Quarterly Walk Through Supervisory Visit
Consumer Name
Name of Direct Support Worker DSW on duty
Is the DSW at work according to approved schedule:
Yes
No
If "no" brief explanation:
Is the DSW staff appropriately dressed and neat in appearance:
Yes
No
If "no", brief explanation:
Consumer Home Assessment: Are the following areas neat and clean in appearance?
Consumer bedroom:
Yes
No
If "no", brief explanation:
Consumer bathroom:
Yes
No
If "no", brief explanation:
Consumer living room area:
Yes
No
If no brief explanation
Consumer kitchen area:
Yes
No
If "no", brief explanation:
On a scale of 1-4 (1=excellent 2=good 3=satisfactory 4=poor) how would you rate the overall appearance of the Consumer's home?
1=excellent
2=good
3=sastisfactory
4=poor
Brief explanation if below satisfactory rating:
Area of deficiencies:
Action implemented to correct deficiencies:
Client Signature
Date
-
Month
-
Day
Year
Date
Hour Minutes
AM
PM
AM/PM Option
Continue
Continue
Should be Empty: