Title Page

  • Site conducted

  • Site conducted

  • Conducted on

  • Prepared by

  • Location


  • HH Staff Member:

Bag Techniques and Equioment Management:

  • Adequate patient care work space was maintaned: clean, kept away from traffic, pets, children, heat or cooling vents, with adequate lighting

  • Clinical bag was placed in liner or hung to keep off floor and upholstered furniture

  • Hand Hygiene was performed prior to entering/reentering clinical bag

  • Equipment &/or clean items removed from clinical bag were placed on a clean surface such as a liner or paper towel

  • Clinical bag was kept closed when not in use

  • Clinical bag items were disinfected and allowed to dry prior to placing back into bag

  • Laptop computer was disinfected with manufacturer approved wipe and allowed to dry, prior to placing into storage

  • Hand hygiene was performed between patient care and touching keyboard/device

  • Laptop computer/device was stored away from patient care supplies

  • Cell phone was disinfected with manufacturer approved wipe and allowed to dry prior to placing into bag or on person prior to leaving home

  • Reusable equipment removed from the home, placed in a separate bag, labeled and transported to agency decontamination area (bloody drainage is placed in biohazard bag)

Hand Hygiene Competency:

  • At the beginning of the home visit

  • At the end of the home visit

  • Prior to entering/reentering the clinical bag

  • Prior to touching patient's intact skin

  • After touching patient's intact skin

  • Before donning gloves

  • After removing gloves

  • Before preparing medications

  • Before performing a procedure

  • After performing a procedure

  • Before moving from a contaminated body site to a clean body site

  • Hand hygine supplies readily available

  • Opportunity Count

PPE usage:

  • Appropriate PPE utilized during visit

Biohazard Material Management

  • Maintained appropriate biohazard disposal procedures

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