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Follow Up visit Checklist & Evaluation

Client Name: Supervisor:

Date: Time: Day: Follow Up Visits are to assist in ensuring that service is being performed in a proper manner. It is done on an unannounced, drop-in basis so we can see the “normal” conditions our Personal Assistant is maintaining in the client’s home. Client spot checks should be performed bi-monthly, no less than every three months.

Caregiver(s) Assigned to this Client:

Items to remember when performing a spot check:

Documentation Logs picked up. (Leave the last couple of days in the care plan book)

Caregiver Performance Evaluations (Check Employee’s Evaluation Report before

leaving).

Fill out the following areas of the Checklist (based on observations during the visit).

Client Care:

Is the client clean, neatly and safely dressed? Details:

Yes | No

Are the client’s clothes appropriate to the weather? Details:

Yes | No

Does the client appear: happy / content / depressed / agitated? Details:

Yes | No

Is the client clean, neatly and safely dressed? Details:

Yes | No

Are the client’s clothes appropriate to the weather? Details:

Yes | No

Does the client have any body odor? Details:

Yes | No

Is the client communicative? Details:

Yes | No

Is the client involved in any activity? Details:

Yes | No

Are there any notable marks on the client’s skin? Details:

Yes | No

Home Inspection:

Does the home appear neat and tidy? Details:

Yes | No

Does it appear the vacuuming and dusting are done regularly? Details:

Yes | No

Is the kitchen clean and fresh smelling? Details:

Yes | No

1. Is the bathroom clean and fresh smelling? Details:

Yes | No

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Is there laundry piled up anywhere? Details:

Yes | No

Are the rugs properly tacked down? Details:

Yes | No

2. Is there clutter in any of the rooms? Details:

Yes | No

3. Are there any safety or other upkeep issues visible? Details:

Yes | No

Care Plan Book:

Is the Care Plan Book in the agreed upon location? Details:

Yes | No

Are the documentation logs being filled out on every visit day? Details:

Yes | No

Are the documentation notes detailed and specific in content? Details:

Yes | No

Do the notes document all services are being done per the Care Plan? Details:

Yes | No

Are the documentation logs and time sheets being kept in stock? Details:

Yes | No

Review the Care Plan itself. Are there any services that need to be added? Details:

Yes | No

Is the Care Plan Book in good condition? Details:

Yes | No

Are meals and medication reminder times documented? Details:

Yes | No

Is there documentation of client non-compliance with any ADL? Details:

Yes | No

Summary of Overall Service Level:

4-Excellent / 3-Good / 2-Fair / 1-Poor Details

Service

Level #

____________________________________ ____________________________ Supervisor Signature Date