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Medication Pass Worksheet Form. This is a Official Federal Forms form and can be use in Centers For Medicare And Medicaid Services.
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Tags: Medication Pass Worksheet, CMS-677, Official Federal Forms Centers For Medicare And Medicaid Services,
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
DEPARTMENT OF HEALTH AND HUMAN SERVICES
CENTERS FOR MEDICARE & MEDICAID SERVICES
:
Index No.
Calendar No.
MEDICATION PASS WORKSHEET
Provider Number
:
Surveyor Name
Plaintiff(s)
-againstInstructions:
1.
2.
3.
4.
Deficiency Formulas:
Date
JUDICIAL Error Rate
SUBPOENA
:
Observe Pass for 20-25 opportunities for error. If one or more errors is found observe another 20-25 opportunities for error.
:
Record your observation of each opportunity for error.
Compare your record with physician orders.
:
Calculate and note error rate
Significant Error + Non-Significant Error
1. One or more Significant Errors = Deficiency
2.
....................................
Defendant(s)
:
Doses.given .+. Doses .ordered but not given
.... ... .... ...
X 100 ≥ 5% = Deficiency
Identifier
Pour
Pass
Record
Resident’s Full Name
Drug Prescription Name,
Dose and Form
Observation of Administration
Drug Order Written As
(when different from observation)
THE PEOPLE OF THE STATE OF NEW YORK
TO
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
FORM CMS-677 (07/95)
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
American LegalNet, Inc.
www.USCourtForms.com
COURT
COUNTY .OF. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . .
......... ..
:
Index No.
MEDICATION PASS WORKSHEET
:
Identifier
Resident’s Full Name
Pour
Calendar No.
Pass
Record
:
Drug Prescription Name,
Drug Order
Observation of Administration
JUDICIAL SUBPOENAWritten As
Dose and FormPlaintiff(s)
(when different from observation)
-against-
:
:
:
Defendant(s)
:
......................................................
THE PEOPLE OF THE STATE OF NEW YORK
TO
GREETINGS:
WE COMMAND YOU, that all business and excuses being laid aside, you and each of you attend before
,
the Honorable
at the
Court
located at
County of
in room
, on the
day of
, 20
, at
o'clock in the
noon, and at any recessed
or adjourned date, to testify and give evidence as a witness in this action on the part of the
Your failure to comply with this subpoena is punishable as a contempt of court and will make you liable to
the party on whose behalf this subpoena was issued for a maximum penalty of $50 and all damages sustained as a
result of your failure to comply.
Witness, Honorable
Court in
County,
, one of the Justices of the
day of
, 20
(Attorney must sign above and type name below)
Attorney(s) for
Office and P.O. Address
Telephone No.:
Facsimile No.:
E-Mail Address:
Mobile Tel. No.:
FORM CMS-677 (07/95)
American LegalNet, Inc.
www.USCourtForms.com
