The following information was requested during the Entrance Conference: A list of Original (Fee for Service) Medicare beneficiaries who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months prior to the survey. ENTRANCE CONFERENCE WORKSHEET (QIS Facility Copy) FORM CMS-20045 (3/2013) INFORMATION TO PROVIDE IMMEDIATELY UPON ENTRANCE 1. Facil ity census and an alphabetical resident census list, with room numbers/units. Note census residents who are not in the facility (e.g., in the hospital, home visit, etc.). 2. ENTRANCE CONFERENCE WORKSHEET (QIS Facility Copy) FORM CMS-20045 (06/07) INFORMATION TO PROVIDE IMMEDIATELY UPON ENTRANCE 1. An alphabetical resident census, with room numbers/units. Note residents on the census who are not in the facility (e.g., in the hospital, home visit, etc.). 2. A completed New Admission Information form. Please list ENTRANCE CONFERENCE WORKSHEET . Facility Name: _____ Survey Date:_____ to: _____ specific information on how surveyors can access the EHRs outside of the conference Please complete the attached form on page 3 which is titled "Beneficiary Notice - Residents Discharged Within the Last Six Months". 24 Hours: ENTRANCE CONFERENCE WORKSHEET 8/2017 3 Beneficiary Notice - Residents Discharged Within the Last Six Months Please complete and return this worksheet to the survey team within 24 hours. Please provide a list of residents who were discharged from a Medicare covered Part A stay with benefit days remaining in the past 6 months. AHCA Forms Health Facilities and Providers. Be certain to look at our Licensing and Certification page for specific links to applications forms.; Please complete this survey to give the Agency feedback regarding your experience with the survey process.; Licensure Application Forms by Provider Type; Consumers. To file a complaint about a health care facility, such as a hospital, nursing home On 04/04/18 the administrator returned the completed worksheets. Three resident names were then selected randomly. The worksheets were returned to the administrator, along with three separate SNF beneficiary protection notification review forms for completion for the three selected residents. The above information was completed and returned. Entrance Conference Worksheet locked Entrance Conference Worksheet Facility Matrix locked Facility Matrix Knowledge Check 1 locked Knowledge Check 1 Information Needed from the Facility Immediately Upon Entrance locked Information Needed from the Facility Immediately Upon Entrance TC Conducts the Entrance Object Moved This document may be found here 5. Conduct a brief Entrance Conference with the Administrator. 6. Signs announcing the survey that are posted in high-visibility areas. 7. A copy of an updated facility floor plan, if changes have been made. 8. The actual working schedules for licensed and registered nursing staff for the survey time period. Also ENTRANCE CONFERENCE WORKSHEET 8/2017 1 INFORMATION NEEDED FROM THE FACILITY IMMEDIATELY UPON ENTRANCE 1. Census number 2. Complete matrix for new admissions in the last 30 days who are still residing in the facility. 3. An alphabetical list of all residents (note any resident out of the facility). 4. A list of residents who smoke, designated ENTRANCE CONFERENCE WORKSHEET 8/2017 1 INFORMATION NEEDED FROM THE FACILITY IMMEDIATELY UPON EN