{"product_id":"activity-department-survey-readiness-self-check-and-care-plan-review-fillable-pdf-with-sources","title":"Activity Department Survey Readiness Self-Check and Care Plan Review, Fillable PDF With Sources","description":"\u003cp\u003eA fillable 7-page self-check for activity directors, life enrichment coordinators and activity professionals in nursing homes, memory care, assisted living and skilled nursing. It follows the sections of the Activities Critical Element Pathway (Form CMS-20065, 7\/2015), the worksheet CMS publishes for surveyors, so you can look at one resident's record the way a surveyor is told to look: assessment, care plan, care in practice, and care plan review.\u003c\/p\u003e\u003cp\u003e\u003cstrong\u003eWHAT IS INSIDE (7 pages)\u003c\/strong\u003e\u003c\/p\u003e\u003col\u003e\n\u003cli\u003eStart here: how to use it, a page guide, and the four sources with dates\u003c\/li\u003e\n\u003cli\u003eStep 1, Assessment: 10 checks on what the assessment shows\u003c\/li\u003e\n\u003cli\u003eStep 2, Care Plan: 17 checks, including 6 that apply only to some residents (for example, residents who stay in their room)\u003c\/li\u003e\n\u003cli\u003eStep 3, Care in Practice: 12 checks to observe and confirm by interview\u003c\/li\u003e\n\u003cli\u003eStep 4, Care Plan Review: a form to complete after each assessment, with progress on goals, refusals and alternatives offered, resident or representative input, and sign-off\u003c\/li\u003e\n\u003cli\u003eStep 5, Be Ready to Answer: the questions CMS tells surveyors to ask residents, activity staff and nursing assistants, with a place to write where your records or staff can answer\u003c\/li\u003e\n\u003cli\u003eAction plan: list every gap with an action, a person and a due date\u003c\/li\u003e\n\u003c\/ol\u003e\u003cp\u003e\u003cstrong\u003eEVERY LINE SHOWS ITS SOURCE\u003c\/strong\u003e\u003c\/p\u003e\u003cul\u003e\n\u003cli\u003eS1: 42 CFR 483.21 Comprehensive person-centered care planning\u003c\/li\u003e\n\u003cli\u003eS2: 42 CFR 483.24(c) Activities\u003c\/li\u003e\n\u003cli\u003eS3: CMS State Operations Manual, Appendix PP, F679 Activities (Rev. 211)\u003c\/li\u003e\n\u003cli\u003eS4: CMS Activities Critical Element Pathway, Form CMS-20065 (7\/2015)\u003c\/li\u003e\n\u003c\/ul\u003e\u003cp\u003eEach check is a short paraphrase, tagged with the source it follows. Nothing is written from memory.\u003c\/p\u003e\u003cp\u003e\u003cstrong\u003eFILES\u003c\/strong\u003e\u003c\/p\u003e\u003cul\u003e\n\u003cli\u003eFillable PDF: type on screen, tick boxes, pick from drop-downs, or print and write by hand\u003c\/li\u003e\n\u003cli\u003eUS Letter and A4\u003c\/li\u003e\n\u003cli\u003eColor and black-and-white (ink-saver) versions\u003c\/li\u003e\n\u003cli\u003eA one-page Read Me First\u003c\/li\u003e\n\u003c\/ul\u003e\u003cp\u003e\u003cstrong\u003eIMPORTANT\u003c\/strong\u003e\u003c\/p\u003e\u003cp\u003eThis is a self-check tool. It is not an official CMS form, it is not endorsed by CMS, and it does not predict or guarantee a survey result. The 2015 pathway form uses older tag numbers, which this tool does not print. CMS can revise survey documents, so check the current Survey Resources on cms.gov. State rules and your facility policy may add requirements. Keep resident names private and secure. Not medical or legal advice.\u003c\/p\u003e\u003cp\u003eInstant digital download. For use in your own facility. Please do not resell or share the files.\u003c\/p\u003e","brand":"BeingBrightStudio","offers":[{"title":"Default Title","offer_id":67985619812627,"sku":null,"price":4.99,"currency_code":"USD","in_stock":true}],"thumbnail_url":"\/\/cdn.shopify.com\/s\/files\/1\/0978\/8732\/2387\/files\/Np3Tal6CIP.jpg?v=1794297073","url":"https:\/\/www.activitydirectorspayactivitydirectors.com\/products\/activity-department-survey-readiness-self-check-and-care-plan-review-fillable-pdf-with-sources","provider":"Activity Directors Pay Activity Directors","version":"1.0","type":"link"}