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Home / Forms / Appendix Z

Compliance Audit Checklist

Internal audit of resident files, training, billing, and safety records.

Kura Solution

Appendix Z — Compliance Audit Checklist

Internal audit of resident files, training, billing, and safety records.

Audit Items (check all that pass)

Resident files completeConsents signedRecovery plans currentProgress notes completedBilling documentation compliantIncident reports filedTraining records currentNaloxone logs maintainedFire safety complianceGrievances trackedSupervision records completeRecovery Works authorizations current

Audit Conducted By *

Date *

Corrective Actions Required

Follow-Up Date

Supervisor Signature

Supervisor Signature *

Sign here

Use mouse, trackpad, or finger to sign.

Supervisor Printed Name *

Date *

Electronic Signature ConsentI agree that the signature(s) I have provided above are my legal electronic signatures, with the same effect as a handwritten signature, under the federal E-SIGN Act (15 U.S.C. § 7001 et seq.) and applicable state law (UETA). I authorize Kura Solution to maintain this signed form as a legal record. I have had the opportunity to read and understand this form and my signature(s) are made knowingly and voluntarily.

A signed PDF copy will download to your device after submission. Records protected under 42 CFR Part 2 & HIPAA.

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