Your residing Personal Care Home

For Entire Year covering

Focus: Resident Personal Care Home

1. House is always neat and clean

2. Meals- All meals high quality, within dietary requirements, served on time

3. Safety- resident safety is important to this personal care home

4. Service is/was provided in a timely fashion

5. Appropriate service rendered according to each individual need

6. Staff is courteous and maintains good attitude

7. Staff is competent and timely in performing required tasks for resident care

8. Staff respects patients� rights, choices, privacy, dignity, and property

9. Staff is sensitive to culturally diverse populations

10. PCH provides protection from abuse, neglect, and exploitation

11. Overall evaluation of PCH

12. Would you recommend this facility to your friends and family

My Alegna ALS Medicaid Agency Experience

13. Helpful in providing choices of personal care home placement

14. Communication of policies and procedures presented clearly

15. Safety- Resident safety is important to Alegna ALS

16. Service is/was provided in a timely fashion

17. Appropriate service rendered according to each individual need

18. Staff (Administrative and Nurse) is courteous and maintains good attitude

19. Staff (Administrative and Nurse) is competent and timely in performing required tasks for resident care

20. Staff (Administrative and Nurse) respects patients� rights, choices, privacy, dignity, and property

21. Staff (Administrative and Nurse) is sensitive to culturally diverse populations

22. Alegna ALS over-sees protection from abuse, neglect, and exploitation

23. Overall evaluation of Alegna ALS

24. Would you recommend this agency for resident placement services to your friends and family

Additional Feedback (Optional)

PERSONAL INFORMATION

First Name:

Last Name:

Email Address:

Address:

City:

State

ZIP Code:

Telephone:

Gender:

Age:

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