DEPARTMENT OF HEALTH SERVICES
Division of Quality Assurance F-62652 (Rev. 04/09)
STATE OF WISCONSIN
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HOME HEALTH AGENCY LICENSURE SURVEY HOME VISIT GUIDE (OPTIONAL)
Name Patient Name Agency Name and Discipline Observed Name Surveyor(s) Violation(s) Noted Mileage To and From Date Home Visit Start Time Date Observed Agency Supervisor Present Agency License Number
Yes
Surveyor Number End Time
No
Yes
List Applicable Cites
No
PROBES (Complete applicable areas only.) Family Situation Patient lives: 01 Alone With Spouse / Family Primary caregiver Is: 02 Self Family Agency 03 Family is: Supportive Capable as caregiver Alert Responsive Inappropriate Depressed Assaultive Patient Rights 01 02 Did the agency explain your rights on admission? Yes No Do you know who is paying for your care? Yes No Have you been involved with the planning of your care / charges as they occur? Yes No Do your caregivers treat you and your property with respect and provide for your privacy? If appropriate, Yes No If you had a problem or concern about your care or caregivers, what would you do? What services does the agency provide for you? (Circle.) 01 RN LPN PT OT ST SW AIDE Yes Yes Yes Yes PCW No No No No How often do they come? Has staff been prompt? Missed visits? Changed their schedule? Meeting your needs?
OBSERVATIONS / COMMENTS
Other Other
Unsupportive Unavailable Oriented Non responsive Forgetful Anxious Disruptive
Behavior / Mental Status
03
04
05
Skilled, Aide, PCW Services
02
F-62652 (Rev. 04/09)
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PROBES (Complete applicable areas only.) Who comes from the agency to supervise your aide / PCW? 03 ___________________________ How often? _________ Does _____________________ review your care with you? Yes No Yes Yes Yes Yes Yes No No No No No Does someone: (Use comment section.) Set up your medications? Hand you your medications? Help obtain your medications? Apply creams, salves, etc.? Apply dressings?
OBSERVATIONS / COMMENTS
04
05
If so, what does ________________________ do for you? 06 Are you on a special exercise / ROM program? Yes No
07
Who developed that for you? ________________________ Who helps you to do this program? ___________________
08
Do you feel the agency services have made a difference in the way you feel? (Explain.) Yes No No Are you on a special diet? (Describe.) Yes If your doctor orders more services or new services, e.g., PT, has the agency been able to respond quickly? Yes No No
Cite Outcome Comments
09
10
11
Do you feel comfortable and safe when staff cares for you? Yes
No N/A
Summary of Surveyor's Findings from Observations of Caregiver
Yes
Procedure/care plan followed Standard precautions followed Patient rights respected Teaching appropriate Medication list current Medications checked and/or assisted/administered correctly Assessment / observations appropriate B/P P T R
Supervision appropriate Changes in condition identified and reported appropriately Other: Surveyor Comments: