Form F-62652 - Home Health Agency Licensure Survey Home Visit Form
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1
2DEPARTMENT OF HEALTH SERVICES
STATE OF WISCONSIN
Division of Quality Assurance
Page 1 of 2
F-62652 (Rev. 04/09)
HOME HEALTH AGENCY LICENSURE SURVEY HOME VISIT GUIDE
(OPTIONAL)
Name – Patient
Agency License Number
Name – Agency
Name and Discipline Observed
Date Observed
Agency Supervisor Present
Yes
No
Name – Surveyor(s)
Surveyor Number
Violation(s) Noted
Mileage To and From
Date – Home Visit
Start Time
End Time
Yes
No
List Applicable Cites
PROBES
OBSERVATIONS / COMMENTS
(Complete applicable areas only.)
Family Situation
Patient lives:
01
Alone
With Spouse / Family
Other
Primary caregiver Is:
02
Self
Family
Agency
Other
Family is:
03
Supportive
Unsupportive
Capable as caregiver
Unavailable
Behavior / Mental Status
Alert
Oriented
Responsive
Non responsive
Inappropriate
Forgetful
Depressed
Anxious
Assaultive
Disruptive
Patient Rights
Did the agency explain your rights on admission?
01
Yes
No
Do you know who is paying for your care?
02
Yes
No
Have you been involved with the planning of your care /
charges as they occur?
03
Yes
No
Do your caregivers treat you and your property with respect
04
and provide for your privacy? If appropriate,
Yes
No
If you had a problem or concern about your care or
05
caregivers, what would you do?
Skilled, Aide, PCW Services
What services does the agency provide for you? (Circle.)
01
RN
LPN
PT
OT
ST
SW
AIDE
PCW
How often do they come?
Has staff been prompt?
Yes
No
Missed visits?
Yes
No
02
Changed their schedule?
Yes
No
Meeting your needs?
Yes
No
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