The Division of
Health Care Policy and Research
&
Centers for Medicare & Medicaid
QIS Resource Manual Overview
Tab 6: QIS Facility-level Task Forms (Mandatory)
Tab 7: QIS Facility-level Task Forms (Triggered)
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All Facility level worksheets, which are also available electronically.- Mandatory Task Forms
- Tab 6: Facility-level Mandatory Task Forms (.zip)
- CMS-20052 Liability Notice and Beneficiary Appeal Rights (.pdf)
- CMS-20053 Dining (.pdf)
- CMS-20054 Infection Control (.pdf)
- CMS-20055 Kitchen (.pdf)
- CMS-20056 Med Admin-Drug Storage (.pdf)
- CMS-20057 Resident Council (.pdf)
- CMS-20058 QAA (.pdf)
- Triggered Task Forms
- Tab 7: Facility-level Triggered Task Forms (.zip)
- CMS-20059 Abuse Prohibition (.pdf)
- CMS-20060 Admit-Transfer-Discharge (.pdf)
- CMS-20061 Environment (.pdf)
- CMS-20062 Sufficient Nursing Staff (.pdf)
- CMS-20063 Personal Funds (.pdf)
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