Attachment Z_Survey Deficiency Summary Report Format 01.pdf
PDF 317 KB Posted
- Attached to
- R499--State Veterans Home (SVH) Nursing Homes
- Solicitation number
- 36C10G24R0016
About this file
This is a template for the Department of Veterans Affairs Survey Deficiency Summary Report used to document compliance findings at State Veterans Homes (SVHs) under Title 38 Code of Federal Regulations Part 51.
The template provides a standardized format for recording survey results across nursing homes, domiciliary care, and adult day health care facilities. It requires completion of general information fields including facility name, location, survey dates, facility type, recognized bed count, and census data. The report structure includes a VA Regulation Deficiency section where surveyors document findings by writing the specific regulation number and name, pasting the regulation description, and providing narrative findings based on observation, interview, and record review. Surveyors must classify each deficiency using defined level of harm categories (ranging from immediate jeopardy to minimal potential harm) and residents affected designations (few, some, or many). The template explicitly instructs users to omit scope and severity letter codes and instead use only the level of harm and residents affected definitions. A scope and severity grid is provided showing the relationship between four harm levels and three scope categories (isolated, pattern, widespread). The document includes a note that life safety deficiencies must be clearly identified with a life safety heading. This is a procedural template without specific products, services, response dates, or pricing terms.
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Department of Veterans Affairs Survey Deficiency Summary Report
This survey report and the information contained herein, resulted from the State Veterans Home (SVH) Survey as a Summary Deficiency Report. Title 38 Code of Federal Regulations Part 51 is applied for SVHs applicable by level of care.
General Information:
Facility Name:
Location:
Dates of Survey:
Nursing Home / Domiciliary / Adult Day Health Care:
Survey Type (Recognition/Annual/For Cause):
Total Recognized Beds:
Census on First Day of Survey:
VA Regulation Deficiency Findings
Initial Comments:
(Example format) A VA (Type) Survey was conducted from (Dates) at (SVH Name, City, State). The facility was not in compliance with Title 38 CFR Part 51 Federal Requirements for State Veterans Homes.
Write the VA Regulation number and name here per Quick Reference Guide per level of care
Cut and paste description of regulation here.
Level of Harm – (incorporate correct language here from table below)
Residents Affected - (incorporate correct language here from table below)
Based on observation, interview, and record review, the facility failed to (Example format of only opening paragraph here)
Note: for any life safety deficiencies recorded, must include the life safety heading.
Department of Veterans Affairs Survey Deficiency Summary Report
Survey Deficiency Summary Reports:
Do not use the scope and severity letter (For example: A or J) Use the level of harm definition only (For example: Actual harm that is not immediate jeopardy) Use the residents affected definition only (For example: few, some, or many)
Guide for Survey Deficiency Summary Report
Scope and Severity Grid
Immediate Jeopardy to resident health or safety
Level 4 J K L
Actual Harm that is not immediate jeopardy
Level 3 G H I
No Actual Harm, with potential for more than minimal harm
Level 2 D E F
No Actual Harm, with potential for minimal harm
Level 1 A B C
Isolated Pattern Widespread
Definitions of Residents Affected Few Some Many
File details come from the government source that posted it. Updated .