Audit Survey 1. Question Title * 1. Please provide the following Facility Name Number of Beds Facility Contact Name Facility Contact Email Question Title * 2. Length of audit: (choose one) One day Two days Three days Four days More than four days Question Title * 3. Name of Auditor (if known) Question Title * 4. Did the auditor provide an entrance conference? Question Title * 5. Audit Result Agreed with the facility staffing numbers as calculated by DPH Disagreed with the facility staffing numbers as calculated by DPH Question Title * 6. If answer to question 5 above was “disagreed” please answer questions 6 and 7.The audit disagreed with facility staffing calculation numbers : 0-10% of the time 10-25% of the time 26-50% of the time 50% or more of the time Question Title * 7. If discrepancies occurred between audit calculations and facility staffing numbers please check all that apply: Staff that the facility counted within the 3.2 calculation were disallowed by the auditors. Disagreement between auditors and facility as to census numbers. Documents or records were determined by the auditor to be incomplete, illegible or inaccurate. Hours of overlapping shifts were not counted. Auditor’s software was unable to calculate certain nursing hours. Employees that provide both nursing and non-nursing duties did not have proper documentation. The patient day was calculated incorrectly. Break times were not included. Inservice time was not included (2 hours on-site a month). Duties identified by the facility as nursing duties were identified by auditors as non-nursing duties. Please Specify Question Title * 8. If the auditor refused to count an employee that the facility counted in the nursing hours, please list his or her job title and major duty. Question Title * 9. Which of the following documents did the auditors use in conducting the audit? (check all that apply) Payroll records Personnel records Payroll codes CDPH Assignment sheets Duty statements Job Descriptions Registry invoices CDPH Census and NHPPD form Staffing schedules Time cards Other (please specify) Question Title * 10. Are there any other comments that you would like to make concerning your staffing audit? Question Title * 11. I would like CAHF staff to contact me regarding my facility’s audit. Yes No Done
