WHCA Nursing Home Post-Survey Questionnaire

This questionnaire is produced and maintained by WHCA/WiCAL, and is not connected or affiliated with DQA, the State of Wisconsin, or CMS. The information you submit in this form will only be shared with WHCA/WiCAL, and will be primarily used to aggregate data, identify patterns, and discover potential survey/enforcement inconsistencies among survey regions and survey teams.

Submitter Information

Name of Facility:

Name:

First Last

Email:

Region where facility is located:(Required)

Northeastern (NERO)

Northwestern (NWRO)

Southeastern (SERO)

Southern (SRO)

Survey Information

Survey Start Date(Required)

Survey Exit Date(Required)

Was the survey during regular operating hours or off-hours?(Required)

During regular operating hours

During off-hours

Type of Survey(Required)

Annual

Complaint

Annual w/ complaint

Self Report/FRI

Infection Control

Revisit

Other

Region where the Survey Team was from:(Required)

Northeastern (NERO)

Northwestern (NWRO)

Southeastern (SERO)

Southern (SRO)

Number of surveyors:(Required)

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

Did the RFOD / RFOS attend any of the Survey?(Required)

Yes

Who attended?(Required)

RFOD and/or RFOS name

If any citations at G or higher were suspected, were you notified:(Required)

Immediately upon surveyor’s discovery

That day

Prior to exit

Sometime after exit

Not at all/only via 2567

Other

If any citations at G or higher were suspected, were you given an opportunity to present additional mitigating information?(Required)

Yes

Not applicable

Do you feel this data was considered prior to issuance of a citation?(Required)

Yes

Did the Survey team offer an exit meeting after each day of the survey?(Required)

Yes

During the survey, did you ever feel the need to communicate with DQA leadership at the regional or state level due to lack of communication or lack of consideration by the survey team?(Required)

Yes

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)

Did you receive any “FYIs” in lieu of citations?(Required)

Yes

Survey/Enforcement Culture

Did you find the Surveyors to be:(Required)

Pleasant

Neutral

Antagonistic

Other

Were the Surveyors' requests for information reasonable?(Required)

Yes

How would you rate the outcome of your Survey:(Required)

Fair and Balanced

Neutral

Punitive

Other

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)

Objectivity (scale 1-5, 1 being objective/fair, 5 being biased/prejudicial)(Required)