Julie Ann Kemman, BBAHeather Stewart, RHITClinical assessment formsSurvey readiness assessmentsDocumentation formsMDS toolsRegulatory formsAccountability reportsQuality Assessment and Performance Improvement (QAPI) formsStewart KemmanThis book contains 100 of the most commonly utilized forms in long-term carefacilities, including:BrewerThe updated content found in this new edition reflects recent regulatory changesto help long-term care providers stay compliant and ensure quality resident care.The updated forms offer easy-to-understand descriptions of implementation processes and timing, and can be used as-is or customized to best meet the particular needs of nursing home staff.Marshall100 Essential Forms for Long-Term Care provides convenient access to a compilation of essential forms that will save nursing home staff time and improvethe documentation accuracy of every department in the long-term care facility.100 Essential Forms for Long-Term CareCarol Marshall, MAKate Brewer, PT, MBA, GCS, RAC-CTPUB CODEBarcodea divisionof BLR75 Sylvan Street Suite A-101Danvers, MA

100Essential FormsforLong-Term CareCarol Marshall, MAKate Brewer, PT, MBA, GCS, RAC-CTJulie Ann Kemman, BBAHeather Stewart, RHIT

100 Essential Forms for Long-Term Care is published by HCPro, a division of BLRCopyright 2014 HCPro, a division of BLRAll rights reserved. Printed in the United States of America.5 4 3 2 1Download forms and tools from this book with the purchase of this product.ISBN: 978-1-55645-227-7No part of this publication may be reproduced, in any form or by any means, without prior written consent ofHCPro, or the Copyright Clearance Center (978-750-8400). Please notify us immediately if you have receivedan unauthorized copy.HCPro provides information resources for the healthcare industry.HCPro is not affiliated in any way with The Joint Commission, which owns the JCAHO and Joint Commissiontrademarks.Carol Marshall, MA, AuthorKate Brewer, PT, MBA, GCS, RAC-CT, AuthorHeather Stewart, RHIT, AuthorJulie Ann Kemman, BBA, AuthorOlivia MacDonald, Managing EditorAdrienne Trivers, Product ManagerErin Callahan, Senior Director, ProductElizabeth Petersen, Vice PresidentMatt Sharpe, Production SupervisorVincent Skyers, Design ManagerVicki McMahan, Sr. Graphic DesignerJason Gregory, Layout/Graphic DesignKelly Church, Cover DesignerAdvice given is general. Readers should consult professional counsel for specific legal, ethical, or clinicalquestions.Arrangements can be made for quantity discounts. For more information, contact:HCPro75 Sylvan Street, Suite A-101Danvers, MA 01923Telephone: 800-650-6787 or 781-639-1872Fax: 800-639-8511E-mail: [email protected] HCPro online at: and

ContentsAbout the Authors.viiSection 1: Audit Forms. 1Form 1.1: Quality auditing form: Nursing documentation. 3Form 1.2: Triple-check form. 8Form 1.3: Resident care status survey tool. 12Form 1.4: Preadmission screen. 17Form 1.5: Dysphagia audit. 19Form 1.6: Psychotropic audit .21Form 1.7: Urinary catheter reminder order. 24Form 1.8: Urinary catheter checklist. 26Form 1.9: Medical staff documentation audit . 28Form 1.10: Safety rounds audit. 30Form 1.11: Kitchen/dietary audit. 34Form 1.12: Discharge record documentation audit. 7Form 1.13: Skilled nursing facility self-audit. 40Form 1.14: MDS chart audit tool. 42Form 1.15: Compliance audit worksheet. 45Form 1.16: CAA completion audit tool. 56Form 1.17: Quarterly Medicare compliance guide. 58Form 1.18: Policy and procedure: Medicare Part A triple-check process. 60Form 1.19: Policy and procedure: Medicare Part B triple-check process. 64Form 1.20: Assessment itinerary announced site visit. 67Form 1.21: Sample checklist for unannounced audit. 69Form 1.22: Resident review worksheet.71Form 1.23: Quality of life assessment resident interview. 73Form 1.24: Quality of life assessment family interview. 75Form 1.25: Quality of life assessment group interview. 77Form 1.26: Statement of deficiencies and plan of correction. 79 2014 HCProiii

100 Essential Forms for Long-Term CareSection 2: Documentation Forms. 81Form 2.1: Admission database assessment. 83Form 2.2: Nursing care flow sheet. 92Form 2.3: Monthly psychoactive summary. 97Form 2.4: Restraint elimination/reduction assessment.100Form 2.5: Fall response assessment.102Form 2.6: Care plan meeting education form.105Form 2.7: Fall risk assessment.109Form 2.8: 48-hour post-fall monitoring form. 111Form 2.9: Incident/accident form. 114Form 2.10: Pain assessment for those with communication barriers/dementia. 116Form 2.11: Pain management tracking form. 118Form 2.12: Pain management assessment.120Form 2.13: ADL/restorative nursing flow sheet.122Form 2.14: ADL data collection form.125Form 2.15: Cognitive/mood/behavioral data collection flow sheet.127Form 2.16: Restorative nursing flow sheet.129Form 2.17: Wandering assessment.132Form 2.18: Product evaluation form.135Form 2.19: Transfer checklist (subacute to LTC units).137Form 2.20: Infection control tracking form.139Form 2.21: Readmission documentation pull list.141Form 2.22: Hospital readmission tracking tool.143Form 2.23: Rehospitalization tracking tool.145Form 2.24: Weight loss communication tool.147Form 2.25: Against medical advice acknowledgment.149Form 2.26: Anti-psychotic drug use assessment.151Form 2.27: Dehydration prevention checklist.154Form 2.28: Elopement drill.156Form 2.29: MDS therapy minutes.159Form 2.30: Swallowing protocol-feeding precaution checklist.161Section 3: Accountability Reports. 165Guidelines for monthly reports (forms 3.1, 3.2, 3.3, 3.4).166Form 3.1: Sample monthly report: Director of nursing.167Form 3.2: Sample monthly report: Assistant director of nursing.170Form 3.3: Sample monthly report: Non-nursing manager.172Form 3.4: Sample monthly report: Maintenance director.174Form 3.5: Task management sheet.176Form 3.6: Utilization review/discharge meeting worksheet.179Form 3.7: Satisfaction survey response tracking.181iv 2014 HCPro

ContentsSection 4: Regulatory Forms. 183Form 4.1: Gantt chart for regulatory planning.185Form 4.2: Standing meeting/committee guidelines.188Form 4.3: Root cause analysis worksheet.192Form 4.4: State department of health survey preparation.195Form 4.5: Frequently used ICD-9 codes in LTC: Mapping guide to ICD-10.197Form 4.6: Transition to ICD-10 guide.200Form 4.7: ICD-10 preparation survey: Knowledge base.202Form 4.8: Preparation for ICD-10: Self-evaluation for coders.204Section 5: Performance Improvement Forms. 207QAPI forms.209Form 5.1: QAPI form. 210Form 5.2: QAPI form: Pain management sample. 211Form 5.3: QAPI form: Fall reduction sample.213Form 5.4: QAPI form: Transfers to hospital sample.215Form 5.5: QAPI form: Psychoactive drug use monitoring sample.217Form 5.6: QAPI form: Restraint reduction sample.219Form 5.7: QAPI form: Infection control and surveillance sample.220Form 5.8: Pain management data collection form for PIP.222Form 5.9: Interdisciplinary action committee (IAC) form.224Form 5.10: Performance improvement project assignment tool.225Section 6: Credentialing and Communication Forms. 227Credentialing and privileging physicians and nurse practitioners: Procedures.228Form 6.1: Request for application intake form: General appointment.231Form 6.2: Request for application intake form: Temporary appointment.232Form 6.3: Credentialing cover letter: Initial appointment.233Form 6.4: Credentialing cover letter: Reappointment.234Form 6.5: Credentialing checklist: Initial appointment.235Form 6.6: Credentialing checklist: Temporary appointment.236Form 6.7: Credentialing checklist: Reappointment.237Form 6.8: Licensure verification.238Form 6.9: Credentialing phone verification form.239Form 6.10: Reappointment evaluation.240Form 6.11: Temporary appointment form.242Form 6.12: Professional exchange report.243Form 6.13: Therapy and nursing communication form.245 2014 HCProv

100 Essential Forms for Long-Term CareSection 7: Additional Documentation Request Forms. 247Form 7.1: Additional documentation request (ADR).249Form 7.2: Internal ADR tracking log.251Form 7.3: ADR appeal documentation checklist.253Form 7.4: Part A denial tracking/appeal request log.255Form 7.5: Part B denial tracking/appeal request log.258Form 7.6: RAC/ZPIC/CERT audit tracking log.261Forms and tools can be accessed with the purchase of this 2014 HCPro

ABOUT THE AUTHORSCarol Marshall, MA, is a risk management specialist based in Fort Worth, Texas. For the past 18years, she has trained managers and staff members in long-term care facilities across the countryabout the benefits of exceptional customer service and risk management. She has offeredtraining programs at numerous state conferences, professional groups, and individual facilities.Kate Brewer, PT, MBA, GCS, RAC-CT, is the president of Greenfield Rehabilitation Agency, acompany that provides physical, occupational, and speech-language pathology services in skillednursing facilities. Having spent over 15 years in long-term care, Brewer has extensive experiencein various processes and approaches to regulatory compliance from a Medicare and surveyperspective. Her areas of expertise include therapy documentation and compliance with Medicareregulations, coordinating the MDS process to ensure optimal reimbursement and compliance,and bridging the gap between the different professions that work together in long-term care.Julie Ann Kemman, BBA, president of Health Care Professional Consulting Services, Inc.,has over 20 years of experience working within the long-term care community. She holds abachelor’s degree in business administration from Northwood University. Julie has held multiplecorporate regional positions for a large nursing home chain and has been the cornerstone in stafftraining, compliance monitoring, and management. Health Care Professional Consulting Services,Incorporated, was started in July 2005 and provides skilled nursing organizations, assisted living,home health agencies, and outpatient rehabilitation providers a variety of consulting services,including billing, collections, training, policy writing, and software implementation.Heather Stewart, RHIT, is a knowledgeable health information management consultantwith more than 16 years of experience in the long-term care industry. Stewart has anextensive background in healthcare compliance, medical coding, and electronic health recordimplementation. 2014 HCProvii

Section 1Audit Forms1. Quality auditing form: Nursing documentation2. Triple-check form3. Resident care status survey tool4. Preadmission screen5. Dysphagia audit6. Psychotropic audit7. Urinary catheter reminder order8. Urinary catheter checklist9. Medical staff documentation audit10. Safety rounds audit11. Kitchen/dietary audit12. Discharge record documentation audit13. Skilled nursing facility self-audit14. MDS chart audit tool15. Compliance audit worksheet16. CAA completion audit tool17. Quarterly Medicare compliance guide18. Policy and procedure: Medicare Part A triple-check process19. Policy and procedure: Medicare Part B triple-check process20. Assessment itinerary announced site visit 2014 HCPro1

100 Essential Forms for Long-Term Care21. Sample checklist for unannounced audit22. Resident review worksheet23. Quality of life assessment resident interview24. Quality of life assessment family interview25. Quality of life assessment group interview26. Statement of deficencies and plan of correction2 2014 HCPro

Form 1.1Quality auditing form: Nursing documentationPurpose:To perform a quick audit to ensure compliance with nursing documentation standards forskilled care.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:Th