Home Care Supervisory Visit Form - Snohomish County Client Name * Date of Visit * Purpose of Visit * Home Visit Complaint Investigation Supervisor Name * Caregiver Name * County * Has the plan of care been reviewed with the client and caregiver? * Yes No Does the Caregiver carry out the established plan of care? * Yes No Does the Caregiver arrive and stay the entire scheduled time? * Yes No Are the tasks being provided in a way satisfactory to the client? * Yes No Comments, if No: * Is the Caregiver clocking in and out of Electronic Timekeeping accurately? * Yes No Comments, if No: * Has there been any changes to the client health since last visit? Yes No N/A Comments, if Yes: * If applicable, Supervisor OBSERVED the Caregiver performing the following tasks: Does the Caregiver follow Agency Policy and Procedures? * Yes No Client Comment/Observations: Summary of Visit Services are delivered consistent with the plan of care? * Yes No Client’s needs are being met? * Yes No Is there any need for more frequent supervision? * Yes No Is the general appearance of the client neat and clean? * Yes No Does the home reflect regular cleaning? * Yes No Brief statement regarding changes in service needs if any: Supervisor's Signature * Clear Client/Responsible Person Signature * Clear Submit