• Document No.

  • Client / Site

  • Conducted on

  • Prepared by

  • Location
  • Personnel

Occupancy, Marketing, & Admissions

  • What is the current census?

  • Is occupancy within budget?

  • Do staff behaviors reflect strong customer service standards?

  • Weekend manager program in place?

  • Marketing Plan Current & Implemented?

  • How many hospital visits in the last 30 days?

  • How many admissions in the next 7 days?

  • How many discharges in the next 7 days?

  • Does Admission Paperwork meet Standards (Focused Audit)?

Labor Management

  • Labor Hours within budget?

  • What is the budgeted labor hours for the facility?

  • What are current labor hours?

  • Is the stand-up tool in place and used?

  • Is staffing plan posted and current?

  • How much agency labor was used in the last 30 days? ($USD)

  • How much agency was pro-staffing? ($USD)

  • How many 1.5T Overtime Hours given in the last 30 days?

  • How many 2T Overtime Hours given in the last 30 days?

  • How many shifts were under the staffing ratio in the last 30 days?

  • How many licensed nurse positions are open?

  • How many CNA positions are open?

Human Resources

  • Monthly Turnover report- is there evidence of positive trends?

  • Is Orientation program in place and current?

  • Employee recognition program in place?

  • Education calendar in place (LMC)?

  • Employee Incentive and referral program in place and promoted?

  • Department evaluation schedule in place and current?

  • Are Employee exit interviews being held and documented?

Safety Programs

  • Can the administrator log into TELS and review the safety committee monthly minutes?

  • Is the Safety Stars Program in place and promoted?

  • Is there evidence of claims report follow up?

  • How many claims YTD?

  • How many Active claims?

  • Are fire drills and inspections in TELS current?

  • Has the administrator updated the disaster manual annually (phone list, evacuation letters updated, includes maps & directions)?

Business Office

  • Accounting timeline routinely met (A/R, A/P/ P/R)?

  • Evidence of Administrator involvement in A/R collections?

  • Evidence of effective time clock management?

  • Facility calendar in place with required meetings (Is it shared with operations)?

  • Patient Trust Records current and reconciled?


  • Case management meetings held weekly with documented action plans?

  • All members of Inter-disciplinary team present and engaged?

  • Triple check system in place?

  • Administrator has reviewed pharmacy bills, and actively screens for high cost medication?

  • Therapy productivity is meeting facility benchmarks?

  • ALOS-Trending?


  • Is the facility meeting the QI average for customer satisfaction for meals?

  • How is customer satisfaction surveys for food trending ?

  • Have the RD reports been reviewed and recommendations followed up on?

  • Kitchen and dining areas meets accepted standards for sanitation and cleanness?

  • Dish machine temperature log has been reviewed and is in compliance?

  • Refrigerator temperature logs for all fridges (medication, snack, resident accessible) are being monitored and cleaned?

Physical Plant

  • Administrator is conducting monthly walk-through of buildings and grounds and has a updated Maintenance work plan that shows progress?

  • Maintenance Logs are accessible and are work is current?

  • Preventive Maintenance Program (TELS) is being reviewed by Administrator and tasks are not over due?

  • Patient equipment (beds, lifts, DME ect.) is being reviewed routinely by maintenance and is in good condition?

  • Water Temps logs are updated and temperatures are in compliance?

  • Laundry dryers are being maintained(lint cleaned every shift, fire box weekly, exhaust snaked once per quarter)?

  • Laundry washers have water temps recorded at a minimum of 160 degrees F, or 75 F if bleach of 125 ppm is used?


  • Nursing consultant reports are reviewed and an action plan available?

  • QAPI report current and action plan in place?

  • Quality measures reviewed & action plan in place? (>5 star state average)

  • Clinical documentation meets accepted standards (Focus audit)?

  • Were there any substantiated complaint surveys since annual survey?

  • Were there any falls with injury in the last 30 days?

  • How many residents?

  • Are care plans in place and being followed?

  • How many In-house acquired decubitus ulcers in the last 30 days?

  • What is the current status of those patients?

  • Do you have appropriate clinical equipment in place to manage those injuries?

  • Central supply system meets accepted standards?

  • Are the ADL's reviewed and action plan in place?

  • Does the current ADL scores meet the facilities benchmarks?

  • What are the current ADL % scores?

  • What is the ADL trend from the last 30 days?


  • Review of RUG's & Evidence of Accurate documentation?

  • Productivity above 75%, less RPM?

  • Overage is less than 10%?

  • Rehab position openings?

Departmental Reviews & Comments

  • Do any additional departmental review need to be completed?

  • Activities?

  • Action Plan:

  • Admissions?

  • Action Plan:

  • Business Office

  • Action Plan:

  • Dietary?

  • Action Plan:

  • Housekeeping?

  • Action Plan:

  • Laundry?

  • Action Plan:

  • Medical Records?

  • Action Plan:

  • Nursing ?

  • Action Plan:

  • Physical Plant?

  • Action Plan:

  • Nursing Practitioner/ Medical Director

  • Action Plan:

  • Social Services?

  • Action Plan:

The templates available in our Public Library have been created by our customers and employees to help get you started using SafetyCulture's solutions. The templates are intended to be used as hypothetical examples only and should not be used as a substitute for professional advice. You should seek your own professional advice to determine if the use of a template is permissible in your workplace or jurisdiction. You should independently determine whether the template is suitable for your circumstances.