AHCA Member Questionnaire
DHS Survey Process

Date

Date / Time

Date

Thank you for taking the time to complete this survey to offer feedback on the DHS survey process. This will take you 5-10 minutes to complete.

Skilled Nursing

Assisted Living

Short-Term Transitional Care

Other (please specify)

	Yes	No
Did the surveyor(s) identify themselves when they entered the building?	Did the surveyor(s) identify themselves when they entered the building? Yes	Did the surveyor(s) identify themselves when they entered the building? No
Did the surveyor(s) explain the reason for their visit Annual/Complaint survey?	Did the surveyor(s) explain the reason for their visit Annual/Complaint survey? Yes	Did the surveyor(s) explain the reason for their visit Annual/Complaint survey? No

Please provide comments for all "NO" responses.

	Yes	No
Were survey team members floated on and off the team?	Were survey team members floated on and off the team? Yes	Were survey team members floated on and off the team? No
Were the surveyor(s) courteous?	Were the surveyor(s) courteous? Yes	Were the surveyor(s) courteous? No
Were the surveyor(s) objective?	Were the surveyor(s) objective? Yes	Were the surveyor(s) objective? No
Did the survyor(s) demonstrate knowledge of the regulations?	Did the survyor(s) demonstrate knowledge of the regulations? Yes	Did the survyor(s) demonstrate knowledge of the regulations? No

Please provide comments for all "NO" responses.

	Yes	No
Was an informal exit offered?	Was an informal exit offered? Yes	Was an informal exit offered? No
Were survey findings explained in an understandable manner?	Were survey findings explained in an understandable manner? Yes	Were survey findings explained in an understandable manner? No
Was the facility provided an opportunity to discuss/provide additional infromation pertinent to the findings before the team exited?	Was the facility provided an opportunity to discuss/provide additional infromation pertinent to the findings before the team exited? Yes	Was the facility provided an opportunity to discuss/provide additional infromation pertinent to the findings before the team exited? No

Please provide comments for all "NO" responses.