Free Post Survey Questionnaire-F-62579 - Wisconsin

DEPARTMENT OF HEALTH SERVICES Division of Quality Assurance F-62579 (Rev. 10/08)

STATE OF WISCONSIN Page 1 of 3

POST SURVEY QUESTIONNAIRE
· · Completion of this form is voluntary. Return this completed form to: Division of Quality Assurance Bureau of Health Services P.O. Box 2969 Madison, WI 53701-2969 This form is available at: http://dhs.wisconsin.gov/forms/DQAnum.asp .
Survey Date

·

Name - Facility

Facility Address

Date Questionnaire Completed

DQA Region

Provider Type

Northeast

Northern

Southeast

Southern

Western

SECTION A. ON-SITE REVIEW PROCESS
5
Strongly Agree

4

3

2
Disagree

1
Strongly Disagree

N/A
Not Applicable

Comment if 1 or 2 is checked.

A.

Survey process was clearly explained.

B.

Survey did not interfere with the delivery of patient / client / resident care.

C. Survey assisted in your understanding of rules/regulations. D. Survey Guide was easy to understand and helpful during survey. E. Survey was completed in a reasonable amount of time. Survey time frames and plan of correction process were explained.

F.

G. Provider / facility staff comments on the survey were positive. H. Client / patient / resident reaction to the survey was positive. I. Communication with surveyor(s) was ongoing during survey. Provider / facility had opportunity to discuss preliminary survey findings with the surveyor / supervisor. Received knowledgeable response from DQA surveyor / supervisor if provider / facility requested clarification during survey process.

J.

K.

Neutral

Agree

F-62579 (Rev. 10/08)

Page 2 of 3

5
Strongly Agree

4

3

2
Disagree

1
Strongly Disagree

N/A
Not Applicable

Comment if 1 or 2 is checked.

L.

The survey was conducted in a professional manner.

M. Surveyor(s) interacted respectfully with facility staff and clients.

SECTION B. POST-SURVEY STATEMENT OF DEFICIENCY
A. Deficiencies clearly explained the basis for findings of noncompliance. Deficiencies identified who, what, when, where, and how, if applicable. Deficiencies included specific actions, errors, or lack of actions to explain findings of noncompliance. Deficiencies were documented by accurate information. Deficiencies clearly and concisely explained noncompliance with rules / regulations. Documentation in deficiencies helped provider / supplier develop a plan of correction. Changes in policies and/or procedures were made as a result of survey findings.

B.

C.

D.

E.

F.

G.

SECTION C. SURVEY TASKS EVALUATION
Were the following survey tasks carried out in accordance with the Survey Guide? Check "Yes," "No," or "N/A" for each task. Survey Task A. Entrance Conference Yes No N/A Comment

B.

Sample Selection

C.

Technical Assistance

D.

Observation

E.

Home Visits

F.

Orientation Tour

Neutral

Agree

F-62579 (Rev. 10/08)

Page 3 of 3

Survey Task G. Assessment of Applicable Regulations

Yes

No

N/A

Comment

H.

Environmental Quality

I.

Life Safety Codes

J.

Clinical Record Reviews

K.

Staff Interviews

L.

Patient / Client / Resident Interviews

M.

Exit Conference

Additional Comments or Information About the Onsite Survey Process

Recommend one change that would improve the survey experience.

Type of On-Site Survey Conducted (Please identify all that apply.)
Medicare / Medicaid Certification State Licensure / Certification LSC / Physical Environment Health Complaint Investigation Other