Corporate Compliance Form
General Facility Information
Facility Information
Rows
Facility Name
Medicare #
VBP Multiplier
Facility Information
Facility Location
Street Address
Street Address Line 2
County
Please Select
Alabama
Alaska
Arizona
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California
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District of Columbia
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Tennessee
Texas
Utah
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West Virginia
Wisconsin
Wyoming
State
Zip Code
Audit Type
Corporate Compliance
Prospective Payment System
Patient Information
Rows
Patient Name
Patient Initials
Date Patient Record Reviewed
Patient-1
Patient-2
Patient-3
Patient-4
Patient-5
Patient-6
Patient-7
Patient-8
Patient-9
Patient-10
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Patient 1
Patient 1 Information
Rows
Facility Name
Patient Name
Date
MRN
Information
General Policy
Payer Type
Medicare/Private
Medicare/Insurance
Medicare/Medicaid
Managed care
Other
Face Sheet Diagnosis
Current Diagnosis for SNF
Hospital Discharge Diagnosis
Hospital Admission Date
-
Month
-
Day
Year
Date
Hospital Discharge Date
-
Month
-
Day
Year
Date
SNF Admission Date
-
Month
-
Day
Year
Date
SNF Discharge Date
-
Month
-
Day
Year
Date
Type a questionDoes the Patient have other SNF stays?
Yes
No
Discharge Location
Home
Home With Home Health
Independent Living
Assisted Living
Hospital
Hospices
Other
Any Missed Days on Part A
Yes
No
A Properly Completed Inquiry Form or Adequate Intake Information was Located for Each Patient Reviewed
Yes
No
The Facility Indicated its Medical Record Retention Policy is That Records are Maintained for At Least Six Years Following the Discharge Date. This Consistent with HIPAA Requirements
Yes
No
The Facility Indicated it is in Compliance With its Policy
Yes
No
1
Rows
Yes
No
Any Missed Days on Part A
2
3
A Properly Completed Inquiry Form or Adequate Intake Information was Located for Each Patient Reviewed
4
5
The Facility Indicated its Medical Record Retention Policy is That Records are Maintained for At Least Six Years Following the Discharge Date. This Consistent with HIPAA Requirements
6
7
The Facility Indicated it is in Compliance With its Policy
8
9
Admission Policies and Procedures Were Available for Staff Use
10
11
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