PROVIDER HOME VISIT REPORT provipgr nome: fe) vet Ceutt-J0# Prelaaseo VISIT COMPLETED BY: DBY: heat. 5 | DATES -2e-ty— ARRIVAL TIME: 12:10 am DEPARTURE TIME: 3s _ amg) PROVIDER STAFF PRESENT: (consistent with staffing schedule Y /'N /No Schedule); No df © bane loot cused" Nina - Clients Present What are they doing? Does it match the Schedule? ‘eam Jer Sins SRY G0 sN\ aS. Moe eh Fin Bats i ‘ena hee i ieee Beran ere Ged |e Please place a check mark next to each domain you review that is in compliance. Place an ‘X’ next to each domain in which there is a problem and describe the problem in the section below: ‘Medication Tracking Sheets up to date with client/staff initials ‘Medications locked and secure “Siapport/training logs up to date COMIROTT Complete and Available fr each resident Sse of Appointments and training times available for each resident _-RGsidents’ Personal Health Information (PHI) is secure Fire Alarms Functional “¥. costa -Finirances and Exits are functional in case of emergency (.e., not obstructed) $< Emergency Food Supply is available and unexpired —MOVe. AuoiloAs— 10. $Agequate Food Supply in Refrigerator and Cabinets 11. x€flealth Food Safety and Handling Procedures Followed 12,__Paper products, hand soap, laundry soap available Ne poled Pape Sa Ben, 13, < Furnishings are present in house per Standards of Care 14, _[2€6mmon Areas of house are reasonably clean 15. 1 -Résidents’ bedrooms are reasonably clean welt 16._}CNo undocumented/unapproved restrictions (ested access to personal er ‘property, rooms, freedom of movement, étc...) OO Afar TH 17, _Other problems (see below) SEN AVaALNEAll Con han 75 COMMENTS: (include any problems noted) . Outs 20 vad, Ckilus tala TUS En garge Perera Koay Stese>, Wires Sata, her heotebendse 4 fguels Cte? tol - Cont acs = COOS Beoke £1 oO ek Caer, Passese CC egtve te “Prey PLEASE CHECK IF FURTHER ACTION REQUIRED BELOW: gS - No further action needed ems Further aetion needed, oe. Provider given Notice of Comection: (circle) Immediate, 30, 60, 90 ACA pesthenmnnteerseneess® FOR RESIDENTIAL PROGRAM BRLOWLINES##+esteussesees FOLLOWUP: Date, Outcome: Additional FOLLOWUP, if needed: Date Outcome: _PROVIDER HOME VISIT REPORT PROVIDER Homi’ -}2oject Ue Fok QeoRedeo VISIT COMPLETED BY: DATE: 22do-fs TIME:9p35— Canim PROVIDER STAFF PRESE Kare efter SC + pt Bae ACTIVITY/DURATION: (specify for entire house or individual client) NoWiirs, sos tee Pk .ea check mark next to each domain you review that is in compliance. Place a zero next to each domain in which there is a problem. Med Sheets . ¢_-Subport/training logs eitetes xosors oe ae ‘aati 2" : “tification Displayed ___ Other problems (note below) Sr Awan COMMENTS: (include any problems noted) PLEASE CHBCK IF FURTHER ACTION REQUIRED BELOW: fo further action needed Further action needed. Provider given Notice of Correction: (circle) Immediate, 30, 60, 90, other__ stvegeenseneervetes¢s# FOR RESIDENTIAL PROGRAM REVIEW BELOW LINESt#sehe19eneeeens FOLLOWUP: Date, Outcome: