The Division of
Health Care Policy and Research
&
Centers for Medicare & Medicaid Services (CMS)
QIS Electronic Forms
and Worksheets
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| CMS Form Number | Form Name | Version Date |
| CRITICAL ELEMENT PATHWAYS | ||
| CMS-20065 | Activities | 06/07 |
| CMS-20066 | Activities of Daily Living (ADL) and/or Range of Motion (ROM) Status (Includes Cleanliness/Grooming and Positioning) | 06/07 |
| CMS-20067 | Behavioral and Emotional Status | 06/07 |
| CMS-20068 | Bowel or Bladder Function/Use of Indwelling Catheter | 06/07 |
| CMS-20069 | Communication and Sensory Problems (Includes Hearing and Vision) | 06/07 |
| CMS-20070 | Dental Status and Services | 06/07 |
| CMS-20071 | Dialysis | 06/07 |
| CMS-20072 | General | 06/07 |
| CMS-20073 | Hospice and/or Palliative Care | 06/07 |
| CMS-20074 | Hospitalization or Death | 06/07 |
| CMS-20075 | Nutrition, Hydration, and Tube Feeding Status | 06/07 |
| CMS-20076 | Pain Management | 06/07 |
| CMS-20077 | Physical Restraints | 06/07 |
| CMS-20078 | Pressure Ulcers | 06/07 |
| CMS-20079 | Psychoactive Medications | 06/07 |
| CMS-20080 | Rehabilitation and Community Discharge | 06/07 |
| CMS-20081 | Ventilator-Dependent Residents | 06/07 |
| CMS-20082 | Unnecessary Drug Review | 06/07 |
| MANDATORY FACILITY-LEVEL TASKS | ||
| CMS-20052 | Demand Billing Review | 06/07 |
| CMS-20053 | Dining Observation | 06/07 |
| CMS-20054 | Infection Control and Immunizations | 06/07 |
| CMS-20055 | Kitchen/Food Service Observation | 09/08 |
| CMS-20056 | Medication Administration Observation and Drug Storage Review | 10/07 |
| CMS-20057 | Resident Council President/Representative Interview | 06/07 |
| CMS-20058 | Quality Assessment & Assurance (QA&A) Review | 06/07 |
| TRIGGERED FACILITY-LEVEL TASKS | ||
| CMS-20059 | Abuse Prohibition Review | 08/07 |
| CMS-20060 | Admission-Transfer-Discharge Review | 06/07 |
| CMS-20061 | Environmental Observation | 09/08 |
| CMS-20062 | Sufficient Nursing Staff Review | 06/07 |
| CMS-20063 | Personal Funds Review | 06/07 |
| OTHER ELECTRONIC FORMS AND WORKSHEETS | ||
| CMS-807 | Surveyor Notes Worksheet | 06/07 |
| CMS-20044 | Offsite Survey Preparation Worksheet | 06/07 |
| CMS-20045 | Entrance Conference Worksheet – Facility Copy | 06/07 |
| CMS-20046 | Entrance Conference Worksheet – Team Copy | 06/07 |
| CMS-20084 | Cognitive Performance Scale (CPS) Calculator | 06/07 |
| NA | QIS Checklist | 10/30/07 |
| NA | QIS Revisit Procedure | 07/30/07 |
| NA | Stage II Care Area Investigation Key | 11/02/07 |
| NA | Extended Survey | 06/07 |
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