Form F-62652 - Home Health Agency Licensure Survey Home Visit Form Page 2
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2F-62652 (Rev. 04/09)
Page 2 of 2
PROBES
OBSERVATIONS / COMMENTS
(Complete applicable areas only.)
Who comes from the agency to supervise your aide / PCW?
03
___________________________ How often? _________
Does _____________________ review your care with you?
04
Yes
No
Does someone: (Use comment section.)
Set up your medications?
Yes
No
Hand you your medications?
Yes
No
Help obtain your medications?
Yes
No
05
Apply creams, salves, etc.?
Yes
No
Apply dressings?
Yes
No
If so, what does ________________________ do for you?
Are you on a special exercise / ROM program?
06
Yes
No
Who developed that for you? ________________________
07
Who helps you to do this program? ___________________
Do you feel the agency services have made a difference in
the way you feel? (Explain.)
08
Yes
No
Are you on a special diet? (Describe.)
09
Yes
No
If your doctor orders more services or new services, e.g.,
PT, has the agency been able to respond quickly?
10
Yes
No
Do you feel comfortable and safe when staff cares for you?
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Yes
No
Summary of Surveyor’s Findings from Observations of Caregiver
Yes
No
N/A
Cite
Outcome
Comments
Procedure/care plan followed
Standard precautions followed
Patient rights respected
Teaching appropriate
Medication list current
Medications checked and/or
assisted/administered correctly
Assessment / observations
appropriate
B/P
P
T
R
Supervision appropriate
Changes in condition identified
and reported appropriately
Other:
Surveyor Comments:
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