Entrance Conference Worksheet - Department Of Health And Human Services
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4DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
ENTRANCE CONFERENCE WORKSHEET
INFORMATION NEEDED FROM THE FACILITY IMMEDIATELY UPON ENTRANCE
1. Census number
2. Complete matrix for new admissions in the last 30 days who are still residing in the facility.
3. An alphabetical list of all residents (note any resident out of the facility).
4. A list of residents who smoke, designated smoking times, and locations.
ENTRANCE CONFERENCE
5. Conduct a brief Entrance Conference with the Administrator.
6. Information regarding full time DON coverage (verbal confirmation is acceptable).
7. Information about the facility’s emergency water source (verbal confirmation is acceptable).
8. Signs announcing the survey that are posted in high-visibility areas.
9. A copy of an updated facility floor plan, if changes have been made.
10. Name of Resident Council President.
11. Provide the facility with a copy of the CASPER 3.
INFORMATION NEEDED FROM FACILITY WITHIN ONE HOUR OF ENTRANCE
12. Schedule of meal times, locations of dining rooms, copies of all current menus including therapeutic
menus that will be served for the duration of the survey and the policy for food brought in from
visitors.
13. Schedule of Medication Administration times.
14. Number and location of med storage rooms and med carts.
15. The actual working schedules for licensed and registered nursing staff for the survey time period.
16. List of key personnel, location, and phone numbers. Note contract staff (e.g., rehab services).
17. If the facility employs paid feeding assistants, provide the following information:
a) Whether the paid feeding assistant training was provided through a State-approved training
program by qualified professionals as defined by State law, with a minimum of 8 hours of training;
b) The names of staff (including agency staff) who have successfully completed training for paid
feeding assistants, and who are currently assisting selected residents with eating meals and/or
snacks;
c) A list of residents who are eligible for assistance and who are currently receiving assistance from
paid feeding assistants.
INFORMATION NEEDED FROM FACILITY WITHIN FOUR HOURS OF ENTRANCE
18. Complete matrix for all other residents. Ensure the TC confirms the matrix was completed accurately.
19. Admission packet.
20. Dialysis Contract(s), Agreement(s), Arrangement(s), and Policy and Procedures, if applicable.
21. List of qualified staff providing hemodialysis or assistance for peritoneal dialysis treatments, if
applicable.
22. Agreement(s) or Policies and Procedures for transport to and from dialysis treatments, if applicable.
23. Does the facility have an onsite separately certified ESRD unit?
24. Hospice Agreement, and Policies and Procedures for each hospice used (name of facility designee(s)
who coordinate(s) services with hospice providers).
8/2017
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