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

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

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

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

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

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

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

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

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

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

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

* 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?

* 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?

* 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?

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

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

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

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

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

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

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

Survey Exit Date

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