1. TYPE OF FACILITY AFC Family AFC Small Group Home (1-6) AFC Medium Group Home (7-12) AFC Large Group Home (13-20) AFC Congregate (21 or more) HFA
2. Current number of residents:
3. Were you at the facility when the onsite inspection was conducted? Yes No
If yes, are you: The licensee/representative? The administrator? Other?
Other Title:
4. Was the inspection process clearly explained to you upon the arrival of the licensing consultant/staff? Yes No Not Applicable
4a. Comments
5. Did the licensing consultant/staff focus primarily on observations and interview of staff and residents to determine if you are in compliance? Yes No
6. Which documents were reviewed during the inspection? Please check all that apply. Financial Records Resident Assessment Plans/Health Facility Program Plan Crisis Intervention/Behavioral Management Incident Reports Meals/Nutrition Personnel Records/Training Other
Comments
7. Were you treated with courtesy, dignity, and fairness by the licensing consultant/staff? Yes No
Comments
8. Did the licensing consultant/staff interact respectfully with facility staff and residents? Yes No
Comments
9. Did the licensing consultant/staff offer you positive comments? Yes No
Comments
10. Did the inspection interfere with the delivery of resident care? Yes No
Comments
11. Using the scale listed below, choose the response that best describes your staffs' comments about the inspection: 1- A positive and helpful experience 2- A positive experience 3- Neutral; (neither positive or negative; neither helpful or lacking) 4- A negative experience 5- A negative and lacking experience
Comments
12. Using the scale listed below, choose the response that best describes your residents' comments about the inspection: 1- A positive and helpful experience 2- A positive experience 3- Neutral; (neither positive or negative; neither helpful or lacking) 4- A negative experience 5- A negative and lacking experience
Comments
13. Did you receive any notices of findings (NOF)? Yes No
Comments
14. Did you receive any rule violations? Yes No
Comments
15. If rule violations were identified, were you provided with technical assistance to assist you in meeting the requirements of the act and the rules? Yes No N/A
Comments
16. Were you offered or provided consultation to assist you in developing methods for the improvement of service? Yes No
Comments
17. Were you offered or provided an exit interview to review the inspection findings? Yes No
Comments
18. Were you given an opportunity to clarify incorrect or missing information? Yes No N/A
Comments
19. Following the exit interview, did you have any unresolved disagreement with the application of the rules? Yes No
Comments
20. Was the licensing staff's supervisor involved in resolving the disagreement? Yes No N/A
Comments
21. How long did it take to complete the inspection?
22. Is there anything else that you believe the licensing consultant/staff should have evaluated? Yes No
Comments
23. Do you prefer the current inspection process over the inspection process used in your facility previously? Yes No N/A
Comments
24. Based on your renewal inspection, how do you rate the following statement: "The licensing renewal inspection process was a meaningful, accurate and balanced assessment of our compliance with the rules and our quality of care provided to residents." 1 Strongly Disagree 2 Disagree 3 Neutral 4 Agree 5 Strongly Agree
Any additional comments:
25. Is there any information that would have been beneficial to have prior to the renewal inspection? Yes No
If yes, please list that information.
THE FOLLOWING SECTION IS OPTIONAL
Name of licensing consultant/staff who conducted the inspection:
Your Name:
Your Phone #:
E-mail Address:
Facility Name:
License #:
