfort of room (hot/cold)?

Kitchen

25. Hair nets used by all?

26. Gloves, aprons on personnel as

appropriate?



Kitchen/dietary auditForm 1.10

Purpose: To periodically review the kitchen and dietary department for compliance with federal standards. This is purposely designed to be brief, addressing the critical areas of a typical kitchen survey.

Directions: Place a check mark in the appropriate column. At the conclusion of the audit, develop a plan of correction, if necessary. Sign and date the form and deliver to the facility administrator.

Should be completed by: This form should be completed by the food service director/manager or one of his/her designees.


Kitchen/dietary audit Form 1.10

Yes/OK No N/A Comments

Facility: _________________________________ Director: ________________________________________

Food Storage:

1. Are refrigerator and freezer shelves/floors

clean, free of mold and debris, etc.?

2. Is the freezer temp 0°F or below/and refrigera-

tor 41°F or below (2–3° variance is ok)?

3. Are refrigerated foods covered, dated, labeled,

and shelved to allow air circulation?

4. Is dry storage maintained in a manner to

prevent pest infestation?

Food preparation:

5. Are frozen raw meats and poultry thawed

in refrigerator?

6. Are food contact surfaces and utensils

cleaned to prevent cross contamination?

Sanitation:

7. Are hot foods maintained at 140°F or above

at steam table?

8. Are cold foods maintained at 41°F or below

when served?

9. Are food trays clean?

10. Are foods covered until served? Protected

on transportation?

11. Employees wash hands?

12. Is dishwasher hot water wash 140°F and rinse

cycle 180°F or chemical sanitation followed?

13. Manual dishwashing: three-compartment sink,

correct water temperature, immersion time?


Yes/OK No N/A Comments

Food temperature section

1. Hot food: (last tray on cart): ___________________

Temperature: _________________

Cold food: (last tray on cart): ___________________

Temperature: __________________

2. Hot food: (last tray on cart): ___________________

Temperature: _________________

Cold food: (last tray on cart): ___________________

Temperature: __________________

Kitchen/dietary auditForm 1.10

14. Check under cabinets, stove, sink: all in order

(no grease, storage, etc)? Is back-splash in

good repair?

Dining:

15. Did meals arrive on time?

16. Protective garment placed on resident,

hand washing observed for resident,

properly seated?

17. All served at one table at once?

18. Is food intake monitored?

Other:


Name

Title

Organization

Street Address

City State ZIP

Telephone Fax

E-mail Address

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Documents

60 Essential Forms · 60 EssEntial Forms For long-tErm CarE DoCumEntation Form 1.1 Quality auditing form: Documentation Purpose: To perform a quick audit to ensure compliance with