Provider Feedback Questionnaire on the Regulatory On-site/Investigation Process Survey

This questionnaire includes open-ended questions and scale response questions.

To answer the scale response questions, please read each statement and select the response that best matches your opinion. Your choices range from:

1= Strongly Disagree......6= Strongly Agree

It should take you no more than 10 minutes to complete the questionnaire.

1.What type of facility/agency are you? (Provider type)

2.What type of on-site visit was performed?

3.Did the on-site visit identify deficient practices?

Yes

No

4.If yes, were the majority of the deficient practices cited valid?

Yes

No

N/A

5.The on-site visit provided an opportunity to identify areas for improvement.

6.The reason for the on-site visit and overview of the process to occur was clear and complete.

8.The purpose of the on-site visit and the initial requests for documentation were clear during the entrance process.

9.An opportunity was provided at the end of the on-site visit to ask questions and receive answers.

Please provide your feedback to the following questions.

10.Did a state employee stand out in professionalism and courtesy that you would like to recognize and commend? If so, please provide his/her name.

11.Was there a state employee that could use additional training, etc., in your opinion and what areas or skills could we improve upon?

12.What worked well during the on-site visit? What were the highlights?

13.Are there opportunities for improvements in our on-site process and, if yes, what specifically could we work on?

14.Do you have any additional comments?

Thank you for completing this questionnaire.