Home Health: Survey Questions

CMS-Related Required Questions, Written Verbatim According to CMS Guidelines

1. Received Care. According to our records, you got care from the home health agency, SAMPLE HOME HEALTH. Is that right?
2. Services Explained. When you first started getting home health care from this agency, did someone from the agency tell you what care and services you would get?
3. Home Safety. When you first started getting home health care from this agency, did someone from the agency talk with you about how to set up your home so you can move around safely?
4. Medication Discussion. When you started getting home health care from this agency, did someone from the agency talk with you about all the prescription and over-the-counter medicines you were taking?
5. See Medication. When you started getting home health care from this agency, did someone from the agency ask to see all the prescription and over-the-counter medicines you were taking?
6. Nurse. In the last 2 months of care, was one of your home health providers from this agency a nurse?
7. Therapist. In the last 2 months of care, was one of your home health providers from this agency a physical, occupational, or speech therapist?
8. Aide. In the last 2 months of care, was one of your home health providers from this agency a home health or personal care aide?
9. Providers Informed. In the last 2 months of care, how often did home health providers from this agency seem informed and up to date about all the care or treatment you got at home? Would you say...
10. Pain Discussion. In the last 2 months of care, did you and a home health provider from this agency talk about pain?
11. Change Medication. In the last 2 months of care, did you take any new prescription medicine or change any of the medicines you were taking?
12. New Meds – Purpose. In the last 2 months of care, did home health providers from this agency talk with you about the purpose for taking your new or changed prescription medicines?
13. New Meds – Times. In the last 2 months of care, did home health providers from this agency talk with you about when to take these medicines?
14. New Meds – Side Effects. In the last 2 months of care, did home health providers from this agency talk with you about the side effects of these medicines?
15. Arrival Communication. In the last 2 months of care, how often did home health providers from this agency keep you informed about when they would arrive at your home? Would you say...
16. Gentleness. In the last 2 months of care, how often did home health providers from this agency treat you as gently as possible? Would you say...
17. Understand Explanation. In the last 2 months of care, how often did home health providers from this agency explain things in a way that was easy to understand? Would you say...
18. Listening. In the last 2 months of care, how often did home health providers from this agency listen carefully to you? Would you say...
19. Courtesy and Respect. In the last 2 months of care, how often did home health providers from this agency treat you with courtesy and respect? Would you say...
20. Overall Care. Using any number from 0 to 10, where 0 is the worst home health care possible and 10 is the best home health care possible, what number would you use to rate your care from this agency’s home health providers?
21. Contact Office. In the last 2 months of care, did you contact this agency’s office to get help or advice?
22. Received Help. In the last 2 months of care, when you contacted this agency’s office did you get the help or advice you needed?
23. Help Response. When you contacted this agency’s office, how long did it take for you to get the help or advice you needed? Would you say...
24. Care Problems. In the last 2 months of care, did you have any problems with the care you got through this agency?
25. Recommend to Others. Would you recommend this agency to your family or friends if they needed home health care? Would you say...
26. Share Information. Your home health care agency may want to review your answers so that they can decide how to address any concerns that you have. We will not share your answers to this survey linked to your name unless you give your permission for this information to be shared with your home health agency. Do you give your permission to provide your answers to this survey linked to your name to your home health agency?

ELECTIVE QUESTION PROVIDED BY PINNACLE

• Areas Appreciated. What have you appreciated about SAMPLE HOME HEALTH?
• Staff Member Appreciated. Are there any employees from SAMPLE HOME HEALTH that you would like to recognize??
• Heard About. Who specifically recommended SAMPLE HOME HEALTH to you?
• Recommended Improvements. What improvements would you recommend SAMPLE HOME HEALTH make?