WARDWELL · WORKING AID · OCTOBER 2026
Use one copy per cited tag. Write record references, not resident names or medical details. This working aid is not a CMS-2567 or an agency-approved submission form. Follow your agency’s instructions; acceptance does not verify compliance.
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What happened, what was corrected for those affected, and what evidence supports the action? Separate completed work from planned work.
What population, records or locations will you review? Who will perform the review, and how will you act on additional findings?
What process will change? Identify the responsible role, revised procedure and how staff will demonstrate the change in practice.
What will be checked, by whom, using which sample and frequency? Record the escalation path and response to a failed check. Choose a plan suited to the actual risk.
List each corrective action and its actual or planned completion date. Check dates against the agency’s instructions. Do not mark unfinished actions complete.
Check every finding against the response. Record the authorized signatory, version submitted, submission receipt, revisions requested and evidence location.