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Ahca inspection checklist

Care clinic surveyor worksheet 2026

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The document is a Health Care Clinic Surveyor Worksheet and Facility Questionnaire designed for authorized Agency employees to assess compliance of health care clinics with established standards. It outlines the survey process, requirements for documentation, and various aspects of clinic operations including ownership, medical director responsibilities, accreditation, and patient care services. The worksheet serves as a tool for conducting initial, annual, or follow-up surveys to ensure clinics meet regulatory standards.

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Click ‘Get Form’ to open the care clinic surveyor worksheet in the editor.
Begin by entering the facility name and FRAES number at the top of the form. This information is crucial for identifying the clinic being surveyed.
Fill in the survey date(s) and your name along with your discipline and ID number. This section helps document who conducted the survey.
Select the type of survey you are conducting: Initial, Annual, Follow-Up, Complaint, or Other. Make sure to circle your choice clearly.
Proceed through each section methodically, answering questions regarding ownership, compliance with health standards, and operational procedures. Use checkboxes for 'Yes' or 'No' responses as indicated.
For any additional comments or explanations required in specific fields, utilize the text boxes provided to ensure clarity and completeness.

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