Monthly LTC Services QA Data Collection Tool
Consumer/Family
State Regulatory Agency
Date
-
Month
-
Day
Year
Date Picker Icon
Period Covered
Name (optional)
First Name
Last Name
Consumer Name (optional)
First Name
Last Name
Respondent:
Resident
Family Member
Conservator or P.O.A
Contact Information
Name and Location of Facility (optional)
Street Address
Street Address Line 2
City
State / Province
Postal / Zip Code
Please Select
United States
Afghanistan
Albania
Algeria
American Samoa
Andorra
Angola
Anguilla
Antigua and Barbuda
Argentina
Armenia
Aruba
Australia
Austria
Azerbaijan
The Bahamas
Bahrain
Bangladesh
Barbados
Belarus
Belgium
Belize
Benin
Bermuda
Bhutan
Bolivia
Bosnia and Herzegovina
Botswana
Brazil
Brunei
Bulgaria
Burkina Faso
Burundi
Cambodia
Cameroon
Canada
Cape Verde
Cayman Islands
Central African Republic
Chad
Chile
China
Christmas Island
Cocos (Keeling) Islands
Colombia
Comoros
Congo
Cook Islands
Costa Rica
Cote d'Ivoire
Croatia
Cuba
Curaçao
Cyprus
Czech Republic
Democratic Republic of the Congo
Denmark
Djibouti
Dominica
Dominican Republic
Ecuador
Egypt
El Salvador
Equatorial Guinea
Eritrea
Estonia
Ethiopia
Falkland Islands
Faroe Islands
Fiji
Finland
France
French Polynesia
Gabon
The Gambia
Georgia
Germany
Ghana
Gibraltar
Greece
Greenland
Grenada
Guadeloupe
Guam
Guatemala
Guernsey
Guinea
Guinea-Bissau
Guyana
Haiti
Honduras
Hong Kong
Hungary
Iceland
India
Indonesia
Iran
Iraq
Ireland
Israel
Italy
Jamaica
Japan
Jersey
Jordan
Kazakhstan
Kenya
Kiribati
North Korea
South Korea
Kosovo
Kuwait
Kyrgyzstan
Laos
Latvia
Lebanon
Lesotho
Liberia
Libya
Liechtenstein
Lithuania
Luxembourg
Macau
Macedonia
Madagascar
Malawi
Malaysia
Maldives
Mali
Malta
Marshall Islands
Martinique
Mauritania
Mauritius
Mayotte
Mexico
Micronesia
Moldova
Monaco
Mongolia
Montenegro
Montserrat
Morocco
Mozambique
Myanmar
Nagorno-Karabakh
Namibia
Nauru
Nepal
Netherlands
Netherlands Antilles
New Caledonia
New Zealand
Nicaragua
Niger
Nigeria
Niue
Norfolk Island
Turkish Republic of Northern Cyprus
Northern Mariana
Norway
Oman
Pakistan
Palau
Palestine
Panama
Papua New Guinea
Paraguay
Peru
Philippines
Pitcairn Islands
Poland
Portugal
Puerto Rico
Qatar
Republic of the Congo
Romania
Russia
Rwanda
Saint Barthelemy
Saint Helena
Saint Kitts and Nevis
Saint Lucia
Saint Martin
Saint Pierre and Miquelon
Saint Vincent and the Grenadines
Samoa
San Marino
Sao Tome and Principe
Saudi Arabia
Senegal
Serbia
Seychelles
Sierra Leone
Singapore
Slovakia
Slovenia
Solomon Islands
Somalia
Somaliland
South Africa
South Ossetia
South Sudan
Spain
Sri Lanka
Sudan
Suriname
Svalbard
eSwatini
Sweden
Switzerland
Syria
Taiwan
Tajikistan
Tanzania
Thailand
Timor-Leste
Togo
Tokelau
Tonga
Transnistria Pridnestrovie
Trinidad and Tobago
Tristan da Cunha
Tunisia
Turkey
Turkmenistan
Turks and Caicos Islands
Tuvalu
Uganda
Ukraine
United Arab Emirates
United Kingdom
Uruguay
Uzbekistan
Vanuatu
Vatican City
Venezuela
Vietnam
British Virgin Islands
Isle of Man
US Virgin Islands
Wallis and Futuna
Western Sahara
Yemen
Zambia
Zimbabwe
Other
Country
Issues or Concerns in the Last Month
Last 30 Days
Health Prevention
Treatment
Treatment Information
Quality of Life
Resident Rights
other
Health Prevention
Short Description
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning?
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate concerns?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Problem Resolution:
1
2
3
4
5
Other Comments:
Issue 2
Issue 2
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 3
Issue 3
How Concerning?
Please Select
Somewhat Concerning
Very Concerning
Potential Jeopardy
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Back
Next
Save
Treatment
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning?
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 2
Issue 2
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning?
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 3
Issue 3
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning?
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Back
Next
Save
Treatment Information
Short Description:
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning?
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Problem Resolution
1
2
3
4
5
Other Comments:
Issue 2
Issue 2
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 3
Issue 3
How Concerning?
Please Select
Somewhat Concerning
Very Concerning
Potential Jeopardy
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Back
Next
Save
Quality of Life
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning?
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 2
Issue 2
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 3
Issue 3
How Concerning?
Please Select
Somewhat Concerning
Very Concerning
Potential Jeopardy
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Back
Next
Save
Resident Rights
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning?
Please Select
Somewhat
Very
Potential Jeopardy
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 2
Issue 2
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 3
Issue 3
How Concerning?
Please Select
Somewhat Concerning
Very Concerning
Potential Jeopardy
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Back
Next
Save
How Concerning?
Please Select
Somewhat Concerning
Very Concerning
Potential Jeopardy
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Back
Next
Save
Back
Next
Save
Other
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning?
Please Select
Somewhat
Very
Potential Jeopardy
Explain:
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 2
Issue 2
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
How Concerning
Please Select
Somewhat
Very
Potential Jeopardy
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Issue 3
Issue 3
How Concerning?
Please Select
Somewhat Concerning
Very Concerning
Potential Jeopardy
Incidence:
New Concern
Concern w/ previous hx
Previous Complaint
Prior State Citation
Staff Contact:
Aide
Shift Supervisor
Nurse
Nursing Director
Director
Other
Was the issue resolved successfully?
Yes
No
Partial
Still Pending
How did you communicate your concern?
Face to Face conversation
Telephone
Email or Letter
How long did it take to recieve a response to your Concern?
Immediate
A few days
More than a week
More than 30 days
Still Pending
No Response
Routing
Facility Director
Facility Grievance Process
Ombudsman
Department of Health
Problem Resoution Process
1
2
3
4
5
Worst
Best
1 is Worst, 5 is Best
Other Comments:
Save
Submit
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