Official Federal Forms
Centers For Medicare And Medicaid Services
Last updated: 5/2/2006
Offsite Survey Prep Worksheet {CMS-801}
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Description
DEPARTMENTOF HEALTH AND HUMAN SERVICESCENTERS FOR MEDICARE & MEDICAID SERVICES OFFSITE SURVEY PREPARATION WORKSHEETFacility 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 currentcomplaints to be investigated onsite.Surveyors/Discipline (list Team Coordinator first):Form CMS-801 (07/95)
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