Attachment K CLC Survey Report Template.pdf

Department of Veterans Affairs Community Living Center Survey Report

1This survey report and the information contained herein, which resulted from the Community Living Center Unannounced Survey are confidential and privileged under 38 U.S.C. 5705 and it is implementing regulations. This material shall not be disclosed to anyone without authorization as provided for by that law or its regulations.

General Information:

Survey Group:

Facility Name:

Survey Modality: (onsite, virtual)

Dates of Survey:

Total Available Beds:

Census on First Day of Survey:

Overall medication Error Rate:

CLC Medical Director:

CLC Nurse Leader:

Pre-Survey Information:

Insert description of survey team pre-survey activities/preparation to include care areas selected:

Based on information reviewed, including brief resident and staff interviews and general observations during the tour, the following care areas were selected for further in-depth review

General Description and Observation of Community Living Center:

Insert description of the following:

a. Current census and description of services to include the population served for each CLC or SCI/D Long Term Care Center neighborhood

b. Census and capacity of each CLC or SCI/D Long Term Care Center neighborhood

c. Brief description of the vendor’s assessment of each CLC or SCI/D Long Term Care Center’s cultural transformation (i.e., person-centered care as described in the SOM)

d. Positive practices observed during the survey.

Department of Veterans Affairs Community Living Center Survey Report

F-Tag Findings

5 Example-F 656 Example-Develop/Implement Comprehensive Care Plan The facility must develop and implement a comprehensive person centered care plan for each resident, consistent with the resident rights set forth at §483.10(c)(2) and §483.10(c)(3), that includes measurable objectives and timeframes to meet a resident's medical, nursing, and mental and psychosocial needs that are identified in the comprehensive assessment.

6 Example- Scope/Severity

HATCh Model Category

7Based on record review and interview, the facility failed to develop a Care Plan for contact precautions for two (2) of four (4) residents reviewed for transmission-based precautions.

1- Notice of survey report content

2-CLC demographic information

3-Description of pre-survey activities to include selection of care areas for further review

4- Description of general information and observations of the Community Living Center

5- Federal tag name/citation and applicable regulatory language

6- Scope and severity and HATCh Model category

7- Statement of deficiency to include outcome statement when applicable