Medicare Certification Audit Checklist
Use this form to review audit readiness, document checklist completion, and record findings for a Medicare certification audit. The exact title must remain consistent throughout the form.
Audit Identification
Audit Reference ID
*
Organization or Facility Name
*
Department, Service Line, or Site Name
Audit Period Start Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Audit Period End Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Reviewer and Checklist Status
Reviewer Name or Team Name
*
Review Date
*
 -
Month
 -
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Checklist Completion Status
*
Not Started
In Progress
Complete
Needs Follow-Up
Overall Audit Outcome Notes
Documentation and Findings
Required certification documents present and complete
*
Survey report
Policies and procedures
Staff training records
Quality assurance records
Patient care documentation
Other
Identified gaps or exceptions
Corrective action plan or next steps
Final submission comments
Submit
Should be Empty: