Component 3: The Relevant Findings

 

Relevant findings are the "evidence" collected by the surveyor to demonstrate the existence of the violation or deficiency.

 

Relevant findings are the result of observations, interviews, and record reviews.

 

The findings allow the agency to compare what it did or failed to do against what is required.

 

The listing of the pertinent facts identified in the violation or deficiency assists the agency in determining the cause of the deficient practice.

 

Example of relevant findings for tag Z194, Verification of Employability and Use of Unlicensed Persons:

 

The findings include:

  • Review of the agency's personnel records for Employees #50, #51, and #52 revealed no Criminal History checks, Nurse Aide Registry checks, or Employee Misconduct Registry checks were documented.
  • An interview was conducted on [date] at [time] with the administrator, who confirmed the agency had not conducted Criminal History checks, Nurse Aide Registry checks, or Employee Misconduct Registry checks for Employees #50, #51, and #52.

 

Relevant