| When I get my home health care: |
Yes |
No |
Comments |
| 1. The staff is polite and treats me, and my family members, with respect. |
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| 2. The staff explains my plan of care to me and us participate in creating the plan of care,
and lets us know ahead of time of any changes. |
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| 3. The staff are properly trained and licensed to perform the type of health care I need. |
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| 4. The agency explains what to do if I have a problem with the staff or the care I am getting. |
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| 5. The agency responds quickly to my requests. |
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| 6. The staff checks my physical and emotional status at each visit. |
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| 7. The staff respond quickly to changes in my health or behavior. |
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| 8. My home is checked and suggestions are made to meet my special needs and to ensure my
safety. |
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| 9. The staff have told me what to do if I have an emergency. |
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| 10. My privacy is protected. |
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