PCA VISITATION FORM 454-462 Wolcott Street, Waterbury, CT 06705 Phone: (203) 941-1700
First Check
Second Check
Third Check
Other Option
PCA’s Name
Name of Assigned Client
Nurse Educator / Visitor Name
Address of Visit
Name of Person(s) interviewed
Date/Time
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
Name of Coordinator
PCA’s Weekly Shift
End Time
Rows
Sunday
Monday
Tuesday
Wednesday
Thursday
Friday
Saturday
Start Time
End Time
Check List
1. Pre-Visit Preparation
2. Personal Appearance and Hygiene
a. Wears clean, professional attire
Yes
No
b. Practices good personal hygiene
Yes
No
c. Has clean, short nails (no artificial nails if policy states)
Yes
No
d. Wears name bad or identification
Yes
No
e. Wears minimal or no fragrance
Yes
No
3. Tasks and Responsibilities
a. Follows the client care plan
Yes
No
b. Accurately completes tasks from assignment lis
Yes
No
c. Assists with mobility/transfers using correct body mechanics
Yes
No
d. Prepares meals according to dietary needs
Yes
No
e. Documents daily activities and observations
Yes
No
f. Clocks in and out of shift correctly
Yes
No
4. Safety and Cleanliness
a. Maintains a safe, clutter-free environment
Yes
No
b. Reports safety hazards or changes in client condition
Yes
No
c. Washes hands before and after tasks
Yes
No
d. Wears gloves for appropriate tasks
Yes
No
e. Disposes of waste properly
Yes
No
f. PCA knows/understands emergency procedures
Yes
No
g. PCA knows how to report an incident
Yes
No
h. Knowledge of Infection Control
Yes
No
5. Documentation & Reporting
a. Clocks in and out properly and timely
Yes
No
b. Communicates with Coordinator as needed
Yes
No
c. Documents or reports any incidents or concerns
Yes
No
6. Time Managment
a. Arrives on time
Yes
No
b. Uses time efficiently (doesn’t sit idly or use phone excessively)
Yes
No
c. Stays focused and organized
Yes
No
d. Completes shift without leaving early or delaying
Yes
No
7. Client and Family Feedback
a. Client appears comfortable with PCA
Yes
No
b. Family reports satisfaction with care provided
Yes
No
c. No complaints or concerns voiced during visit
Yes
No
d. PCA is responsive to client/family preferences
Yes
No
VISIT TYPE:
Routine
Unannounced
Follow-Up
Red Flags Identified?
Yes
No
IF Yes, Describe:
Client or Family Present?
Yes
No
IF Yes, List Names:
Follow-Up Needed
Yes
No
Already Done
Education Provided?
Supervisor Notified
Revisit Scheduled
Incident Report Filed
Additional Notes or Observations (Notes)
PCA’s Signature
Supervisor Signature
Date
/
Month
/
Day
Year
2 digit month, 2 digit day, 4 digit year
Date
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