VA Pittsburgh Community Nursing Home Satisfaction Survey

VA Pittsburgh Healthcare System

Contracted Nursing Home Program Survey

OMB No. 2900-0770
Estimated Burden: 5 minutes

Expiration Date: 9/30/2020

The Paperwork Reduction Act of 1995: This information is collected in accordance with section 3507 of the Paperwork Reduction Act of 1995. Accordingly, we may not conduct or sponsor and you are not required to respond to, a collection of information unless it displays a valid OMB number. We anticipate that the time expended by all individuals who complete this survey will average 5 minutes. This includes the time it will take to follow instructions, gather the necessary facts and respond to questions asked. Customer satisfaction is used to gauge customer perceptions of VA services as well as customer expectations and desires. The results of this mailed survey will lead to improvements in the quality of service delivery with the VA Pittsburgh Healthcare System’s Contracted Nursing Home Program. Participation in this survey is voluntary and failure to respond will have no impact on benefits to which you may be entitled.

VA Pittsburgh Healthcare System

Veteran Satisfaction Survey

Contracted Nursing Home Program

Dear Veteran,

Our records indicate that VA Pittsburgh had recently authorized Contracted Nursing Home services for you. Your opinion regarding this service is important to us. Please complete the following questions and return this form in the self-addressed stamped envelope. If you have any questions or concerns regarding this survey, feel free to contact Amber Bertovich, LCSW, Social Work Coordinator, at 412-860-7209.

Contracted Nursing Home Name:___________________________________________________

Person completing this form:

______ I am the Veteran who received Contracted Nursing Home services

______ I am a Family member/caregiver of the Veteran who received services

1) When you were in the contracted nursing home facility, did you receive visits from the VA staff?	 Yes  No
2) Were the VA staff courteous and helpful during their visits?	 Yes  No
3) Did you know who to call for concerns about your contracted nursing home placement?	 Yes  No
4) If you had a concern reported during your placement, did the Community Nursing Home staff address and resolve the concerns with the facility?	 Yes  No  No concerns reported
5) During your placement did the contracted community nursing home provide quality care and meet your medical needs?	 Yes  No
6) Overall, how would you rate your experience during the contracted nursing home placement?	 Poor  Fair  Good  Very Good  Excellent
If you could change one thing about your contracted nursing home care, what would it be?
______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Any suggestions for improvement of the VA Community Nursing Home Program?
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________
Additional Comments:
_______________________________________________________________________________
_______________________________________________________________________________ _______________________________________________________________________________ _______________________________________________________________________________

Please choose the response that best describes your agreement with the following statements:

10. “I got the services that I needed.”

 Strongly disagree

 Disagree

 Neither agree nor disagree

 Agree

 Strongly Agree

11. “It was easy to get the services that I needed.”

 Strongly disagree

 Disagree

 Neither agree nor disagree

 Agree

 Strongly Agree

12. “I felt like a valued customer.”

 Strongly disagree

 Disagree

 Neither agree nor disagree

 Agree

 Strongly Agree

13. “I trust VA to fulfill our Country’s commitment to Veterans.”

 Strongly disagree

 Disagree

 Neither agree nor disagree

 Agree

 Strongly Agree

We value your opinion as we work to improve Community Nursing Home care management services for you!

Thank you for your time and input. Please return in the self-addressed envelope.