Attachment D Survey Observation Record.xlsx
XLSX spreadsheet 55 KB Posted
- Solicitation number
- 36C10G24R0017
About this file
This is a Facility-Based Survey Observation Record template for evaluating Community Living Centers (CLCs) and State Veterans Homes under an Operational Support Contract with the Department of Veterans Affairs. The form serves as an assessment instrument for survey teams conducting inspections of VA CLCs to measure compliance with contract requirements across multiple operational dimensions.
The template is structured to document observations across entrance, daily operations, and exit phases of the survey process. It requires scoring by multiple team members—including three general surveyors, one life safety surveyor, and a team leader—using a standardized four-point scale (4=Conforms to contract requirements; 3=Minor nonconformance; 2=Does not conform but can be made to conform; 1=Does not conform and cannot be made to conform; 0=Did not observe). Key evaluation areas include surveyor professionalism and conduct, entrance and exit conference procedures, resident and family interviews, medication observations (minimum 25 required), meal observations, staff interactions, nursing competency assessments for special populations (spinal cord injury, dementia, ventilator-dependent), and adherence to privacy rules and proper interviewing techniques. The record captures facility-specific data such as location, authorized bed count, operating census, and neighborhood descriptions, with sections for notes and comments at each evaluation stage to document specific examples and observations. This template is designed to ensure consistent, comprehensive assessment of CLC operational performance and surveyor conduct quality throughout the inspection process.
View the file
Other files
Show all 20
On GovTribe
Work with this file
- Download the original file
- Contacts named in this file
- Similar government files
- Ask GovTribe AI about this file
Text version
CLC Description
| Community Living Center or State Veterans Home |
| Date of Survey Observation |
Name of CLC
Location
| Number of Beds |
| Authorized |
Operating
Census
CLC Medical Director and ACNS
Neighborhood(s) Description:
Census per Neighborhood
Special Population
Entrance FACILITY BASED SURVEY OBSERVATION RECORD of OPERATIONAL SUPPORT CONTRACT Community Living Center Survey Contract
| Site: | Names | |||
| Observer: | Team Leader | Team Member | Team Member | Life Safety Surveyor |
| Date: |
| Criterion | Data Definition | Enter Notes for each Contract Surveyor |
| Timeliness | Entrance to CLC | |
| Daily enter and exit | ||
| Final exit |
| Entrance Conference | Team Leader identified, and team introduced |
| Clear explanation of process | |
| Checklist for life safety and clinical survey provided |
SCORE
Score Key:
4. Conforms to the contract requirements
3. Minor nonconformance
2. Does not conform but can be made to conform
1. Does not conform and cannot be made to conform
0. Did not observe
Team Lead
| Team Leader/Discipline | Score Key - 4. Conforms to the contract requirements 3. Minor nonconformance 2. Does not conform but can be made to conform 1. Does not conform and cannot be made to conform | |
| Enter Surveyor Name and Discipline here | Score | Comments |
| Coordinad Entrance/Daily/Exit Conferences | ||
| Timeliness | ||
| Business Attire | ||
| Badge worn | ||
| Ineraction with VAMC/CLC Leaders | ||
| Interaction with CLC Staff | ||
| Consultative in nature - answers questions, explains procedures/processes if needed, transparent with areas of concern | ||
| Interacts with residents |
| Meal Observations |
| Non-intrusive |
| If potential error, intervenes (i.e. aspiration concerns, etc.) |
| Resident Council Interviews |
| Dynamics of Interviewer |
| Questions are simple and clear |
| No leading questions |
| Resident Council Minutes Reviewed |
| Ample time allotted for meeting |
| Resident Family Interviews |
| No leading questions |
| Privacy Rules respected |
| Medication Observations (Minimum of 25 observations) |
| Non-intrusive |
| Interacts with resident to inform them of why the surveyor is there |
| If potential error, intervenes |
| Surveyor Observation of Resident Care |
| Non-intrusive |
| Interacts with resident to inform them of why the surveyor is there |
| If potential error, intervenes |
| Staff Interviews |
| No leading questions |
| Privacy Rules respected |
| Use of critical element pathways accompany care delivery observations and are not used in lieu of. Describe specific examples |
| *Review of Nursing Competency for Special Populations (e.g., SCI, Dementia, Vent) |
| Privacy Rules respected |
| Total Score - |
| Notes: |
Return to Projects
Score Key:
4. Conforms to the contract requirements
3. Minor nonconformance
2. Does not conform but can be made to conform
1. Does not conform and cannot be made to conform
0. Did not observe
Surveryor One
| Team Leader/Discipline | Score Key - 4. Conforms to the contract requirements 3. Minor nonconformance 2. Does not conform but can be made to conform 1. Does not conform and cannot be made to conform | |
| Enter Surveyor Name and Discipline here | Score | Comments |
| Timeliness | ||
| Business Attire | ||
| Badge worn | ||
| Ineraction with VAMC/CLC Leaders | ||
| Interaction with CLC Staff | ||
| Consultative in nature - answers questions, explains procedures/processes if needed, transparent with areas of concern | ||
| Interacts with residents |
| Meal Observations |
| Non-intrusive |
| If potential error, intervenes (i.e. aspiration concerns, etc.) |
| Resident Council Interviews |
| Dynamics of Interviewer |
| Questions are simple and clear |
| No leading questions |
| Resident Council Minutes Reviewed |
| Ample time allotted for meeting |
| Resident Family Interviews |
| No leading questions |
| Privacy Rules respected |
| Medication Observations (Minimum of 25 observations) |
| Non-intrusive |
| Interacts with resident to inform them of why the surveyor is there |
| If potential error, intervenes |
| Surveyor Observation of Resident Care |
| Non-intrusive |
| Interacts with resident to inform them of why the surveyor is there |
| If potential error, intervenes |
| Staff Interviews |
| No leading questions |
| Privacy Rules respected |
| Use of critical element pathways accompany care delivery observations and are not used in lieu of. Describe specific examples |
| *Review of Nursing Competency for Special Populations (e.g., SCI, Dementia, Vent) |
| Privacy Rules respected |
| Total Score - |
| Notes: |
Return to Projects
Score Key:
4. Conforms to the contract requirements
3. Minor nonconformance
2. Does not conform but can be made to conform
1. Does not conform and cannot be made to conform
0. Did not observe
Surveryor Two
| Team Leader/Discipline | Score Key - 4. Conforms to the contract requirements 3. Minor nonconformance 2. Does not conform but can be made to conform 1. Does not conform and cannot be made to conform | |
| Enter Surveyor Name and Discipline here | Score | Comments |
| Timeliness | ||
| Business Attire | ||
| Badge worn | ||
| Ineraction with VAMC/CLC Leaders | ||
| Interaction with CLC Staff | ||
| Consultative in nature - answers questions, explains procedures/processes if needed, transparent with areas of concern | ||
| Interacts with residents |
| Meal Observations |
| Non-intrusive |
| If potential error, intervenes (i.e. aspiration concerns, etc.) |
| Resident Council Interviews |
| Dynamics of Interviewer |
| Questions are simple and clear |
| No leading questions |
| Resident Council Minutes Reviewed |
| Ample time allotted for meeting |
| Resident Family Interviews |
| No leading questions |
| Privacy Rules respected |
| Medication Observations (Minimum of 25 observations) |
| Non-intrusive |
| Interacts with resident to inform them of why the surveyor is there |
| If potential error, intervenes |
| Surveyor Observation of Resident Care |
| Non-intrusive |
| Interacts with resident to inform them of why the surveyor is there |
| If potential error, intervenes |
| Staff Interviews |
| No leading questions |
| Privacy Rules respected |
| Use of critical element pathways accompany care delivery observations and are not used in lieu of. Describe specific examples |
| *Review of Nursing Competency for Special Populations (e.g., SCI, Dementia, Vent) |
| Privacy Rules respected |
| Total Score - |
| Notes: |
Return to Projects
Score Key:
4. Conforms to the contract requirements
3. Minor nonconformance
2. Does not conform but can be made to conform
1. Does not conform and cannot be made to conform
0. Did not observe
Surveryor Three
| Team Leader/Discipline | Score Key - 4. Conforms to the contract requirements 3. Minor nonconformance 2. Does not conform but can be made to conform 1. Does not conform and cannot be made to conform | |
| Enter Surveyor Name and Discipline here | Score | Comments |
| Timeliness | ||
| Business Attire | ||
| Badge worn | ||
| Ineraction with VAMC/CLC Leaders | ||
| Interaction with CLC Staff | ||
| Consultative in nature - answers questions, explains procedures/processes if needed, transparent with areas of concern | ||
| Interacts with residents |
| Meal Observations |
| Non-intrusive |
| If potential error, intervenes (i.e. aspiration concerns, etc.) |
| Resident Council Interviews |
| Dynamics of Interviewer |
| Questions are simple and clear |
| No leading questions |
| Resident Council Minutes Reviewed |
| Ample time allotted for meeting |
| Resident Family Interviews |
| No leading questions |
| Privacy Rules respected |
| Medication Observations (Minimum of 25 observations) |
| Non-intrusive |
| Interacts with resident to inform them of why the surveyor is there |
| If potential error, intervenes |
| Surveyor Observation of Resident Care |
| Non-intrusive |
| Interacts with resident to inform them of why the surveyor is there |
| If potential error, intervenes |
| Staff Interviews |
| No leading questions |
| Privacy Rules respected |
| Use of critical element pathways accompany care delivery observations and are not used in lieu of. Describe specific examples |
| *Review of Nursing Competency for Special Populations (e.g., SCI, Dementia, Vent) |
| Privacy Rules respected |
| Total Score - |
| Notes: |
Return to Projects
Score Key:
4. Conforms to the contract requirements
3. Minor nonconformance
2. Does not conform but can be made to conform
1. Does not conform and cannot be made to conform
0. Did not observe
Life Safety Surveyor
| Team Leader/Discipline | Score Key - 4. Conforms to the contract requirements 3. Minor nonconformance 2. Does not conform but can be made to conform 1. Does not conform and cannot be made to conform | |
| Enter Surveyor Name here | Score | Comments |
| Timeliness | ||
| Business Attire | ||
| Badge worn | ||
| Ineraction with VAMC/CLC Leaders | ||
| Interaction with CLC Staff | ||
| Consultative in nature - answers questions, explains procedures/processes if needed, transparent with areas of concern |
| Total Score - |
| Notes: |
Return to Projects
Score Key:
4. Conforms to the contract requirements
3. Minor nonconformance
2. Does not conform but can be made to conform
1. Does not conform and cannot be made to conform
0. Did not observe
Daily Debriefs FACILITY BASED SURVEY OBSERVATION RECORD of OPERATIONAL SUPPORT CONTRACT Community Living Center Survey Contract
| Site: | Names | |||
| Observer: | Team Leader | Team Member | Team Member | Life Safety Surveyor |
| Date: |
| Criterion | Data Definition | Enter Notes for each Contract Surveyor |
| Professional Behavior (personal observation) | Interaction w/ VAMC/CLC leaders | |
| Interaction w/ CLC staff | ||
| Consultative in nature – answers questions, explains procedures/ process (if needed), transparent with areas of concern | ||
| Interaction w/residents | ||
| Daily Conferences | Scheduled | |
| Informs staff of areas of observations from the day | ||
| Allows staff to ask questions | ||
| Allows staff to present additional documentation | ||
| Ample time allotted | ||
| Review of all potential areas of concern | ||
| Positives mentioned | ||
| Time allotted for questions | ||
| Additional information from staff allowed | ||
| Feedback link provided | ||
| SCORE |
3. Minor nonconformance
2. Does not conform but can be made to conform
1. Does not conform and cannot be made to conform
Exit FACILITY BASED SURVEY OBSERVATION RECORD of OPERATIONAL SUPPORT CONTRACT Community Living Center Survey Contract
| Site: | Names | |||
| Observer: | Team Leader | Team Member | Team Member | Life Safety Surveyor |
| Date: |
| Criterion | Data Definition | Enter Notes for each Contract Surveyor |
| Professional Behavior (personal observation) | Interaction w/ VAMC/CLC leaders | |
| Interaction w/ CLC staff | ||
| Consultative in nature – answers questions, explains procedures/ process (if needed), transparent with areas of concern | ||
| Interaction w/residents | ||
| Exit Conference | Scheduled | |
| Informs staff of areas of observations from the day | ||
| Allows staff to ask questions | ||
| Allows staff to present additional documentation | ||
| Ample time allotted | ||
| Review of all potential areas of concern | ||
| Positives mentioned | ||
| Time allotted for questions | ||
| Additional information from staff allowed | ||
| Feedback link provided | ||
| SCORE |
3. Minor nonconformance
2. Does not conform but can be made to conform
1. Does not conform and cannot be made to conform
0. Did not observe
File details come from the government source that posted it. Updated .