IHSS/HCBS Personal Care Provider & Homemaker Attendant Supervisory Visit 1390 South Potomac St. Unit 116, Aurora, CO 80012(720) 328-2995 (720) 485-3981 (720) 328-1146Employee/ Attendant Name: Date MM slash DD slash YYYY Professionalism:Arrives at schedule appointment on time and client aware of routine Yes No NA Wears appropriate badge, dress, and PPP gears Yes No NA Demonstrate confidentiality and responsibility Yes No NA Home Folder:Consumer is familiar with how to contact the office Yes No NA Current care plans is in the client’s folder Yes No NA Consumer understand the right of the client Yes No NA Interventions:Client contacts office with any need to change plan of care Yes No NA Attendant follows the written plan of care Yes No NA Follows the current ordered frequency and duration Yes No NA Consumer is satisfied with care Yes No NA Changes made to the Plan of Care Yes No NA Reporting:Documents visit accurately Yes No NA Documents is presented to office in the required timeframe Yes No NA Current written Plan of Care present in home Yes No NA Infection Control:Washes hands (correct technique) and or uses alcohol gel Yes No NA Demonstration proper waste disposal Yes No NA Use appropriate home infection control measures Yes No NA Use of proper body mechanics: Yes No NA Suggestion: Comments Instruction Visit or phone call:Date MM slash DD slash YYYY Supervisor Signature:Date MM slash DD slash YYYY Employee Signature:Date MM slash DD slash YYYY Consumer or Representative Signature:Date MM slash DD slash YYYY