Attachment Z_Survey Deficiency Summary Report Format.pdf
PDF 114 KB Posted
- Attached to
- R499--State Veterans Home (SVH) Nursing Homes
- Solicitation number
- 36C10G24R0016
About this file
This is a template document for the Department of Veterans Affairs Survey Deficiency Summary Report used to document compliance findings at State Veterans Homes (SVHs) against Title 38 Code of Federal Regulations Part 51 requirements.
The template establishes the structure and format for reporting survey deficiencies across nursing homes, domiciliary facilities, and adult day health care settings. It requires completion of general information fields including facility name, location, survey dates, survey type (recognition, annual, or for cause), total recognized beds, and census data. The deficiency findings section directs surveyors to document specific VA regulation violations by citing the regulation number and name from the applicable Quick Reference Guide, including a description of the regulation and the facility's failure to comply. Each deficiency must be classified using defined terminology for level of harm (immediate jeopardy, actual harm not immediate jeopardy, potential for more than minimal harm, or potential for minimal harm) and residents affected (few, isolated; some, pattern; or many, widespread). The document includes a Scope and Severity Grid for reference but explicitly instructs that Survey Deficiency Summary Reports must use only the level of harm definition and residents affected definition without referencing the grid letter designations. Life safety deficiencies require specific notation with a life safety heading.
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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:
Onsite / Virtual:
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
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
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)
File details come from the government source that posted it. Updated .