Attachment U_ Final Survey Report Format.pdf

This is a Department of Veterans Affairs State Veterans Homes Survey Report template used to document compliance findings during facility inspections. The report captures general facility information including name, location, survey dates, facility type (nursing home, domiciliary, or adult day health care), survey classification (recognition, annual, or for cause), total recognized beds, census on the first survey day, and surveyor identification. The template is designed to record VA Regulation deficiency findings against Title 38 Code of Federal Regulations Part 51 standards applicable to each level of care.

The report structure requires surveyors to document each deficiency by entering the specific VA Regulation number and name, pasting the relevant regulation description, and providing findings that include initial comments and detailed findings. For each deficiency, surveyors must assign a "Not Met" rating, specify scope and severity, and indicate the number of residents affected (few, some, or many). The template includes multiple blank rows for recording multiple deficiencies identified during a single survey. This standardized format enables consistent documentation and tracking of State Veterans Homes' compliance with federal regulations governing resident care and facility operations.