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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, and 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 the 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 caregivers receive continuing education & training?
���� ���� ���� ���� ���� �� Will I be able to choose my caregiver?
���� ���� ���� ���� ���� �� Can I request an alternative caregiver if I am unhappy?
���� ���� ���� ���� ���� �� Does the 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, and 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 the agency design a care plan for me?
���� ���� ���� ���� ���� �� Is my care plan written? Do I get a copy?
���� ���� ���� ���� ���� �� Does the agency consult my family when designing my care plan?
���� ���� ���� ���� ���� �� Does the agency consult my doctor when designing my care plan?
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