Advance Directive Review and Update

Inspection template for periodic review of resident advance directives in a nursing home to confirm code status, healthcare proxy, living will, and DNR documentation are current, accessible, and aligned with resident wishes.

Inspection Details

• Resident identifier and review date recorded
  Document the resident name or internal identifier, unit/room, and the date of the advance directive review.
• Review trigger identified
  Select the reason for this review.
• Reviewer name and role documented
  Record the staff member completing the review and their role/title.
• Resident or legal representative participation documented
  Confirm whether the resident, healthcare proxy, or legal representative participated in the review when appropriate.

Advance Directive Documents Current and Complete

• Code status is documented and current
  Verify the resident's current code status is clearly documented and reflects the latest order or directive.
• Healthcare proxy or durable power of attorney for health care is present and current
  Confirm the designated healthcare proxy or health care agent document is present, legible, and not expired or superseded.
• Living will or equivalent advance directive is present and current
  Confirm the resident's living will or equivalent directive is available in the record and reflects current wishes.
• DNR or other resuscitation order is present when applicable
  Verify that any DNR, DNAR, or equivalent resuscitation order is present when applicable and matches the resident's current code status.
• Documents are signed, dated, and authorized as required
  Check that required signatures, dates, witness or notary requirements, and provider authorizations are complete for each applicable document.
• Most recent version is clearly identified in the record
  Confirm the chart contains the latest version and any prior superseded forms are clearly marked or archived per policy.

Resident Wishes and Care Plan Alignment

• Documented wishes match current resident preferences
  Verify the advance directive content aligns with the resident's current stated wishes or the legally authorized representative's instructions.
• Any change in preferences has been escalated for update
  Confirm any discrepancy, change in condition, or new preference has been communicated to the care team and routed for order or document update.
• Care plan reflects current code status and goals of care
  Check that the resident care plan, treatment preferences, and emergency response instructions align with the current advance directive documentation.
• Resident or representative informed of available options and implications
  Confirm the resident or representative was offered review of available advance care planning options and informed of the implications of the current orders.

Accessibility and Availability to Care Team

• Advance directive documents are readily accessible in the chart or EHR
  Verify the current documents can be located quickly by nursing and clinical staff in the paper chart or electronic health record.
• Copies are available to relevant care settings
  Confirm copies are available to the nursing unit, on-call coverage, transfer packet, and other relevant care settings per facility policy.
• Emergency response staff can identify code status without delay
  Verify code status and resuscitation preferences are visible or retrievable in a way that supports timely emergency response.
• Document location and access method recorded
  Record where the current documents are stored and how staff access them during routine care and emergencies.

Deficiencies, Corrective Actions, and Sign-Off

• Deficiencies identified
  Select all deficiencies observed during the review.
• Corrective action documented for each deficiency
  Confirm a corrective action, responsible person, and target completion date are documented for each non-conformance.
• Follow-up review date set
  Enter the date and time for follow-up verification of any open corrective actions.
• Inspector signature
  Inspector attestation that the review was completed accurately.
• Supervisor or clinical leader review completed
  Confirm supervisory review when required by facility policy or when critical deficiencies are identified.