Through the mutual sharing of survey experiences, the MHCA provider community becomes more knowledgeable of survey trends, best practices, interpretation and opportunities for mutual education.
 
Instructions:  Complete this form following your agency's survey. Individual responses will be kept confidential. Please comment on both the positives and negatives of the survey process.

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* 1. What type of survey did you receive?

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* 2. Date of Survey

Date

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* 3. What were the areas of emphasis in this survey?

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* 4. Where did you get surveyed?

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* 5. What did the surveyor focus on that you did well?

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* 6. If you received deficiencies, please send a copy of the Statement of Deficiencies and Plan of Correction (if applicable) to mrubenstein@mnhomecare.org. (If you wish, delete any reference identifying your agency).

Please comment on deficiencies.

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* 7. Please comment below on any recommendations, other concerns, or the survey process (include surveyor's observations, your rebuttal, and subsequent communications as desired; also include surveyor's suggestions, assistance, etc.)

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* 8. What tips or advice do you have for someone expecting a survey?

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* 9. OPTIONAL: The Survey and Regulatory Analysis Team would appreciate having the following information in case there is a need for clarification or follow-up.

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