Submitter Information

Name of Facility:

Email:

Survey Information

Survey Start Date(Required)

Survey Exit Date(Required)

Number of surveyors:(Required)

If different number of surveyors for different days, please specify.

Who attended?(Required)

RFOD and/or RFOS name

Survey Results

Number of citations issued:(Required)

Number at non-harm F or lower:(Required)

Number at harm level: (G, H, I)(Required)

Number at IJ (J, K, L):(Required)

Number at substandard quality of care:(Required)

Survey/Enforcement Culture

Please list the surveyors involved in the survey process. How would you rate this surveyor on:

How Many Surveyors would you like to rate?(Required)

Surveyor 1 full name:(Required)

Surveyor 2 full name:(Required)

Surveyor 3 name:(Required)

Surveyor 4 full name:(Required)

Surveyor 5 full name:(Required)

DQA has issued a memo on expectations for providers and surveyors during the survey process. Did the Survey Team comply with its responsibilities set forth in the memo? (Please briefly explain) A Link to the memo is below.(Required)

DQA Shared Expectations Memo: https://www.dhs.wisconsin.gov/publications/p0/p00098.pdf

Additional Information

Please provide any additional information you feel is relevant to this questionnaire (note: do not provide confidential material or protected health information for any individual) (optional)

For example: if you would like to provide additional information or context on your surveyor rating scale choices, please provide that information here.

WHCA Nursing Home Post-Survey Questionnaire