Overall Compliance
0%
Needs Improvement
Items Completed
0/20
Needs Attention
20
Survey Ready
No
Comprehensive compliance assessment for CMS F758 survey
Overall Compliance Score
85%
Good - Survey ReadySurvey Readiness Status
Minor gaps require attention before survey
Target completion: January 27, 2026
5 residents missing documented informed consent
Priority: Critical | Target: January 25, 2026
12 medications overdue for 14-day review
Priority: Critical | Target: January 24, 2026
3 residents with no documented GDR attempts
Priority: High | Target: January 27, 2026
Prioritize informed consent documentation for 5 residents
Complete overdue medication reviews within 48 hours
Schedule GDR assessment meetings for 3 residents
Implement weekly compliance monitoring going forward
Conduct staff training on F758 documentation requirements
Supporting Documents
15 files
Medication Files Reviewed
100%
Prescriber Signatures Verified
100%
Review Documentation Complete
85%
Facility demonstrates good compliance with F758 requirements. Minor gaps identified are being actively addressed through documented remediation plans. With completion of current action items by target dates, facility will achieve excellent survey readiness status. Recommend continued weekly monitoring to maintain compliance.
Critical Gaps
2
High Priority
2
In Progress
2
Resolved
0
5 residents missing documented informed consent for psychotropic medications
12 medications overdue for 14-day review
3 residents with no documented GDR attempts in past 6 months
8 medication orders missing specific diagnosis documentation
Side effect monitoring protocols not documented for 6 residents
Psychotropic medication orders include specific diagnosis and clinical rationale
Each medication order must document the specific diagnosis being treated and clinical justification
Behavioral symptoms documented before medication initiation
Evidence of behavioral symptoms that led to psychotropic medication use
Informed consent obtained from resident or representative
Documented informed consent including risks, benefits, and alternatives
Prescriber orders are current and signed
All psychotropic medication orders are properly signed by authorized prescriber
Medications reviewed at least every 14 days
Documentation of medication review within required 14-day timeframe
Review includes assessment of continued need
Each review documents assessment of ongoing clinical necessity
Side effects monitored and documented
Regular monitoring and documentation of potential adverse effects
Effectiveness of medication documented
Clinical response to medication is regularly assessed and recorded
GDR attempts documented unless clinically contraindicated
Evidence of gradual dose reduction attempts or clinical justification for not attempting
GDR outcomes and resident response documented
Detailed documentation of GDR results and resident's clinical response
Clinical rationale for continuing current dose after failed GDR
Clear documentation of why current dose is necessary after unsuccessful GDR
Consent obtained before initiating psychotropic medication
Documented informed consent prior to first dose
Consent includes discussion of risks and benefits
Evidence that risks, benefits, and alternatives were explained
Consent updated when medication changes significantly
New consent obtained for major dosage changes or medication switches
Adverse drug reactions promptly identified and documented
System for identifying and documenting adverse reactions
Appropriate action taken in response to adverse events
Evidence of clinical response to identified adverse reactions
Adverse events reported to prescriber and documented
Communication with prescriber regarding adverse events is documented
Monitoring protocols established for each medication
Written protocols for monitoring each psychotropic medication
Vital signs and clinical parameters monitored per protocol
Regular monitoring of relevant clinical parameters
Laboratory monitoring completed as indicated
Required lab work completed and documented