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Social Media Directory
Long Term Care
Public Meeting Announcement
Infection Prevention Information
Long Term Care
Licensure or Renewal Application
MHCC Consumer Guide to LTC (Nursing Homes)
File a Complaint
Advancing Excellence in America’s Nursing Homes
Nursing Home Compare
Notice of Proposed Involuntary Discharge or Transfer
Click here for the form in Microsoft® Word
Click here for the form in Adobe® Acrobat
Sample Template for Development of Emergency Plans
for Nursing Homes
Click here for the template in Microsoft® Word
Click here for the template in Adobe® Acrobat
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
Model Admission Agreements for Resident and
Click here for Resident agreement
Click here for Financial resident's agent agreement
Emergency Preparedness Survey for Nursing Homes
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
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:
nh_self_report.doc (click for the form in Microsoft® Word)
nh_self_report.pdf (click for the form in Adobe® Acrobat)
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
201 W. Preston Street, Baltimore, MD 21201-2399
(410) 767-6500 or 1-877-463-3464
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