Home Care Supervisory Visit Form - Pierce County
Purpose of Visit *
Has the plan of care been reviewed with the client and caregiver? *
Does the Caregiver carry out the established plan of care? *
Does the Caregiver arrive and stay the entire scheduled time? *
Are the tasks being provided in a way satisfactory to the client? *
Is the Caregiver clocking in and out of Electronic Timekeeping accurately? *
Has there been any changes to the client health since last visit?
Does the Caregiver follow Agency Policy and Procedures? *

Summary of Visit

Services are delivered consistent with the plan of care? *
Client’s needs are being met? *
Is there any need for more frequent supervision? *
Is the general appearance of the client neat and clean? *
Does the home reflect regular cleaning? *