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LTCO-00001 - CVA Activity Log
Added emails
0
Incorrect emails
0
Skipped emails
0
Add users to selection
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Drag and drop csv file with emails
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Import
Region
*
Value is not selected
-- Select one --
North 1
North 2
Central 1
Central 2
Coastal
South 1
South 2
Email Address
*
Email
form field Email Address
is not in correct form
Name
*
Month
*
Value is not selected
-- Select one --
January
February
March
April
May
June
July
August
September
October
November
December
Facility
*
Add additional activities
Remove additional activities
Date
*
Date
form field Date
must be in the format: MM/dd/yyyy
Number of Residents Seen
*
Form field Number of Residents Seen has
Invalid numeric value.
Number of Hours
*
Form field Number of Hours has
Invalid numeric value.
Activity of CVA Problem/Complaint
*
Value is not selected
-- Select one --
Food Services - Food quality, quantity, variation, choice temperature and timing
Personal hygiene – fail to provide hygiene services: baths, soiled clothing, teeth/dentures not cleaned
Incontinence care – fail to provide proper incontinence care as requested
Access to health care services – fail to access services for podiatry, dental, vision, hearing, etc.
Visitation – restriction on ability to choose visits
Rights and preferences – deprivation of other rights: religion, speech, vote, smoking, to refuse care
Other
HIDDEN - Activity of CVA Problem/Complaint Text
Activity of CVA Problem/Complaint Text
Complainant Vol/Res/Other
*
Name/Room Number/All Residents
*
Resolved?
*
Value is not selected
-- Select one --
Yes
No
Partially
Total Number of Residents Seen
Form field Total Number of Residents Seen has
Invalid numeric value.
Total Number of Hours
Form field Total Number of Hours has
Invalid numeric value.
Number of Resident Council Meetings Attended
Form field Number of Resident Council Meetings Attended has
Invalid numeric value.
Survey Team Contact
Value is not selected
-- Select one --
Yes
No
Other significant events (such as conducting Residents’ Rights Bingo) or comments (such as meeting with DOH survey team) or pending activities.
Email Address:
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