Free Post On-Site Review Questionnaire Nurse Aide Training Programs-F-62590 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62590 (Rev. 07/08)

STATE OF WISCONSIN Page 1 of 2

POST ON-SITE REVIEW QUESTIONNAIRE NURSE AIDE TRAINING PROGRAMS
Completion of this form is voluntary. Copies of this form are available at: http://dhs.wisconsin.gov/forms/DQAnum.asp
Name - Training Program On-site Review Date

Training Program Address

Date Questionnaire Completed

On-site Review Reason

Certification

Complaint Investigation

Use the following scale and check the number that applies. 5 = Strongly Agree 4 = Agree 3 = Neutral 5 SECTION A. ON-SITE REVIEW PROCESS 1. On-site review process was clearly explained. 2. On-site review did not interfere with the delivery of patient care in the clinical setting. 3. On-site review assisted in your understanding of rules / regulations. 4. On-site review was completed in a reasonable amount of time. 5. On-site review time frames and plan of correction process were explained. 6. Primary Instructor / student reaction to the on-site review was positive. 7. Communication with DQA Nurse Consultant was ongoing during on-site review. 8. Training Program had opportunity to discuss preliminary on-site review findings with the DQA Nurse Consultant. 9. Received knowledgeable response from DQA Nurse Consultant if training program requested clarification during on-site review. 10. The on-site review was conducted in a professional manner. 11. DQA Nurse Consultant interacted respectfully with training program staff and students. 4 2 = Disagree 3 2 1 NA 1 = Strongly Disagree NA = Not Applicable

Comment if 1 or 2 is checked.

F-62590 (Rev. 07/08)

Page 2 of 2

5

4

3

2

1 NA

Comment if 1 or 2 is checked.

SECTION B. POST-ON-SITE REVIEW STATEMENT OF DEFICIENCY 1. Deficiencies clearly explained the basis for findings of noncompliance. 2. Deficiencies identified who, what, when, where and how, if applicable. 3. Deficiencies included specific actions, errors, or lack of actions to explain findings of noncompliance. 4. Deficiencies were documented by accurate information. 5. Deficiencies clearly and concisely explained noncompliance with rules / regulations. 6. Documentation in deficiencies helped training program develop a plan of correction. 7. Changes in policies and / or procedures were made as a result of on-site review findings. Additional Comments or Information About the On-site Review Process

Recommend one change that would improve the on-site review experience.