Please provide responses to the following questions about your recent MDH survey.

What surprised you about the new survey process?

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* 1. What surprised you about the new survey process?

What went well during the new survey process?

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* 2. What went well during the new survey process?

What did not go well during the new survey process?

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* 3. What did not go well during the new survey process?

How many licensed beds are at your facility?

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* 4. How many licensed beds are at your facility?

How many total surveyors were on your survey team?

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* 5. How many total surveyors were on your survey team?

If the survey team included surveyors "in training" or federal surveyors, please identify how many surveyors were in training or were federal surveyors.

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* 6. If the survey team included surveyors "in training" or federal surveyors, please identify how many surveyors were in training or were federal surveyors.

How many OHFC complaints were investigated during your survey?

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* 7. How many OHFC complaints were investigated during your survey?

How many days did your survey last…from entrance conference to exit conference?

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* 8. How many days did your survey last…from entrance conference to exit conference?

Use the scale below to rate this statement: Surveyors showed respect towards staff during the survey.

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* 9. Use the scale below to rate this statement: Surveyors showed respect towards staff during the survey.

Use the scale below to rate this statement: Surveyors showed respect towards residents, families, and visitors during the survey.

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* 10. Use the scale below to rate this statement: Surveyors showed respect towards residents, families, and visitors during the survey.

During the exit conference, was the facility provided the opportunity to discuss and supply additional information that you believe was pertinent to the identified MDH findings?

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* 11. During the exit conference, was the facility provided the opportunity to discuss and supply additional information that you believe was pertinent to the identified MDH findings?

Do you feel information shared during the exit conference was understandable and provided you with enough information so you are aware of survey concerns and areas where deficiencies may be issued?

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* 12. Do you feel information shared during the exit conference was understandable and provided you with enough information so you are aware of survey concerns and areas where deficiencies may be issued?

Based on feedback from surveyors and information provided at the entrance conference, do you feel information from either your Facility-Wide Assessment OR QAPI plan will be used to support deficiencies?

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* 13. Based on feedback from surveyors and information provided at the entrance conference, do you feel information from either your Facility-Wide Assessment OR QAPI plan will be used to support deficiencies?

Please select all regulatory topic areas (F-Tags) that you anticipate being cited under.

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* 14. Please select all regulatory topic areas (F-Tags) that you anticipate being cited under.

Please select all Emergency Preparedness (EP) requirements you anticipate being cited (E-Tags) under.

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* 15. Please select all Emergency Preparedness (EP) requirements you anticipate being cited (E-Tags) under.

Any specific survey or regulatory compliance findings you would like Care Providers of Minnesota to be aware of?

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* 16. Any specific survey or regulatory compliance findings you would like Care Providers of Minnesota to be aware of?

Based on your survey, are there areas where you believe Care Providers of Minnesota should provide new or additional training?

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* 17. Based on your survey, are there areas where you believe Care Providers of Minnesota should provide new or additional training?

Do you anticipate initiating an IDR (Informal Dispute Resolution) or IIDR (Independent Informal Dispute Resolution) regarding any of the deficiencies?

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* 18. Do you anticipate initiating an IDR (Informal Dispute Resolution) or IIDR (Independent Informal Dispute Resolution) regarding any of the deficiencies?

Please provide the name of your facility (in case we need to contact you for additional information or clarification):

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* 19. Please provide the name of your facility (in case we need to contact you for additional information or clarification):

Please provide the date of your survey's exit conference:

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* 20. Please provide the date of your survey's exit conference:

Survey Exit Date
Anything else about your survey you would like to share?

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* 21. Anything else about your survey you would like to share?

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