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������������ ������ ������������ ������ ������������ �� �������� ABOUT THE AGENCY ���� ���� ���� ���� ���� �� Can your agency provide all of my care needs? ���� ���� ���� ���� ���� �� If No, will your agency help coordinate or help find the additional services or products I need? ���� ���� ���� ���� ���� �� Is there an additional charge to help coordinate or help find those services or products? ���� ���� ���� ���� ���� �� Is the agency: Licensed, Bonded & Insured? ���� ���� ���� ���� ���� �� Does your agency carry malpractice insurance? ���� ���� ���� ���� ���� �� Is the owner of the agency local? ____ ____ ___ How long has the agency been in business in my community? ���� ���� ���� ���� ���� �� Is the agency JCHAO (Joint Commission on Accreditation of Healthcare Organizations) accredited? �� ���� ���� ���� ���� ���� �� Is the agency a member of any professional organizations? �� ���� ���� ���� ���� ���� �� Does the agency get inspected by an outside organization? �� ���� ���� ���� ���� ���� �� May I see the inspection results? ���� ���� ���� ���� ���� �� Am I able to reach someone from your agency at all hours? ���� ���� ���� ���� ���� �� Does your agency have a client list of references I can call? ���� ���� ���� ���� ���� �� Does my caregiver get evaluated on the care I receive? �� ���� ���� ���� ���� ���� �� Have the agency’s caregivers passed criminal background checks & drug screening? �� ���� ���� ���� ���� ���� ������ Have personal references been secured on all caregivers? ���� ���� ���� ���� ���� �� How is my caregiver supervised? ���� ���� ���� ���� ���� �� Am I able to talk to my caregiver’s supervisor if needed? ���� ���� ���� ���� ���� �� Will I always have the same caregiver? ���� ���� ���� ���� ���� �� Has my caregiver been trained in giving the care I need? ���� ���� ���� ���� ���� �� Do your caregivers receive continuing education & training? ���� ���� ���� ���� ���� �� Will I be able to choose my caregiver? ���� ���� ���� ���� ���� �� Can I request an alternative caregiver if I am unhappy? ���� ���� ���� ���� ���� �� Does your agency provide full-time “Live In” caregivers? ���� ���� ���� ���� ���� �� And if Yes, is there a discounted rate for care services? ABOUT THE CAREGIVER ���� ���� ���� ���� ���� �� Is the caregiver an agency employee or an independent contractor with a registry? ���� ���� ���� ���� ���� �� Are the caregiver’s: Licensed, Bonded & Insured? �� ���� ���� ���� ���� ���� �� Does the caregiver have workers’ compensation coverage? ���� ���� ���� ���� ���� �� Does the agency do a background screening on caregivers? ���� ���� ���� ���� ���� �� Are caregiver’s driving record and driver’s license checked? ���� ���� ���� ���� ���� �� Will my caregiver speak my language? ____ ____ ___ How many years of experience does my caregiver have in the kind of care I will be receiving? ���� ���� ���� ���� ���� �� Will my caregiver be fully informed of my care needs and limitations? ABOUT THE CARE ���� ���� ���� ���� ���� �� Will your agency design a care plan for me? ���� ���� ���� ���� ���� �� Is my care plan put into writing? ���� ���� ���� ���� ���� �� Does the agency consult my family when designing my care plan? ���� ���� ���� ���� ���� �� Does the agency consult my doctor when designing my care plan? www.PolkElderCare.com 43


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