A 4-page Word report for a supervisor’s visit to check a caregiver’s work and the client’s satisfaction in non-medical home care.

For USA home care agency owners and supervisors who need a consistent record of each supervisory visit. Plus 1 agency instructions page to remove before use.

What’s included

1. Page 1: letterhead, section 1 visit information (client, caregiver, supervisor, date, times, visit type and mode, caregiver present or not), and section 2 care-plan adherence checklist
2. Page 2: section 3 observed competencies (Met, Needs improvement, Not observed) and section 4 client/family feedback questions with comments
3. Page 3: section 5 home safety checklist with abuse, neglect, or exploitation reporting guidance, section 6 changes in condition observed, section 7 concerns and corrective actions table, and section 8 next supervisory visit
4. Page 4: section 9 signatures (supervisor, caregiver, client or representative) and an Agency Use Only review and follow-up checklist
5. Agency instructions page (10 points on frequency, virtual visits, who supervises, scope, reporting, privacy, and customizing), to remove before use

Add your logo and name

1. Open the Word file and replace the Your Logo Here box with your logo.
2. Replace Agency Name in the letterhead; the report body says “the Agency,” so no other name edits are needed.
3. Replace the Street Address, City, State ZIP line and the Phone, Email, Website line with your details.
4. Set the letterhead text to black, enter your state and policy visit frequency in section 8, delete the instructions page, and save.

Customizable template, not legal advice; check your state’s requirements. Not a license to operate, not HIPAA software, and no medical claims. The report records observations only, not clinical assessments.