Current LTCSP Forms & Materials 6/19/2021 – Are You Using the Right Version?

The Centers for Medicare & Medicaid Services (CMS) makes periodic updates to the Long-Term Care Survey Process materials. The most current version is dated 6/19/2021. Ensure you have the current information, including the Entrance Conference Form, Matrix and Critical Element Pathways – they may not all be the same since the LTCSP was implemented. You can always locate the most current materials on the CMS Nursing Homes webpage.

Helpful Tips:

Here are many of the updated forms contained in the .zip file of Survey Resources via the CMS webpage.

FormDocument Link
Entrance Conference Form

Focused Infection Control Survey Entrance Conference Form
Entrance Conference Form (6/2021)

FICS Entrance Form (6/2021)
Matrix for ProvidersCMS 802 (11/2020)
List of Revised F-tagsList of Revised Ftags (6/2021)
SNF Beneficiary Protection ReviewForm CMS-20052 Beneficiary Notice (1/2018)
Dining ObservationForm CMS-20053 Dining Observation (1/2018) 
Infection Prevention, Control & ImmunizationsForm CMS-20054 Infection Prevention Control and Immunization (6/2021)
Kitchen ObservationForm CMS-20055 Kitchen (5/2017)
Medication Administration ObservationForm CMS-20056 Med Admin (11/2017)
Resident Council InterviewForm CMS-20057 Resident Council (12/2017) 
Quality Assessment and Assurance (QAA) and Quality Assurance and Performance Improvement (QAPI) Plan ReviewForm CMS-20058 Quality Assessment and Assurance Review (2/2017)
Abuse Critical Element PathwayForm CMS-20059 Abuse (5/2017)
Environmental ObservationsForm CMS-20061 Environment (11/2017)
Sufficient and Competent Nurse Staffing ReviewForm CMS-20062 Sufficient Nursing Staff Pathway (1/2018)
Personal Funds ReviewForm CMS-20063 Personal Funds (2/2017) 
Activities Critical Element PathwayForm CMS-20065 Activities (5/2017) 
Activities of Daily Living (ADL) Critical Element PathwayForm CMS-20066 Activities of Daily Living (5/2017)
Behavioral and Emotional Status Critical Element PathwayForm CMS-20067 Behavioral-Emotional (2/2017)
Urinary Catheter or Urinary Tract Infection Critical Element PathwayForm CMS-20068 Urinary Catheter or UTI (5/2017)
Communication and Sensory Problems (Includes Hearing and Vision) Critical Element PathwayForm CMS-20069 Comm-Sensory (5/2017) 
Dental Status and Services Critical Element PathwayForm CMS-20070 Dental (11/2017)
Dialysis Critical Element PathwayForm CMS 20071 Dialysis (5/2017)
General Critical Element PathwayForm CMS-20072 General (2/2017) 
Hospice and End of Life Care and Services Critical Element PathwayForm CMS-20073 Hospice and End of Life (5/2017)
Death Critical Element PathwayForm CMS-20074 Death (1/2018)
Nutrition Critical Element PathwayForm CMS-20075 Nutrition (5/2017)
Pain Recognition and Management Critical Element PathwayForm CMS-20076 Pain Mgt (5/2017) 
Physical Restraints Critical Element PathwayForm CMS-20077 Physical Restraints (5/2017)
Pressure Ulcer/Injury Critical Element PathwayForm CMS-20078 Pressure Ulcer (5/2017) 
Specialized Rehabilitative or Restorative Services Critical Element PathwayForm CMS-20080 Rehab and Restorative (5/2017)
Respiratory Care Critical Element PathwayForm CMS-20081 Respiratory Care (7/2018) 
Unnecessary Medications, Psychotropic Medications, and Medication Regimen Review Critical Element PathwayForm CMS-20082 Unnecessary Medications (5/2017)
Medication Storage and LabelingForm CMS-20089 Medication Storage (2/2017)
Preadmission Screening and Resident Review Critical Element PathwayForm CMS-20090 PASARR (5/2017)
Extended SurveyForm CMS-20091 Extended Survey (1/2018)
Hydration Critical Element PathwayForm CMS-20092 Hydration (5/2017)
Tube Feeding Status Critical Element PathwayForm CMS-20093 Tube Feeding (5/2017) 
Positioning, Mobility & Range of Motion (ROM) Critical Element Pathway Form CMS-20120 Positioning, Mobility, ROM (1/2018)
Hospitalization Critical Element PathwayForm CMS-20123 Hospitalization (11/2017)
Bladder or Bowel Incontinence Critical Element PathwayForm CMS-20125 Bladder and Bowel Incontinence (11/2017)
Accidents Critical Element PathwayForm CMS-20127 Accidents (5/2017)
Neglect Critical Element PathwayForm CMS-20130 Neglect (5/2017)
Resident Assessment Critical Element PathwayForm CMS-20131 Resident Assessment (5/2017)
Discharge Critical Element PathwayForm CMS-20132 Discharge (11/2017)
Dementia Care Critical Element PathwayForm CMS-20133 Dementia Care (5/2017)
Focused Infection Control Survey ProtocolSurvey – COVID-19 FIC Survey Protocol 6/21

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