HCBS/Personal Care Provider Supervisory Visit

Employee Name

Date

Client’s Name

Professionalism:

1. Arrives to work on time and stays the required length of time

2. Dress appropriately including Badge

3. Knows how to use supplies or Adaptive Equipment correctly

4. Caregiver follows careplan and routine appropriate for client

5. Demonstrates respect for client’s privacy, rights, and property

6. Only performs duties within his or her job description

7. Relates well with consumer and or family members

Skills:

1. Gives care with dignity

2. Uses Proper Body Mechanics

3. Knowledgeable of tasks required of PCW

Infection Control:

1. Uses proper hand washing technique at the beginning, during, and after shift

2. Wears gloves with meal preparation, bathing, cleaning, and disposal of waste

3. Properly disposes of waste and uses other infection control measures.

Medicaid Regulation on Transportation: No transportation can be provided by PCW

PCW transporting client via personal or client’s vehicle

Consumer’s comments

Consumer’s signature or Representative

Date

Personal Care Worker’s signature

Date

Supervisor’s signature

Date

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