Policy Manual sample

MDT Home Health Care Agency, Inc. QAPI Questionnaires/Surveys Summary Table: Period from: ________________ to ______________ (Every Quarter) Rating from 1 “Disagree” - 5 “Strongly Agree” Summarize Total Patient in each Question Question Always/Good Sometimes Never Total 4 - 5 % Total 2 - 3 % Total 1 % 1. Did you like your nurse/aide/therapist? 2. Was your nurse/aide/therapist always there when she was expected to be there? 3. Did your nurse/aide/therapist always wear a clean uniform? 4. Did your nurse/aide/therapist appear to know her job? 5. Was your nurse/aide/therapist punctual? 6. Would you say the nurse/aide/therapist took good care of you? 7. Was your nurse/aide/therapist a good listener? 8. Perception of effectiveness of Care Provided: Care Plan Management, Disease Management, Pain Management, Patient’s Safety, Medication Management, Infection Prevention, Fall prevention. 9. Your nurse/aide/therapist were always available to communicate with you? 10. Other Goals 90 - 100 % of Customers 0 % Action Plan if Goals not Met: (Indicate Responsible party, and due date) 9 Inservice to our Employees requesting reinforced in areas with problems:_________________________________________ _____________________________________________________________________________________________________ 9 Reinforced Punctuality and frequency _____________________________________________________________________ _____________________________________________________________________________________________________ 9 Patient Care, Safety, Treatment need improvement _________________________________________________________ _____________________________________________________________________________________________________ 9 Interdisciplinary, Physician, Family/Patients Communication need improvement____________________________________ _____________________________________________________________________________________________________ 9 Other ______________________________________________________________________________________________ Evaluator/Title Name: __________________________ Signature: _______________ Date:___________________ Home Health Agency - - Skilled Professional Services D-16