We're halfway through 2026. Time for a compliance check-in. This issue includes a mid-year scorecard to assess where your facility stands, plus an updated inspection preparation checklist.
Mid-Year Compliance Scorecard
Score your facility on each area. Give yourself 2 points for "fully compliant," 1 point for "partially compliant," and 0 for "needs work."
Staffing (max 10 points) - All staff CPR certifications are current (2 pts) - All staff First Aid certifications are current (2 pts) - New hire orientation completed within 2 weeks for all employees hired in 2026 (2 pts) - Dementia training documented for applicable staff (2 pts) - Personnel files complete with TB clearance and background checks (2 pts)
Medication Management (max 10 points) - MARs complete with no gaps for past 6 months (2 pts) - Controlled substance counts accurate at every shift change (2 pts) - All PRN medications have current physician orders (2 pts) - Medication storage is locked and properly labeled (2 pts) - No expired medications in storage (2 pts)
Documentation (max 10 points) - All resident admission agreements are complete per HSC 1569.880 (2 pts) - Physician reports updated within the past 12 months for every resident (2 pts) - Care plans updated within 7 days of any significant changes (2 pts) - Personal Rights (LIC 613A) signed by all current residents (2 pts) - Incident reports filed within required timeframes for all 2026 incidents (2 pts)
Physical Environment (max 10 points) - Fire extinguishers inspected within the past 12 months (2 pts) - Quarterly fire drills documented with all required details (2 pts) - Evacuation diagrams posted and current (2 pts) - Smoke detectors and CO detectors functional (2 pts) - Facility clean, well-lit, and hazard-free (2 pts)
Emergency Preparedness (max 10 points) - Emergency disaster plan current and reviewed in 2026 (2 pts) - Emergency contact lists updated (2 pts) - Advance healthcare directives on file for applicable residents (2 pts) - Emergency supplies stocked and accessible (2 pts) - Staff trained on emergency procedures within the past 12 months (2 pts)
Scoring: - 45-50 points: Excellent. You're inspection-ready. - 35-44 points: Good but with gaps. Address the 0-point areas immediately. - 25-34 points: Concerning. Multiple areas need attention before an inspector visits. - Below 25: Critical. Prioritize the highest-risk areas (medication management, staffing certifications, incident reporting).
Updated Inspection Preparation Checklist
Based on Q1-Q2 2026 citation data, here's an updated priority checklist:
Priority 1 — Fix this week (highest citation risk): - Review all MARs for documentation gaps in the past 30 days - Check CPR/First Aid expiration dates for every staff member - Verify controlled substance counts match narcotic ledger - Confirm all incident reports are filed and current
Priority 2 — Fix this month: - Update any overdue care plans - Review admission agreements for completeness - Service fire extinguishers if approaching annual inspection date - Schedule quarterly fire drill if none conducted since March
Priority 3 — Schedule for next month: - Update emergency disaster plan for summer/fire season - Review and refresh staff training documentation - Audit physician reports for annual renewal dates - Check medication orders for upcoming expirations
Compliance Tip of the Month
Create a "Citation Prevention" binder. Keep a single binder (physical or digital) with: - Last 12 months of MARs - Current staff certification tracker - Fire drill logs - Incident report copies - Most recent CCLD inspection report and POC (if any)
When an inspector arrives, hand them this binder first. It shows organization and preparation, and it gives you control over what they review initially.
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