Form Cms-801 - Offsite Survey Prep Worksheet
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1DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
OFFSITE SURVEY PREPARATION WORKSHEET
Facility Name: ________________________________________
Ombudsman Name/Number: ___________________________
Facility Address: ______________________________________
Ombudsman Contact Date: ____________________________
Provider Number: _____________________________________
Offsite Review Date: __________________________________
Total Beds: ___________________________________________
Survey Begin Date: ___________________________________
List potential facility areas of concern and any potential residents to be reviewed during the survey. List any current
complaints to be investigated onsite.
Surveyors/Discipline (list Team Coordinator first):
Form CMS-801 (07/95)
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Parent category: Medical