Attachment U_ Final Survey Report Format 01.pdf

This document is a template for a Department of Veterans Affairs State Veterans Homes (SVH) Survey Report used to document compliance findings against Title 38 Code of Federal Regulations Part 51.

The report template is designed to capture survey results for State Veterans Homes operating at nursing home, domiciliary, or adult day health care levels. The template requires completion of general information fields including facility name, location, survey dates, survey type (Recognition/Annual/For Cause), total recognized beds, census on the first day of survey, and surveyor identification. The core section documents VA regulation deficiencies through a structured format that includes: the specific VA regulation number and name referenced from the Quick Reference Guide applicable to the level of care; the full description of the regulation; a rating designation of "Not Met"; scope and severity assessment; identification of residents affected (Few, Some, or Many); and detailed findings. Initial comments should follow a specified format stating the survey type, dates, facility name and location, and a statement that the facility was not in compliance with Title 38 CFR Part 51 Federal Requirements for State Veterans Homes. The template provides multiple blank rows for documenting additional deficiency findings as needed, allowing for comprehensive documentation of all identified compliance issues during the survey process.