Attachment B-7: Personal Care Services | ADMINISTRATION-5600-MANUAL

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

Item #

HCBS Personal Care Services Survey Questions

Answer Options

How often do the following occur?

Always
Sometimes
Never

My Personal Care (PC) aide treats me with respect.

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

My PC aide is very thorough in doing his/her job.

My Personal Care Aide is considerate of my privacy and dignity when assisting me with my personal care needs.

My PC aide stays the full amount of time that is agreed upon in my Care Plan.

I was offered a substitute PC aide when the regular aide could not come.

Do the Personal Care Services you receive help you to continue to be able to live at home?

Are these Personal Care Services effective in helping you in your everyday life?

Overall, how satisfied are you with the Personal Care Services you receive?

Satisfied
Somewhat Satisfied
Dissatisfied

10.

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

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

11.

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

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

12.

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

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.