Exit this survey >> Survey Process Quality Assurance Questionnaire 1. Quality Assurance Questionnaire Completion of this form by a facility representative is voluntary. Question Title * 1. Please enter the date you are completing this questionnaire: Please enter a valid date: Date Question Title * 2. Please enter your Facility Information: Your Name & Title: Company Name: Address: Address 2: City/Town: State: -- select state -- AL AlabamaAK AlaskaAS American SamoaAZ ArizonaAR ArkansasCA CaliforniaCO ColoradoCT ConnecticutDE DelawareDC District of ColumbiaFM Federated States of MicronesiaFL FloridaGA GeorgiaGU GuamHI HawaiiID IdahoIL IllinoisIN IndianaIA IowaKS KansasKY KentuckyLA LouisianaME MaineMH Marshall IslandsMD MarylandMA MassachusettsMI MichiganMN MinnesotaMS MississippiMO MissouriMT MontanaNE NebraskaNV NevadaNH New HampshireNJ New JerseyNM New MexicoNY New YorkNC North CarolinaND North DakotaMP Northern Mariana IslandsOH OhioOK OklahomaOR OregonPW PalauPA PennsylvaniaPR Puerto RicoRI Rhode IslandSC South CarolinaSD South DakotaTN TennesseeTX TexasUT UtahVT VermontVI Virgin IslandsVA VirginiaWA WashingtonWV West VirginiaWI WisconsinWY Wyoming ZIP/Postal Code: Email Address: Phone Number: Question Title * 3. Select your Facility Type: Nursing Home Abortion Clinic Adult Day Care Center Adult Family Care Home Ambulatory Surgical Center Assisted Living Facility Birth Center Community Mental Health Center Comprehensive Outpatient Rehabilitation Facility Crisis Stabilization Unit & SRT End Stage Renal Disease Facility Forensic Toxicology Laboratory Health Care Clinic Health Care Services Pool Home for Special Services Home Health Agency Home Medical Equipment Homemaker Companion Sitter Hospice Hospital Intermediate Care Facility for the Mentally Retarded Laboratory - CLIA Multiphasic Health Test Center Nurse Registry Organ Procurement Outpatient Physical Therapy/Speech Pathology Services Portable X-Ray Supplier Prescribed Pediatric Extended Care Psychiatric Residential Treatment Facility Residential Treatment Center for Children & Adolescents Residential Treatment Facility Rural Health Clinics Transitional Living Facility Transplant Center Question Title * 4. Select the Field Office serving your facility: Field Office 2 (Tallahassee/Pensacola) Field Office 3 (Alachua) Field Office 4 (Jacksonville) Field Office 5 (St. Petersburg/Tampa) Field Office 7 (Orlando) Field Office 8 (Ft. Myers) Field Office 9 (Delray Beach/Ft. Laud) Field Office 11 (Miami) Out of State Question Title * 5. Enter your State License Number: Question Title * 6. Survey Date: Please enter a valid date: Date Question Title * 7. Please enter survey TEAM MEMBERS and their ROLE: (for example: Jane Doe, Dietician) 1st Team Member Name & Surveyor Type 2nd Team Member Name & Surveyor Type 3rd Team Member Name & Surveyor Type 4th Team Member Name & Surveyor Type 5th Team Member Name & Surveyor Type 6th Team Member Name & Surveyor Type Question Title * 8. Please respond to each question below Yes No 1. Did the team members clearly identify themselves? 1. Did the team members clearly identify themselves? Yes 1. Did the team members clearly identify themselves? No 2. Was an entrance conference performed reviewing the functions and purpose of the survey and explaining responsibilities of the facility staff? 2. Was an entrance conference performed reviewing the functions and purpose of the survey and explaining responsibilities of the facility staff? Yes 2. Was an entrance conference performed reviewing the functions and purpose of the survey and explaining responsibilities of the facility staff? No 3. Was each team member professional and courteous? 3. Was each team member professional and courteous? Yes 3. Was each team member professional and courteous? No 4. Did your staff benefit from the team members' knowledge of the regulations? 4. Did your staff benefit from the team members' knowledge of the regulations? Yes 4. Did your staff benefit from the team members' knowledge of the regulations? No 5. Was information provided by the team members (explanation of the problem areas, observations, etc.) consistent with the regulations? 5. Was information provided by the team members (explanation of the problem areas, observations, etc.) consistent with the regulations? Yes 5. Was information provided by the team members (explanation of the problem areas, observations, etc.) consistent with the regulations? No 6. Were issues of non-compliance explained in a clear, concise manner, with examples cited? 6. Were issues of non-compliance explained in a clear, concise manner, with examples cited? Yes 6. Were issues of non-compliance explained in a clear, concise manner, with examples cited? No 7. Was a thorough exit conference conducted allowing for responses from the facility staff? 7. Was a thorough exit conference conducted allowing for responses from the facility staff? Yes 7. Was a thorough exit conference conducted allowing for responses from the facility staff? No 8. At the completion of the exit conference, did you have a clear understanding of the expectations of your facility in terms of noted areas? 8. At the completion of the exit conference, did you have a clear understanding of the expectations of your facility in terms of noted areas? Yes 8. At the completion of the exit conference, did you have a clear understanding of the expectations of your facility in terms of noted areas? No Question Title * 9. Please feel free to expand or provide additional comments on any responses on the questionnaire:(max 2,000 characters) Done >>