Forms
Notice of Proposed Involuntary Discharge or Transfer

 
Sample Template for Development of Emergency Plans
for Nursing Homes

NOTE: This sample template is used to assist nursing 
homes in complying with COMAR 10.07.02.24 
(Emergency Preparedness). It is not meant to exclude 
other formats so long as they include all elements of 
the regulations.
 
Model Admission Agreements for Resident and 
Resident's Agent
Click here for Resident's Agent Agreement 2012
 
Montgomery County Advanced Practice Center (APC) for 
Public Health Preparedness

Nursing Home Self-Report Form
Instructions for using the Comprehensive Care Facilities 
& Extended Care Facilities Self-Report Form

The form was created for use by facilities to self-report ​alleged violations of neglect and abuse, including injuries of unknown source, and misappropriation of resident 
property/funds (refer to April 12, 2005 memorandum from Carol Benner regarding 
the clarification of reporting 

requirements). It is not mandatory that facilities use this form, but a facility must include, at a minimum, the information requested on this form.

The form should be used to forward both the “first report” and “results of investigation” to the OHCQ/Long Term Care Unit via fax 410-402-8113 or email nh.selfreport@maryland.gov.

The facility should complete the top of the form for the “first report” and forward to OHCQ within 24 hours of the incident.

The results of the investigation of the reported incident,should then be entered on the bottom of the form and be forwarded to OHCQ. One complete form (i.e., includes the first report and investigation results) should be forwarded within 5 days of the incident.

The Nursing Home Self-Report Form can be downloaded and viewed with Microsoft® or Word Adobe Acrobat®.

Choose the document type you need below:
 
SAMPLE STAFFING
A sample of how a facility could use an erasable white board with names hand written in to be in compliance with .55 A and B about staffing. Remember this is to be done per shift per unit or floor