Family Satisfaction Feedback Form-Agape Day Living

Family Satisfaction Feedback Form

We’d love to hear about your customer experience. Feel free to share suggestions, ideas, or anything that comes to mind.

First name

Last name

Do you feel that your family members are safe at Agape Day Living?

Yes

Are you actively involved in their care?

Yes

Do you know their rights as a participant?

Yes

Do you feel their rights are being honored as a participant?

Yes

Do you feel they are being treated with dignity and respects?

Yes

Did you receive information that helps you understand where to report a problem if one were to occur?

Yes

Residents and guardians / legal representatives are encouraged to express concerns about any changes forthcoming or implemented. Please use participant complaint and improvement form. Input regarding such concerns will be solicited by the Q.I. Committee via resident/guardian feedback forms. Q.I. Committee will review collected data to determine impact on the residents as well as the Adult Day Center’s overrall performance. Please be assured that corrective changes will take place if needed.

In a spirit of excellence, we are striving to care for your loved one to the best of our ability.

If you have any questions regarding your loved one’s care, please inform the Administrator/Site manager.

Persons to report to if you feel your rights have been violated in any way:

Administrator
Lawyer
Georgia Advocacy Office
Georgia Legal Aid
Regional Board
Office of Resident Protection

Please share any additional comments or suggestions here