* = Required Information
 
Yes
No
Comment
1. I was satisfied with the agency's efforts to support my quality of life.
2. The care was delivered timely.
3. I felt the staff was available on weekends, and after hours when we needed them
4. I understood my treatment plan and services provided.
5. I know how to file a complaint with the state and/or the agency.
6. I was notified if there was a change in my condition timely, and/or change in discipline seeing me.
7. My safety needs were identified and appropriate interventions improved my safety in the home.
8. I feel the organization exceeded my expectations. If Yes, please list in the comment section how the organization exceeded your expectations.
9. Regarding Medication Management:
a. I understood the use/purpose of my medication(s)
b. My medications were provided by the organization in a timely manner
c. My pain was controlled by the medication to a level of less than 3
Additional Comments
Security code