Attachment B-10: Respite Care Services | ADMINISTRATION-5600-MANUAL

Item #	HCBS Respite Care Services Survey Questions	Answer Options
How often do the following occur?	Always Sometimes Never
1.	The Respite Care aide treats my Care Receiver with respect.
2.	I am satisfied with the time my Respite Care aide is scheduled to arrive.
3.	The Respite Care aide is very thorough in doing her/his job.
4.	The Respite Care aide is considerate of my Care Receiver’s privacy and dignity when assisting with personal care needs.
5.	The Respite Care aide stays the full amount of time agreed upon in the Care Plan.
6.	My Care Receiver was offered a substitute Respite Care aide when the regular aide could not come.
7.	Do the Respite Care Services received help your Care Receiver to continue to be able to live at home?	Yes No
8.	Overall, how satisfied are you with the Respite Care Services?	Satisfied Somewhat Satisfied Dissatisfied
9.	Who would you contact first if you had a problem with the Respite Care Services?	Respite Care Worker’s Supervisor or Agency Area Agency on Aging Division of Aging Services Do Not Know Others:
10.	In your opinion, how could we improve Respite Care Services? Please mark all that apply.	Need the same Respite Care aide each time. Need better trained Respite Care aides. I would like to choose my Respite Care aide. Need the Respite Care aide to do more. Need the Respite Care aide to arrive on time as scheduled. Need the Respite Care aide for more hours and/or more days. Need the Respite Care aide to do things the way I want them to be done.
11.	Please tell us any other suggestions you have to improve the quality of Respite Care Services.	Comments:

Item #

HCBS Respite Care Services Survey Questions

Answer Options

How often do the following occur?

Always
Sometimes
Never

The Respite Care aide treats my Care Receiver with respect.

I am satisfied with the time my Respite Care aide is scheduled to arrive.

The Respite Care aide is very thorough in doing her/his job.

The Respite Care aide is considerate of my Care Receiver’s privacy and dignity when assisting with personal care needs.

The Respite Care aide stays the full amount of time agreed upon in the Care Plan.

My Care Receiver was offered a substitute Respite Care aide when the regular aide could not come.

Do the Respite Care Services received help your Care Receiver to continue to be able to live at home?

Overall, how satisfied are you with the Respite Care Services?

Satisfied
Somewhat Satisfied
Dissatisfied

Who would you contact first if you had a problem with the Respite Care Services?

Respite Care Worker’s Supervisor or Agency
Area Agency on Aging
Division of Aging Services
Do Not Know
Others:

10.

In your opinion, how could we improve Respite Care Services? Please mark all that apply.

Need the same Respite Care aide each time.
Need better trained Respite Care aides.
I would like to choose my Respite Care aide.
Need the Respite Care aide to do more.
Need the Respite Care aide to arrive on time as scheduled.
Need the Respite Care aide for more hours and/or more days.
Need the Respite Care aide to do things the way I want them to be done.

11.

Please tell us any other suggestions you have to improve the quality of Respite Care Services.

Comments:

If the survey is to be administered by mail, please do not ask the consumer to identify him/herself, unless he or she wishes to be contacted for follow-up. Add lines at the end of the survey for the consumer to indicate voluntarily a desire for a contact and to provide his or her name and telephone contact information.