Attachment B-9: Adult Day Care Services | ADMINISTRATION-5600-MANUAL

Item #	HCBS Adult Day Care Services Survey Questions	Answer Options
How often do the following occur?	Always Sometimes Never
1.	The center staff respects my Care Receiver’s privacy.
2.	I am satisfied with the help my Care Receiver gets from the staff.
3.	The staff members listen to my Care Receiver’s requests.
4.	I am satisfied with the meals my Care Receiver eats at the center.
5.	My Care Receiver enjoys the activities offered at the center.
6.	My Care Receiver feels safe while at the center.
7.	My Care Receiver knows what to do in an emergency at the center.
8.	Do Adult Day Care Services help your Care Receiver to continue to be able to live at home?	Yes No
9.	Overall, how satisfied are you with the Adult Day Care Services?	Satisfied Somewhat Satisfied Dissatisfied
10.	Who would you contact first if you had a problem with the Adult Day Care Services?	Adult Day Care Staff Adult Day Care Administrator Area Agency on Aging Division of Aging Services Do Not Know Others:
11.	In your opinion, how could we improve the Adult Day Care Services? Please mark all that apply.	Need more hours and/or more days of Adult Day Care Services. Need better trained Adult Day Care staff. The Adult Care building needs repairs. The furniture/chairs need to be repaired or replaced with new ones. Transportation provided/or arranged by the Adult Day Center needs improving.
12.	Please tell us any other suggestions you have to improve the quality of the Adult Day Care Services.	Comments:

Item #

HCBS Adult Day Care Services Survey Questions

Answer Options

How often do the following occur?

Always
Sometimes
Never

The center staff respects my Care Receiver’s privacy.

I am satisfied with the help my Care Receiver gets from the staff.

The staff members listen to my Care Receiver’s requests.

I am satisfied with the meals my Care Receiver eats at the center.

My Care Receiver enjoys the activities offered at the center.

My Care Receiver feels safe while at the center.

My Care Receiver knows what to do in an emergency at the center.

Do Adult Day Care Services help your Care Receiver to continue to be able to live at home?

Overall, how satisfied are you with the Adult Day Care Services?

Satisfied
Somewhat Satisfied
Dissatisfied

10.

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

Adult Day Care Staff
Adult Day Care Administrator
Area Agency on Aging
Division of Aging Services
Do Not Know
Others:

11.

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

aaa

Need more hours and/or more days of Adult Day Care Services.
Need better trained Adult Day Care staff.
The Adult Care building needs repairs.
The furniture/chairs need to be repaired or replaced with new ones.
Transportation provided/or arranged by the Adult Day Center needs improving.

12.

Please tell us any other suggestions you have to improve the quality of the Adult Day 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.