Quality Assurance Form Template for periodic quality checks on services provided. This form is structured to comprehensively assess service quality across various dimensions, ensuring client satisfaction and regulatory compliance.
Quality Assurance Form
Agency Information
- Agency Name: __________________________________________
- Location/Branch: ________________________________________
- Service Date(s): _________________________________________
- Date of Quality Check: ___________________________________
Client Information
- Client Name: ___________________________________________
- Client ID (if applicable): _________________________________
- Primary Caregiver/Service Provider: _________________________
Section 1: Service Quality Assessment
For each category, select the rating that best describes the level of satisfaction and service quality, using the following scale:
- E - Excellent
- S - Satisfactory
- NI - Needs Improvement
| Service Quality Category | Rating (E/S/NI) | Comments |
|---|---|---|
| Timeliness of Service | ||
| Professionalism of Staff | ||
| Effectiveness of Communication | ||
| Quality of Care Provided | ||
| Respect for Client’s Privacy | ||
| Client-Centered Approach | ||
| Overall Client Satisfaction |
Section 2: Care Plan Compliance
Confirm that services provided align with the client’s individualized care plan.
| Care Plan Element | Compliant (Y/N) | Comments (If “No,” provide details) |
|---|---|---|
| Adherence to Care Instructions | ||
| Goal Achievement Tracking | ||
| Medication Administration | ||
| Assistance with ADLs | ||
| Behavior Support Plan Compliance |
Section 3: Documentation Review
Evaluate the documentation and record-keeping for accuracy, completeness, and compliance with agency standards and state regulations.
| Documentation Type | Compliant (Y/N) | Comments (If “No,” provide details) |
|---|---|---|
| Daily Progress Notes | ||
| Incident Reports (if any) | ||
| Service Logs | ||
| Medication Administration Records | ||
| Client Grievance Reports (if any) |
Section 4: Health and Safety Compliance
Assess the caregiver and client’s adherence to health and safety protocols as outlined by agency policies and state regulations.
| Health and Safety Standard | Compliant (Y/N) | Comments (If “No,” provide details) |
|---|---|---|
| Proper Infection Control Practices | ||
| Use of Personal Protective Equipment (PPE) | ||
| Emergency Preparedness | ||
| Incident Response Protocol |
Section 5: Observations and Additional Notes
Use this section to document any additional observations or recommendations for improvement.
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Section 6: Reviewer Information
- Reviewer Name: __________________________________________
- Reviewer Title/Position: _________________________________
- Date of Review: _________________________________________
- Reviewer Signature: ______________________________________
Section 7: Follow-up Action Plan (If applicable)
If areas are identified as "Needs Improvement," document an action plan below.
| Area Needing Improvement | Action Required | Target Date for Completion | Person Responsible |
|---|---|---|---|
Contact for Further Assistance
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📧 Email: licensing@waivergroup.com
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