Read the following instructions carefully

1. Complete the questions below by selecting the root causes you think are barriers to Home Referrals (multiple selections are allowed)
2. Describe any root cause(s) NOT listed by using the Other (comment) box
WARNING: DO NOT USE PATIENT SPECIFIC INFORMATION SUCH AS NAMES, DOB, SOC SECURITY #, ETC. IN THIS SURVEY. SECURITY VIOLATIONS WILL BE REPORTED TO CMS.

What are Facility Specific Barriers that you think are attributable to having a low Home Referrals in your facility?

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* 1. What are Facility Specific Barriers that you think are attributable to having a low Home Referrals in your facility?

What are Patient-Related Factors that you think are attributable to low Home Referrals in your facility? Make sure to include FPR and/or gather patients' perspective when completing this section.

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* 2. What are Patient-Related Factors that you think are attributable to low Home Referrals in your facility? Make sure to include FPR and/or gather patients' perspective when completing this section.

What are Organizational Factors (operational, policies, systemic) that you think are attributable to low Home Referrals in your facility?

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* 3. What are Organizational Factors (operational, policies, systemic) that you think are attributable to low Home Referrals in your facility?

What are Product/Methods/Material Factors that you think are attributable to low Home Referrals in your facility?

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* 4. What are Product/Methods/Material Factors that you think are attributable to low Home Referrals in your facility?

Completion of this root cause analysis was easy to do on-line.

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* 5. Completion of this root cause analysis was easy to do on-line.

Provide first and last name of person completing this survey

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* 7. Provide first and last name of person completing this survey

Any additional thoughts or comments you would like to provide about this process?

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* 8. Any additional thoughts or comments you would like to provide about this process?

Provide name of facility

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* 9. Provide name of facility

Provide 6-digit CMS provider number (CCN#, begins with a 45 or 67).

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* 10. Provide 6-digit CMS provider number (CCN#, begins with a 45 or 67).

I have printed a completed copy of this RCA survey with all the answers for my records (right-click over the survey and select "Print")

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* 11. I have printed a completed copy of this RCA survey with all the answers for my records (right-click over the survey and select "Print")

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