Assisted Living Survey Tools, Forms and Guidelines
Survey Tools:The survey tool consists of the applicable ARMs and MCAs. It is formatted in a table for easier understanding and application. This is the same form surveyors use to determine compliance when they visit your facility. The current draft form will be replace with a finalized form when the Secretary of States Office publishes the adopted Assisted Living Rules which became effective April 26, 2004. The additional forms used during an on-site survey are also provided.
Assisted Living ARM Survey Tool:
- Index to Assisted Living Arm Survey Tool:
- Assisted Living ARM Definitions:
- ARM for License Application Process:
- Assisted Living MCA Survey Tool:
- Restraint and Safety Device Survey Tool:
- Restraint and Safety Device ARM 37.106.2902 Definitions
- Entrance Conference Tool:
- Employee File Review (Excel Format only)
- Resident File Review (Excel Format only)
- Resident Agreement Criteria
- Statement of Deficiencies and Plan of Correction Form
Complaint Survey Tools:
When conducting a complaint survey, in addition to the applicable survey tools listed above, the health care facility surveyor will also use the following tools to organize and analize the collected data. This procedure may also be benificial for the provider/administrator when conducting a facility investigation and/or follow-up on an incident/accident report.
- Investigation Log
- Complaint Analysis Tool
Page last updated: 11/13/2006
