Supervisory Visit Form

Member & DCW Information

Member Information

State

Member's Name (Last, First, M.I.)

Member ID

Direct Care Worker Information

DCW Name

DCW Date of Birth

Visit Details

Supervisory Visit Date

Service Type

Attendant Care Homemaker

Visit Type & Modality

Select the type of supervisory visit being documented, then indicate whether it was conducted in-person, virtually, or by phone.

Visit Type

Day 5

5-Day Call

Initial check-in within 5 days

Day 30

30-Day

Visit with member at 30 days

Day 60

60-Day

Visit at 60 days (if needed)

Day 90

90-Day Initial

Required first 90-day visit

Every 90 Days

90-Day Continuing

Ongoing quarterly visits

Visit Modality

👤

In-Person

Face-to-face visit at member's home

📹

Virtual

Video call with audio and video

📞

Telephonic

Phone call only

Supervisor Attestation

Attest to the following regarding the preparation for the visit by checking and initialing the statements:

I have reviewed data in the Electronic Visit Verification (EVV) system regarding any missed and late service visits and the agency's response to those situations (documented as resolution codes) to inform discussions pertaining to actual events or risks to the non-provision of services.

Initials

I have reviewed the Member's Person Centered Service Plan (PCSP) and any documentation outlining tasks to be performed by the DCW to familiarize myself with the individualized assessed needs and preferences related to the provision of services to support observations of the care delivery and competency of the DCW.

Initials

I have reviewed the documentation that the DCW completed the Pre-Service Orientation for this Member and reviewed this Member's current Planning Document.

Initials

Observation of Member & Environment

Check the appropriate response and enter a comment for each item to document evidence in support of the observation.

1. Does the member appear to be in a safe and clean environment?

Yes No

2. Is the Member able to freely navigate their environment (with or without assistance) without barriers, obstacles, or risks impacting health, safety or service delivery?

Yes No

3. Is the Member's condition consistent with previous visitations?

Yes No

4. Is the Member clean and wearing clean clothes?

Yes No

Observation of DCW

5. Was support provided that is consistent with the assessed need outlined in the PCSP? (e.g., tasks outlined in the Member's HCBS Needs Tool)

Yes No

6. Does the DCW demonstrate competency in providing the assessed services in accordance with the Member's individualized service needs and preferences as outlined in the PCSP? (e.g., level of assistance needed with each task including supporting the Member to perform as much of the tasks as they are willing and able)

Yes No

7. Is the DCW observed to be providing person-directed care? (e.g., asking when and how they would like assistance; referring to them by name; providing personal care in private)

Yes No

8. Is the DCW observed to have a positive relationship with the Member? (e.g., respectful communication related and unrelated to care; positive body language)

Yes No

9. Is the DCW observed to be communicating with the Member in their preferred language and style?

Yes No

Discussion with Member

All questions shall be directed to the Member who shall be given the opportunity to participate in the visit supporting their self-determination. If the Member is unable to engage in the discussion, reflect that in the comment section.

10. Please describe what the DCW typically does when they come to your home?

11. Does the DCW listen to you and provide assistance in support of your preferences?

Yes No

12. Does the DCW support you to do some things for yourself and only help when you need it?

Yes No

13. Do you know who to contact when your DCW doesn't show up or cannot provide services that day?

Yes No

14. Do you think you are receiving care that meets your needs in the way you want them to be met?

Yes No

15. What else would you like to tell me about the services being provided by your DCW?

Check-In with DCW

This part of the discussion is reserved for a discussion with the DCW. Ensure the discussion is private and refrain from documenting any private health information mentioned by the DCW.

16. What are the most challenging aspects of your caregiving role? What is impacting your ability and availability to provide paid care?

17. Are you able to take care of yourself and recharge? Are you taking measures to maintain your own health and well being?

18. Are you able to access the resources you need to effectively care for your loved one? Is there anything specific you wish you had more support with?

Post Visit Follow-Up

For any follow-up items marked "yes", please include the action that will be undertaken to address it and the timeline for completion.

19. Is there an opportunity to improve the DCW's competency to provide the assessed services in a person-directed manner and in accordance with the Member's individualized service needs and preferences as outlined in the PCSP?

Yes No

20. Is there an opportunity to provide additional support to the DCW who is a live-in caregiver?

Yes No

21. If the Member has a fixed EVV device, did you observe that it was not fixed within the home? (Note: Consider discussing alternative device options)

Yes No

22. Is it time to review the Member's contingency plan? (Note: It must be reviewed at least annually)

Yes No

23. During this visit did you learn of any previously unreported instances of services not being provided as authorized or scheduled? (Note: Reasons for non-provision shall be documented and reported to the Support Coordinator)

Yes No

24. Have you determined the Member has exhibited the need for additional medical or psychosocial support, or a change (decline or improvement) in condition? (Note: This shall be documented and reported to the Support Coordinator)

Yes No

Signatures

I have or will review the findings of the visit with the DCW and relevant action items that pertain to follow up specific to training and support needs of the DCW.

Monitor/Supervisor

Name

Signature

Date

Member/Health Care Decision Maker (HCDM)

Name

Date

Member Signature

Have the member sign below using their finger or stylus.

Not signed

Record a brief verbal attestation from the member (max 30 seconds). Useful when a written signature isn't possible.

0:00 / 0:30

Supervisory Visit Documentation

Service Delivery Monitoring and Supervisory Visit Documentation

Member & DCW Information

Member Information

Direct Care Worker Information

Visit Details

Visit Type & Modality

Visit Type

Visit Modality

Supervisor Attestation

Observation of Member & Environment

Observation of DCW

Discussion with Member

Check-In with DCW

Post Visit Follow-Up

Signatures

Monitor/Supervisor

Member/Health Care Decision Maker (HCDM)

Form Submitted Successfully