Supervisory Visit Form

1

RN Supervisors Name * This field is required.

2

Date* This field is required.

Date

3

What participant is completing the evaluation?

Client

POA

Guardian

4

Clients Name* This field is required.

5

Client's ID # From Caresmartz* This field is required.The client's ID # is in Caresmartz on their profile listed as "Medicaid/Patient ID"

6

Staff's Name* This field is required.

Use the most recent aide on duty if the client has multiple caregivers staffed.

7

Location * This field is required.

8

If this is a telephone call or video call a screenshot of call time is required. Please upload here.

Drag and drop files here

Select files to upload

Max. file size: 10.6MB

9

General Information- select all that apply.* This field is required.

Caregiver is present

Client lives alone

POA/Guardian is present

Client resides with family/guardian

10

Reason for the Visit- select all that apply* This field is required.

45/60 DAY EVALUATION

SIGNIFICANT CHANGE/UPDATE OF PLAN

11

Client Evaluation of Provider Support- select one* This field is required.

12

Family Evaluation of Provider Support- if POA or Guardian is representing the client.* This field is required.

13

Evaluation of Duties Performed-select all that apply * This field is required.

Observation of Support

Equipment Usage

Review of Documentation

*Other- type in box below if other.

14

*Other- type N/A if not applicable * This field is required.

15

Training Instruction Provided ?

Yes

No

16

Details of training instruction provided. Type N/A is not applicable.

17

Supervisory Evaluation of Staff

18

Is the staff asking for money, food, telling you about their financial problems, or asking to borrow/loan them money for food, or items? This is a safe space to share.* This field is required.

19

Is there any uneasiness with debit cards, snap benefit cards or other forms of payment? Any concerns of medication missing/theft? This is a safe space to share.* This field is required.

20

Do you feel safe with staff?

21

If you have a concern do you know that you can reach a Supervisor at Nattingham like myself or an administrator with the agency?

22

Does the client feel they adhere to their Care Plan?

23

How does the client feel about the staff's interactions with them?

24

Does the client feel confident in the staff's ability to understand their needs or changes?

25

Is the caregiver's regular appearance clean, neat, professional/business casual?

26

RN Supervisor's Name

First Name

Last Name

27

Signature* This field is required.

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28

Date* This field is required.

Date