Operational Checklists
Five role-specific checklists designed to be printed and used at the point of care. Each form maps directly to the Conditions of Participation documentation requirements in 42 CFR Part 418 — so that completing the form means satisfying the CoP.
Checkbox fields are formatted for in-person completion. Write-in lines capture patient-specific data. Every item carries its regulatory citation so surveyors can see exactly which CoP requirement is being documented.
Available Checklists
Referral Intake Checklist
Eligibility screening steps, clinical records collection, triage classification (eligible / MA / insufficient info / not eligible), and pre-evaluation handoff tasks. Use this before dispatching a nurse.
- Medicare Part A eligibility confirmation
- MA vs. fee-for-service triage
- Clinical records checklist
- 4-way triage classification
Admission Day Checklist
Pre-visit prep, patient rights delivery sequencing (before any clinical task), initial assessment content requirements, and post-visit documentation handoffs. The 48-hour clock and patient rights sequencing rule in a single checklist.
- 48-hour RN assessment deadline
- Patient rights sequencing (before clinical tasks)
- Initial assessment content domains
- IDG handoff and file checklist
Election Statement and NOE Checklist
All required election statement elements including the post-October 2020 additions, the addendum process, and the 5-day NOE deadline tracker with space to record submission and MAC acceptance dates.
- Election statement required elements
- Post-Oct 2020 required disclosures
- Addendum process steps
- 5-day NOE deadline tracker
Certification of Terminal Illness Checklist
Benefit period structure with correct signatory rules per period, required certification content, a narrative writing area, and the face-to-face attestation requirements (3rd+ periods) including the FY 2026 signature date requirement.
- Correct signatory per benefit period
- Patient-specific narrative area
- F2F attestation requirements (3rd+ periods)
- FY 2026 signature date rule
IDG Comprehensive Assessment Checklist
All 7 required IDG assessment domains with discipline-specific checklists, clinician sign-off fields per domain, plan-of-care completion steps, and a full IDG discipline signature grid. Designed to be passed between team members.
- All 7 required domains with checkboxes
- Per-domain clinician sign-off
- N/A deferral documentation
- IDG discipline signature grid
How to use these checklists. Open a checklist and use your browser's print function, or click "Print This Checklist" on the page. Forms are formatted for US Letter paper at 0.6-inch margins. Each item's regulatory citation indicates the specific CoP requirement being satisfied — not a substitute for legal or compliance guidance.