Quarterly Quality Assurance Evaluation for Services
Date Completed
*
/
Month
/
Day
Year
Date
Client Name
*
First Name
Last Name
Name of Responsible Party Completing This Form
*
Method of Completion
*
Please Select
Online
In Person with Care Manager
In your overall opinion, over the last three months, has the overall standard of care improved, declined, or stayed about the same?
*
Please Select
Improved
Declined
Stayed About the Same
I have not used the services enough to form an opinion
How often would you say your caregiver is on time?
*
Please Select
Always
Usually
Sometimes
Never
On a scale of 1-10, with 0 being the worst service possible and 10 being the best service possible, how would you rate your service?
*
Worst
1
2
3
4
5
6
7
8
9
Best
10
1 is Worst, 10 is Best
How often would you say that your caregiver works as long as they are supposed to?
*
Please Select
Always
Usually
Sometimes
Never
How often would you say that your caregivers treated you with dignity, courtesy, and respect?
*
Please Select
Always
Usually
Sometimes
Never
How often would you say that your caregivers gave you the proper amount of privacy you needed?
*
Please Select
Always
Usually
Sometimes
Never
In the last 3 months, when a caregiver has been unable to work a day they were scheduled, how often were you offered a replacement?
*
Please Select
Always
Usually
Sometimes
Never
In the last three months how often have the Grace Givers staff explained things in a way that was easy to understand?
*
Please Select
Always
Usually
Sometimes
Never
In the last three months, how often did Grace Givers staff encourage you to do things for yourself that you could?
*
Please Select
Always
Usually
Sometimes
Never
In the last 3 months, did you get the help from your caregivers that you needed with toileting, or to get dressed, showered, or bathed?
*
Please Select
Yes
No
Did not need personal care assistance
In the last 3 months, did you get the help from your caregivers you needed with meals?
*
Please Select
Yes
No
In the last 3 months, did you get the help from your caregivers you needed with light housekeeping?
*
Please Select
Yes
No
In the last 3 months, did you get the help from your caregivers you needed with errands and/or transportation?
*
Please Select
Yes
No
Are you currently able to access the Family Portal Online with ease?
*
Please Select
Yes
No
Haven't Tried
In the next 3-4 weeks do you anticipate your number of weekly hours to increase, decrease, or remain the same?
*
Please Select
Increase
Decrease
Remain the Same
Would you like to receive text alerts?
*
Please Select
Yes
No
Would you like to receive our monthly newsletter by email?
*
Please Select
Yes
No
Please list any health changes we need to be aware of in the last three months. (If none, write n/a)
*
Have you got any new equipment in the home in the last three months (example: walker, wheel chair, grab bars, lift chair, etc) if none, write n/a
*
Are there any resources you need that Grace Givers Does not provide? (medication set up, social services, home health, hospice, deep cleaning, etc) if none, write n/a
*
Have there been any other changes in the home we need to be aware of? ( pets, visitors, new rules, new needs etc) if no, write n/a
*
Please list any ways you feel we can improve our services such as types of training, etc. If none write n/a
*
Responsible Party Signature
Submit
Should be Empty: