The Division of
Health Care Policy and Research
&
Centers for Medicare & Medicaid
QIS Resource Manual Overview
Tab 5: QIS Stage I Review Forms
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- CMS-807 Surveyor Notes Worksheet
- Examples of Stage I worksheets. (Stage I reviews are completed directly in the QIS DCT.)
- Cognitive Performance Scale Calculator to manually calculate CPS score if a resident's cognitive status is questionable.
- Tab 5: Stage I Review Forms (.zip)
- CMS-807 Surveyor Notes (.pdf)
- CMS-20047 Admission Record Review (.pdf)
- CMS-20048 Census Record Review (.pdf)
- CMS-20049 Family Interview (.pdf)
- CMS-20050 Resident Interview and Observation (.pdf)
- CMS-20051 Staff Interview (.pdf)
- CMS-20084 Cognitive Performance Calculator (.pdf)
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