Connecticut Association of Health Care Facilities

 
 

Survey - CT DPH Survey Evaluation

The Survey is intended to be a means of evaluating surveyor behavior and whether or not the survey process was successful.  We are sure that you can fairly and accurately evaluate whether surveyors are courteous and respectful, whether issues and problems were communicated appropriately during the survey and whether the Exit Conference provided a reasonable opportunity to discuss possible deficiencies.  The Survey is intended to be a way to give the Department of Public Health feedback on what surveyors are doing well.  The Survey is not meant to be used only as a way to complain about inappropriate or unfair behavior.  We want to give CT DPH a comprehensive picture of how Providers perceive the survey process - the good and the bad.

The Survey is not designed or intended to provide any feedback on the deficiencies the facility receives.  Disagreement about deficiencies should be pursued through the Informal Dispute Resolution process and further appeals if necessary.

ALL RESPONSES WILL BE HELD IN THE STRICTEST CONFIDENCE.

Facility Name
Name of Person Reporting the Information
Dates of Visit
Type of Visit (check all that apply)
     Standard     QIS     Complaint     Revisit
 
Please rate the Survey overall, rating on a scale of five (5; best) to one (1; worst).  If you have given a five (5) or a one (1) in any category, please give us a note in the Examples section of what was particularly good or particularly bad.  Under the rating system used here, a three (3) is satisfactory.
 
Were the surveyors courteous?   
Were issues clearly explained? 
Was enough time allowed to gather information/respond to questions? 
Were potential findings/problems communicated throughout the survey? 
Were surveyors respectful of residents? 
Were surveyors respectful of staff? 
Were clinical records left in good order? 
Was adequate time allowed for the Exit Conference? 
Were possible findings clearly explained at the Exit Conference? 
Did you have the opportunity to discuss and respond to these possible finds at the Exit Conference? 
 
Name of Team Leader/Principal Surveyor
Names of Other Surveyors
 

Examples/Comments?  Please write them below.

If you would like to respond using the full Survey Evaluation Tool and faxing it over to us, please click HERE.

Thank you.

   

If you're getting an Error Message when clicking on Send, try holding down the CTRL key, then clicking on Send. 
If all else fails, print out this completed form and fax it to 860-290-9478.