* = Required Information

Your residing Personal Care Home

For Entire Year covering

20132014201520162017Year

Focus: Resident Personal Care Home

1. House is always neat and clean

AgreeSomewhat AgreeDisagree

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

AgreeSomewhat AgreeDisagree

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

AgreeSomewhat AgreeDisagree

4. Service is/was provided in a timely fashion

AgreeSomewhat AgreeDisagree

5. Appropriate service rendered according to each individual need

AgreeSomewhat AgreeDisagree

6. Staff is courteous and maintains good attitude

AgreeSomewhat AgreeDisagree

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

AgreeSomewhat AgreeDisagree

8. Staff respects patients´┐Ż rights, choices, privacy, dignity, and property

AgreeSomewhat AgreeDisagree

9. Staff is sensitive to culturally diverse populations

AgreeSomewhat AgreeDisagree

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

AgreeSomewhat AgreeDisagree

11. Overall evaluation of PCH

OutstandingGood AdequateNeeds ImprovementPoor

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

YesNo

My Alegna ALS Medicaid Agency Experience

13. Helpful in providing choices of personal care home placement

AgreeSomewhat AgreeDisagree

14. Communication of policies and procedures presented clearly

AgreeSomewhat AgreeDisagree

15. Safety- Resident safety is important to Alegna ALS

AgreeSomewhat AgreeDisagree

16. Service is/was provided in a timely fashion

AgreeSomewhat AgreeDisagree

17. Appropriate service rendered according to each individual need

AgreeSomewhat AgreeDisagree

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

AgreeSomewhat AgreeDisagree

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

AgreeSomewhat AgreeDisagree

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

AgreeSomewhat AgreeDisagree

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

AgreeSomewhat AgreeDisagree

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

AgreeSomewhat AgreeDisagree

23. Overall evaluation of Alegna ALS

OutstandingGood AdequateNeeds ImprovementPoor

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

YesNo

Additional Feedback (Optional)

PCHAlegna ALSBoth
Please list any areas in which our services can be improved.
Please share any additional comments.

PERSONAL INFORMATION

First Name:

Last Name:

Email Address:

Address:

City:

State

ZIP Code:

Telephone:

Gender:

Age:

Would you like someone to contact you regarding your responses on this survey?

YesNo

Thank you for taking the time to complete our survey. We rely on your feedback to help us improve our services. Your input is greatly appreciated and as always, we look forward to providing you with the best in quality senior care.