Core Set for PACE CRSP - National PACE Association

GUIDELINES FOR PACE

STAFF COMPETENCY REVIEWS

CRSP

Core Resource Set for PACE

801 North Fairfax Street • Suite 309 • Alexandria, Virginia 22314Phone: 703-535-1565 • Fax: 703-535-1566 • www.NPAonline.org

TABLE OF CONTENTS

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INTRODUCTION . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 1MODEL STAFF COMPETENCIES BY POSITION:CERTIFIED NURSE ASSISTANT COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 3COMMUNITY SERVICES ADMINISTRATIVE ASSOCIATE COMPETENCY PROFILE . . . . . . . . . . . . . . 7COORDINATOR OF COMMUNITY BASED SERVICES ANNUAL COMPETENCY ASSESSMENT . . . . . 11DRIVER (TRANSPORTATION) ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . 16DRIVER (TRANSPORTATION) COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 17HOME CARE COORDINATOR ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . 21HOME CARE COORDINATOR COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 22HOME CARE NURSING TECHNICIAN COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . 29INTAKE COORDINATOR ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . 34INTAKE COORDINATOR COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 35INTAKE SPECIALIST COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 40LPN ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 44LPN COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 45MARKETING & PLANNING COORDINATOR ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . 50MARKETING & PLANNING COORDINATOR COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . 51MEDICAL SOCIAL WORKER ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . 56MEDICAL SOCIAL WORKER COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 57NURSE PRACTITIONER COMPETENCY PROFILE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 61NURSING TECHNICIAN ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . 67NURSING TECHNICIAN COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 68OCCUPATIONAL THERAPIST ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . 73OCCUPATIONAL THERAPIST COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 74PERSONAL CARE ATTENDANT COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . 79PHARMACIST ANNUAL COMPETENCY ASSESSMENT. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 83PHARMACIST COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 84

TABLE OF CONTENTS

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PHYSICAL THERAPIST ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . 88PHYSICAL THERAPIST COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 89PHYSICIAN ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 94PHYSICIAN COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 85RECEPTIONIST COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 100RECREATION THERAPY ASSISTANT COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . 103RECREATION THERAPY COMPETENCY PROFILE. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 107REGISTERED DIETICIAN COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 112REGISTERED NURSE COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 117RESTORATIVE ASSISTANT COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 124SPEECH THERAPY ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . 129SPEECH THERAPY COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 130STAFF ASSISTANT ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . 134TRANSPORTATION COORDINATOR ANNUAL COMPETENCY ASSESSMENT . . . . . . . . . . . . . . . 135TRANSPORTATION COORDINATOR COMPETENCY PROFILE . . . . . . . . . . . . . . . . . . . . . . . . 136SAMPLE POLICIES:SAMPLE COMPETENCY BASED PERFORMANCE PROGRAM . . . . . . . . . . . . . . . . . . . . . . . . 140SAMPLE COMPETENCY PROFILE ACTION PLAN (FOR ATTACHMENT AT THE END OF COMPETENCY PROFILE). . . 143SAMPLE INITIAL COMPETENCY SELF-ASSESSMENT . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 144SAMPLE PERFORMANCE EVALUATION. . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . . 146

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12.7 GUIDELINES FOR PACE STAFF COMPETENCY REVIEWS

GUIDELINES FOR PACE STAFF COMPETENCY REVIEWS

INTRODUCTION

The PACE Regulation §460.66 requires PACE programs to provide training to maintain andimprove the skills and knowledge of each staff member that results in his or her continuedability to demonstrate the skills necessary for the performance of the position. This sectionprovides sample competency evaluation forms for a number of direct care positions. Section§460.71 requires that PACE organizations extend those requirements to the contract staff whoprovide direct care to participants. In addition, the PACE programs must provide each employ-ee and all contracted staff with an orientation, which must include the organization’s mission,philosophy, policies on participant rights, emergency plans, ethics, the PACE benefit and poli-cies and procedures relevant to each individual’s job duties.

Included in this section are model competencies organized alphabetically by position and sam-ple policies. The sample competency profile action plan found on page 143 can be attached toeach model competency profile. This section does include sample competency reviews fornon-direct care staff when samples were available.

NPA wishes to thank Palmetto SeniorCare for sharing their materials and Nadia Zerkani, MikeSnow and Geri-Ayn Gaul for serving as the technical advisory group for these resources.

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2 2.7 GUIDELINES FOR PACE STAFF COMPETENCY REVIEWS

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CERTIFIED NURSE ASSISTANT COMPETENCY PROFILE

Key for met/not met categories and self-needs assessment:1. Able to perform independently2. Able to perform after review of information3. Able to perform with assistance only4. Unable to perform

Time frame:3 months = 3m6 months = 6m1 year = 1 yr

*=Annual evaluation required


Name: Date of hire:

Title: Employee number:

BLS renewal date: Evaluation date:

Specialty certification: Unit specific competency testing score:

Expiration date: Other:

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Task/behavior References:A. Review policy/procedureB. Manufacturer’s manualC. Video reviewD. Skills labE. Written testF. Self-study packetG. Direct observation

Date InstructorInitials

TimeFrame

Met Notmet

Self-needsAssessment

A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour 3mDress code Policy # 3mClock in/out, sign in/out Direct Observation 3mTelephone system/intercomsystem

Direct Observation 3m

Location of manuals Guided tour & DirectObservation

3m

Department meetings (staff,in-service)

Direct Observation 3m

Complaint log book Guided tour & DirectObservation

3m

B. DEPARTMENT SAFETY PROCEDURESFire Safety Procedure* Fire and Safety manual/P&P 3m

Disaster plan/evacuationplan*

Disaster manual/P&P 3m

Location of safety manuals*

Unit tour 3m

MSDS notebook - agentsused*

Hazardous materials manual

3m

Hazardous Waste precau-tions*

Policy # 3m

CPR/basic life support * Direct Observation 3m

Body mechanics* PT program 3m

Emergency equipment* /“911” system

Policy # 3m

Use of restraints* Policy # 3mFall precautions/participant safety

Nursing P&P 3m

C. INFECTION CONTROLHand washing Policy # 3mStandard precautions* Policy # 3mDisposal of infectiouswaste

Policy # 3m

TB control/fit testing Policy # 3mImmunizations (PPD yearly)

Policy # 3m

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TimeFrame

Met NotMet


D. RESOURCE MANAGEMENTTour of supply room(s) & stor-age areas

Guided tour 3m

E. RESPIRATORY MANAGEMENTOperation of oxygen equip-ment/tank/regulator

Direct observation 3m

Suctioning (oral) Direct observation 3mF. NUTRITIONAL MANAGEMENTEnteral tubes (gastrostomytubes)


Continuous/bolus feedings Direct observation 3mOral feedings Direct observation 3mG. ELIMINATION MANAGEMENTIntermittent/indwellingcatheter (male and female)

Policy # 3m

Incontinent care Policy #Direct observation

3m

H. USE OF EQUIPMENT Suction devices Direct observation 3mThermometers Direct observation 3mLift scales Direct observation 3mStanding scales Direct observation 3mFeeding pump Direct observation 3mWheelchairs Direct observation 3mSplints (hand, AFOs) Direct observation 3mBath chair/shower chair Direct observation 3mStethoscope Direct observation 3mManual BP cuff Policy # 3mI. CARE OF PARTICIPANTSAirway management Direct observation 3mEmergency intervention Mock codes, situation

analysis6m

Cardiopulmonary arrest Policy # 6mOstomy/fistula care Policy # 3mPatient hygiene needs/footcare


Vital signs Policy # 3m

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Date competency profile completed: ____________________________

Action plan initiated: Yes No (If yes, please add action plan to competency profile.)

I understand that it is my responsibility to notify my immediate supervisor if at any time I amunable to perform the basic competencies required to practice in my assigned clinical area.

Employee signature: ________________________________________________________

Preceptor signature: ________________________________________________________

(Attach the competency profile action plan here.)



TimeFrame

Met NotMet


Simple wound care Policy # 3mAssist recreation therapystaff with appropriate day-room activities


J. PARTICIPANT SPECIFIC COMPETENCIESAge specific Self-study module 3mLatex allergy Self-study module 3mCultural respect Self-study module 3mK. MANAGEMENT OF INFORMATIONNursing technician docu-mentation


Reporting of significantobservations to supervisingRN


Participant confidentiality Policy and procedure man-ual

3m

L. UNIT SPECIFICManagement of wanderingparticipants

Unit learning resources 3m

M. QUALITY IMPROVEMENTOccurrence report Preceptor training 3mConcern/Complaint log P&P manual 3mStandard precautions moni-tor

P&P manual 3m

QI committee Site QI meeting minutes

3m

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COMMUNITY SERVICES ADMINISTRATIVE ASSOCIATE COMPETENCY PROFILE



*=Annual evaluation required

Name: Date of hire:


Driver’s license number: Evaluation date:

Driver’s license renewal date: Specialty certification (if applicable):

Expiration date:BLS renewal date (every two years)*: Other:

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ABCDEFG


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour by program

director and/or center manag-er

3m

Dress code Policy # 3mClock in/out Policy # 3m

Telephone system/intercomsystem

Policy # 3m

Location of manuals Guided tour/preceptor 3m

Department meetings (staff,in-service)

Clinical ladder manual 3m

Beeper paging Policy # 3mPACE training PACE manual, preceptor

orientation3m

B. DEPARTMENT SAFETY PROCEDURESAnnual mandatory safetytraining (includes corporatecompliance)*

Safety training manual &video

3m

Review of emergency proce-dures, both medical and non-medical*

Disaster manual, P&P manual 3m

Fire safety procedure*, includ-ing check of fire alarm system




Location of safety manuals* Unit tour 3m

MSDS notebook-agentsused*

Hazardous materials manual 3m

Hazardous waste precautions*


Body mechanics* PT/OT presentation 3mCPR/basic life support Policy # 6m

911 system Preceptor 3m

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ABCDEFG


TimeFrame

Met Notmet


C. INFECTION CONTROLHandwashing Policy # 3m

Standard precautions * Policy # 3mImmunizations PPD yearly (mandatory)* Flu vaccination (counseling)

Policy # 3m

D. RESOURCE MANAGEMENTTour of supply room(s)/cabinets Guided tour 3mOrdering supplies Requisition

P&P manual, section #Supply list

6m

E. MANAGEMENT OF CENTER INFORMATIONMaintains the following administra-tive reports for inspection:

P&P manual, section # 3m

Statistical Log P&P manual, section # 3m

Daily menus and substitutions (for 30 days)


Record of (PACE program)activities (for one year)


Current center staff, volunteerand intern education, experience and training records


Assists in the collection of the following information:

Incident (occurrence) reporting Policy # 3m

Medical record Medical record manual 3m

Documents teaching of staff Policy # 3mParticipant confidentiality Policy # 3mReview of marketing policy toinclude prohibited marketing prac-tices*

P&P manual, mandatory in-service

3m

Death notification Policy # 3m

Physician Policy # 3m

Coroner Policy # 3mOversees transfers of participantsinto and out of (PACE program)

Preceptor 6m

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Employee signature: ________________________________________________________

Preceptor signature: ________________________________________________________



ABCDEFG


TimeFrame

Met Notmet


F. CARE OF PARTICIPANTSEmergency intervention, includ-ing fire and disaster drills

Situational analysis, drillreports, P&P Manual, sec-tion #

3m

G. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3mLatex allergy* Self-study module 3mCultural sensitivity/diversity* Self-study module 3m

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COORDINATOR OF COMMUNITY BASED SERVICES COMPETENCY PROFILE



* = Annual evaluation required

Name: Date of hire:


License number: Evaluation date:

License renewal date: Center assigned:

BLS renewal date (every two years)*: Hospital nursing CBO completed: Yes / NoDate:

ACLS renewal date (if applicable): Specialty certification (if applicable):

Expiration date:Other: Unit specific competency testing score:

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ABCDEFG


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEW1. Tour of (PACE program) Guided tour by program

director and/or site supervisor

3m

2. Dress code Policy # 3m3. Sign in/out Policy # 3m

4. Telephone system/intercomsystem

Policy # 3m

5. Location of manuals Guided tour/preceptor 3m

6. Department meetings (staff,in-service, management team)

Clinical manual 3m

7. Beeper paging Policy # 3m8. Standards of practice ANA Standards and Scope of

Gerontological NursingPractice

3m

B. DEPARTMENT SAFETY PROCEDURESFire safety procedure*, includ-ing check of fire alarm system


Disaster plan/evacuation plan* Disaster manual, P&P manual 3mLocation of safety manuals* Unit tour 3mMSDS notebook-agents used * Hazardous materials manual 3m

Water analysis Manual 3mHazardous waste precautions Hazardous materials manual 3mBody mechanics* PT program 3m

CPR/basic life support Policy # 3m

911 system Preceptor, guided tour 3m

Use of restraints* Lap buddy

Policy #PT program

3m

Fall precautions/participantsafety

Nursing P&P 3m

C. INFECTION CONTROLHandwashing Policy # 3mStandard precautions * Policy # 3mDisposal of infectious waste Policy # 3m

Isolation protocols Infection Control Manual 3m

TB control/fit check Policy # 3m

Immunizations (PPD yearly) Policy # 3m

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ABCDEFG


TimeFrame

Met Notmet


D. RESOURCE MANAGEMENTTour of supply room(s)/cabi-nets

Guided tour 3m

Ordering supplies Requisition

P&P manual, section #Supply list

6m

Scheduling of staff P&P manual 3mManaging center budget P&P manual 6mHuman resource manage-ment of assigned staff

Policy # 6m

E. MANAGEMENT OF CENTER INFORMATIONMaintains the following admin-istrative reports for inspection:


Statistical log P&P manual, section # 3m Daily menus and substitu-

tions (for 30 days)P&P manual, section # 3m

Record of center activities (for one year)


Current center staff, vol-unteer and intern educa-tion, experience and training records


Collects or ensures the collection of the following information: Incident (occurrence)

reportingPolicy # 6m

Adverse drug reaction reporting and medication errors reporting

Policy # 6m

Medical record Medical record manual 6mDocuments teaching of staff Policy # 6mParticipant confidentiality Policy # 6mDeath notification Policy # 6m Physician Policy # 6m Coroner P&P manual, section # 6m

Oversees transfers of partici-pants into and out of (PACEprogram)


Oversees disenrollmentprocess


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ABCDEFG


TimeFrame

Met Notmet


Performs baseline assess-ment of participants if needed

Charting tools, policy # 3m

Physical assessment data Policy # 3m Fall risk assessment Fall risk assessment tool 3m

F. RESPIRATORY MANAGEMENTOperation of Oxygen equip-ment, including O2 concentra-tor*

P&P Manual, section # 3m

Supplemental O2 Therapies * P&P Manual, section # 3mG. ELIMINATION MANAGEMENTIncontinent care Policy #, skin care resource

book3m

H. USE OF EQUIPMENTPressure relieving devices Equipment manuals, situa-

tional analysis, unit learningresources

3m

Glucometer (use and calibra-tion)

“ 3m

Waffle boot “ 3mWaffle wheelchair/head cush-ion

“ 3m

Hoyer/maxi lift 3mI. CARE OF PARTICIPANTSVenipuncture Policy # 3mSpecimen collection Policy # 3mPressure ulcers Policy # 3mDeath and dying (includingpost-mortem management)

Policy # 6m

Emergency intervention,including fire and disasterdrills

Situational analysis, drillreports, P&P manual, sec-tion #

3m

J. PARTICIPANT SPECIFIC COMPETENCIESAge specific Self-study module 3mLatex allergy Self-study module 3mCultural sensitivity/diversity Self-study module 3m

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Action plan initiated: Yes No(If yes, please add action plan to competency profile.)


Employee signature: ____________________________________________________

Preceptor signature: ____________________________________________________



ABCDEFG


TimeFrame

Met Notmet


K. GENERALAdministrative call P&P manual, section # 6m

Reports to managementteam


Handling of grievances P&P manual, section # 6m

Chairs program-wide committees


L. QUALITY CONTROL CHECKSChart review P&P manual 3m

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DRIVER (TRANSPORTATION) ANNUAL COMPETENCY ASSESSMENT

(PACE program)

Name: __________________________ Employee #: _______ Department: _______

Date of Hire: _______________ Instructor Signature: ___________________________

TIME FRAME: Self-needs assessment:3 months 1. Able to perform independently6 months 2. Able to perform after review of information1 year 3. Able to perform with assistance only

4. Unable to perform

Standards How standard met:A. Review policy/procedureB. Direct observationC. Video reviewD. Competency testing labE. Written testF. Self-study packet

ABCDEF


TimeFrame

Met Notmet

Self-needsassessment

Limitations of participantmovement

P&P manual 1 yr

Immunizations (PPD everyyear)

Policy # 1 yr

Cultural respect Self-study module 1 yrLatex allergy Self-study moduleAge specific Self-study module 1 yrDriver’s license renewal (ifapplicable)Defensive driving renewal(if applicable)CPR every 2 years Policy #; competency testing

lab2 yr

Disaster/fire drills Policy #/ participation 1 yrDepartment manuals Tour 1 yrCorporate compliance Video & class 1 yrInfection control P&P manual/in-service

training1 yr

Emergency equipment &scavenger hunt

Direct observation 1 yr

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DRIVER (TRANSPORTATION) COMPETENCY PROFILE

++ = General orientation or annual published timeframes* = Annual evaluation required

Task/Behavior References:A. Review policy/procedureB. Manufacturer’s manualC. Video reviewD. Skills labE. Written testF. Self-study packetG. Direct observation

ABCDEFG


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour B 3m“PACE” training PACE manual, P&P manu-

al, Preceptor orientationA 3m

Dress code Policy # A,B 3mClock in/out & sign in/out Policy # A,B 3mTelephone system andintercom system

Policy # B 3m

Beeper paging Direct observation A,B 3mLocation of manuals Guided tour B 3mLocation of grievance log andmaintenance log

Guided tour A,B 3m

Department and in-servicemeetings

Direct observation A,B 3m

B. DEPARTMENT SAFETY PROCEDURESAnnual mandatory safetytraining*

Safety training manual andvideo

A,C,E

++

Fire safety procedure* Guided tour/disaster manu-al/fire drill participation

A,B ++


Guided tour/disaster manual

++

Location of safety manuals* Guided tour ++



++

Hazardous waste precau-tions


++

Body mechanics* PT program ++CPR/basic life support (every2 years)*

Policy # 6m

Emergency procedures-”911”system*

Disaster manual 3m

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ABCDEFG

DateInstructorInitials

TimeFrame

Met Notmet


Review of all emergency pro-cedures, both medical andnon-medical*

P&P manual, disaster manual A 3m

Use of restraints Guided tour B 3mFall precautions PACE manual, P&P manual,

Preceptor orientationA 3m

C. INFECTION CONTROLHandwashing Hazardous materials manual A,B 3mToilet liners Product instructions B,G 3mStandard precautions* Policy # A,B 3mDisposal of infectious waste Policy # A,B 3mTB control/fit testing Policy # A,B 3mImmunizations (PPD yearly)* Policy # A,B 3mD. USE OF EQUIPMENTOperating van* Vehicle manual, defensive

driving course knowledge,preceptor supervision

A,C,G

6m

Van lifts* Operating manual, preceptorsupervision, video

A,B,C,G

6m

Fire extinguisher Instructions/annual manda-tory in-service

A,G,G

6m

First aid kit Instruction guide, first aidcourse

B 6m

Seat belts* Operating manual, preceptorsupervision

A,B,G

6m

Tie downs* Operating manual, preceptorsupervision

A,B,G

6m

Two-way radio Instruction guide, preceptorsupervision

A,B,G

6m

Wheelchair Instruction guide, preceptorsupervision

B,G 6m

Oxygen tank* Instructions, preceptorsupervision

A,B 6m

Secure guard system Instruction guide, preceptorsupervision

A,B,G

6m

E. CARE OF PARTICIPANTSLoading/unloading partici-pants on/off vans

Preceptor supervision B 6m

Transportation of participants Preceptor supervision B 6m

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ABCDEFG


TimeFrame

Met Notmet


F. PARTICIPANT SPECIFIC COMPETENCIESAge* Self-study module E,F 3mCultural respect* Self-study module E,F 3mLatex allergy information* Self-study module A,C,

E,F3m

G. MANAGEMENT OF INFORMATIONMileage log Transportation manual,

preceptor instructionsA,B 6m

Daily vehicle checklist “ A,B 6mFuel log “ A,B 6mDaily participant log “ A,B 6mDaily employee attendanceroster

“ A,B 6m

Utilization sheets “ A,B 6mMedication log “ A,B 6mReview of participants’ rights(mandatory)*

Policy & Procedure manual,mandatory in-service train-ing

A 6m

Participant confidentiality* “ A 6mReview of marketing policy toinclude prohibited marketingpractices*

“ A 6m

Corporate compliance* Safety training manual &video

A,C,E

6m

H. CENTER SPECIFICPharmacy, supply, mail pick-ups

Transportation manual, preceptor instructions

A,B 6m

Van maintenance procedure “ B,G 6m“No available family” proce-dure

“ A 6m

Field trips “ A,B 6mSaturday respite “ A,B 6mOutside appointments “ A,B 6mI. QUALITY IMPROVEMENTParticipation in center QIprojects

QI meeting minutes A,B 6m

Grievance log Site supervisor/designee,preceptor

A,B 6m

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HOME CARE COORDINATOR ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr


Policy # 1 yr

Cultural respect Self-study module 1 yrLatex allergy Self-study moduleAge specific Self-study module 1 yrAssessment, PACE docu-mentationCPR every 2 years Policy #, competency testing

lab2 yr

Disaster/fire drills Policy #, participation 1 yrDepartment manuals Tour 1 yrCorporate compliance Video & class 1 yrInfection control P&P manual, in-service

training1 yr

Emergency equipment Direct observation 1 yr

Mandatory training Video and post-test 1 yr

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HOME CARE COORDINATOR COMPETENCY PROFILE


ABCDEFG


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour & scavenger

hunt3m

“PACE” training PACE manual, P&P manu-al, Preceptor orientation

3m

Dress code Policy # 3mSign in/out Policy # 3mTelephone system andintercom system

Policy # 3m

Beeper paging Direct observation 3mLocation of manuals Guided tour 3mDepartment meetings Staff In-service Home care coordinators

(monthly)


Log books Concern log Complaint log Missed visit log Travel log

Preceptor/center tour 3m

Authorizations Authorization manual 3mDataPACE requirements DataPACE manual 3mOn-call responsibilities P&P manual 3mCommunity-based services Home care contracts

& providers Durable medical equipment

(DME) contracts & providers

Preceptor 6m

Lunch duty P&P manual 3mLate stay duty P&P manual 3mInterdisciplinary team responsi-bilities

Preceptor, P&P manual 3m

B. DEPARTMENT SAFETY PROCEDURESAnnual mandatory safety train-ing*


3m

Review of emergency proce-dures and equipment, bothmedical and non-medical

3m

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ABCDEFG


TimeFrame

Met Notmet


Fire safety procedure* Guided tour/disaster manu-al/fire drill participation

A,B 3m


Guided tour/disaster manual

3m

Location of Safety manuals* Guided tour 3m



3m

Hazardous waste precau-tions


3m

Body mechanics* PT program 3mCPR/basic life support (every2 years)*

Policy # 6m

Emergency procedures ”911” system Emergency drug box Emergency plan of care Vial of life

P&P manual 3m

Use of restraints* Policy #, restraint P&P 3m

Fall precautions/participantsafety*

Nursing P&P 3m

C. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3mDisposal of infectious waste Policy # 3mImmunizations PPD yearly (mandatory)* Flu vaccination

(counseling)

Policy # 3m

Location and use of personalprotective equipment (PPE)*

Safety training manual &video, tour

3m

D. RESOURCE MANAGEMENTTour of supply room(s)/cabi-nets

Guided tour 3m

Ordering DME Warehouse requisition DME provider

Site supervisor authoriza-tion

3m

Pharmacy orders P&P manual section # 3mNarcotics responsibility P&P manual section # 3m

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ABCDEFG


TimeFrame

Met Notmet


E. ASSESSMENT OF PARTICIPANTSIntake criteria Manual section # 3mIntake admission assessment(health history/physicalassessment) Q 3-5 months PRN

Medical records manual,section #

3m

Transfer, intracenter: receiv-ing (PACE program)


Transfer, intracenter: sending(PACE program)


Disenrollment criteria P&P manual, section # 3m

Home care visit P&P manual, preceptor 3mHome safety checks P&P manual, preceptor 3mPACE assessment P&P manual, preceptor 3m

Physical assessment data Neurological Behavior Respiratory Cardiovascular Integumentary and

altered skin conditions Gastrointestinal Renal/urinary Reproductive (include

date of last PAP) Identifies both normal and

abnormal findings of systems

Policy # 3m

F. EDUCATION & RESPIRATORY MANAGEMENTSupplemental O2 Therapies Manual 3mOxygen Therapy* Manual 3mRespiratory Therapy Hand held nebulizer

Policy # 3m

Suctioning (oral, tracheal,nasotracheal)*

Manual 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


G. EDUCATION AND CARE OF NUTRITIONAL MANAGEMENTNasogastric tubes Policy # 3m

Entral tubes (gastrostomytubes, PEGs)

Manual 3m

H. EDUCATION AND CARE OF ELIMINATION MANAGEMENTIntermittent/indwellingcatheter (male & female)

Policy # 3m

Suprapubic catheter Policy # 1yrCondom catheter Policy # 3mSmall volume enemas Policy # 3mIncontinent care Policy #, skin care resource

book3m

AV fistula graft/dialysiscatheter

Policy # 3m

Bowel regime Bowel program 3mI. EDUCATION AND CARE OF EQUIPMENTSuction devices P&P manuals 3mInfusion pumps P&P manuals 3mWheelchairs P&P manuals 3mThermometers P&P manuals 3mHand held nebulizer P&P manuals 3mTrapeze bar P&P manuals 3mPressure relieving devices P&P manuals 3mGlucometer P&P manuals 3mKangaroo pump P&P manuals 3mSpecialty beds/hospital beds P&P manuals 3mOxygen concentrator P&P manuals 3mIce packs P&P manuals 3mPortable oxygen P&P manuals 3mSide rails P&P manuals 3mHover/maxi lift P&P manuals 3mSafety frame P&P manuals 3mElevated commode seat P&P manuals 3mShower chair P&P manuals 3mTransfer bench P&P manuals 3mTub grab bar P&P manuals 3mHumidifier P&P manuals 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


J. EDUCATION OF CAREGIVERS TO PARTICIPANT CAREAirway management P&P manuals 3mPain management P&P manuals 3m IV therapy Policy # 3m Venipuncture

(peripheral/central)Policy # 3m

IVAD’s* Policy # 6mEmergency intervention-”911”system and emergency plan

Situation analysis 6m

Cardiopulmonary arrest* Policy # 6mOstomy/fistula care P&P manuals 3mPressure ulcers Policy # 3mEye care Policy # 6mDeath and dying (includingpost mortum management)

Policy # 6m

K. PARTICIPANT SPECIFIC COMPETENCIES Age specific* Self-study module 3m Cultural diversity* Self-study module 3m Latex allergy* Self-study module 3m

L. MANAGEMENT OF INFORMATIONMedical record Medical record manual 3mDocuments teaching/disen-rollment instructions

Policy # 3m

Patient confidentiality* Policy # 3mInformed consent Policy # 3mDeath notification Policy # 3m Family Policy # 3m Physician Policy # 3m Coroner Policy # 3m SCOPA Policy # 3m

Home care assignment sheet Policy # 3mIntracenter transfer docu-mentation/receiving andsending

Policy # 3m

M. UNIT SPECIFIC/EDUCATIONORTHOPEDIC Stump care P&P manual 6m Cast/splint care P&P manual 6m Application and

maintenance of slingsP&P manual 6m

CRSP




ABCDEFG


TimeFrame

Met Notmet


Immobilizers, cervical collars, braces

P&P manuals 6m

Neurovascular checks P&P manuals 3m

ROM P&P manuals 6mDiabetic foot care P&P manuals 3m

General P&P manuals 3mManagement of participantswho wander

P&P manuals 3m

N. NEUROSCIENCESeizure precautions/use ofanticonvulsants (action &side effects)

Resource book: The ClinicalPractice of Neurological &Neurosurgical Nursing

3m

Evaluation of LOC (appropri-ate actions in caring forpatient and notifying MD)

“ 3m

Medication instruction:actions, indications, sideeffects

“ 3m

O. CANCER MANAGEMENTLeukopenic precautions andbleeding protocols

Self-study module 6m

P. HOME CARE TECHNICIAN MANAGEMENT Orientation P&P manual 3mSkills checklist P&P manual 3m

Scheduling P&P manual 3mPerformance evaluation P&P manual 3mDisciplinary action P&P manual 3mPersonnel records P&P manual 3mQ. PROVIDER COORDINATIONScheduling P&P manual 3mMonitoring service delivery P&P manual 3mAuthorization Authorization manual 3mHome care assignment sheet P&P manual 3m

CRSP










ABCDEFG


TimeFrame

Met Notmet


Quality control checks - at(PACE program)

P&P manual 3m

Emergency drug box checks

Policy # 3m

Refrigerator checks P&P manual 3m Chart review P&P manual 3m Glucometer checks and

other CLIA wavered equipment checks

P&P manual, direct obser-vation

3m

QI council Meeting minutes 3mQuality control checks - athome

P&P manual 3m

Vector/animal control P&P manual 3m Vial of life P&P manual 3m Smoke detector

monitoringP&P manual 3m

Adequate plumbing P&P manual 3m Security P&P manual 3m Adequate stove P&P manual 3m Safe access to all areas of

homeP&P manual 3m

Electricity P&P manual 3mSerious occurrence reporting*

Policy # 3m

Incident reporting Policy # 3mAdverse drug reaction reporting

Policy # 3m

CRSP



HOME CARE NURSING TECHNICIAN COMPETENCY PROFILE




Name: Date of hire:



License renewal date: Center assigned:

BLS renewal date (every two years)*: Hospital nursing CBO completed: Yes / NoDate:

ACLS renewal date (if applicable): Specialty certification (if applicable):

Expiration date:Other: Unit specific competency testing score:

CRSP




ABCDEFG


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour 3m“PACE” training PACE manual, P&P manual,

Preceptor orientation3m

Dress code Policy # 3mTime sheet, Sign in/out Policy # 3mBeeper paging Preceptor orientation 3mOn-call system Policy & procedure section #Location of manuals Guided tour 3mDepartment meetings (staff, in-service)


End of month documentation Preceptor orientation 3m

B. DEPARTMENT SAFETY PROCEDURESAnnual mandatory safety train-ing (includes corporate compli-ance)*


3m

Review of emergency procedures and equipment, both medical and non-medical (below)*

3m

Fire safety procedure* Disaster manual, P&P 3mDisaster plan, evacuation plan* Disaster manual, P&P 3mLocation of safety manuals* Unit tour 3mMSDS notebook-agents used* Hazardous materials manual 3mHazardous waste precautions* Hazardous materials manual 3mCPR/basic life support (every 2years)*

Policy # 6m

Body mechanics PT program 3mEmergency equipment*, “911”system, vial of life

Policy & procedure section # 3m

Use of restraints* Policy # 3mFall precautions, participantsafety*

Nursing P&P 3m

C. INFECTION CONTROLHand washing Policy # 3mStandard precautions* Policy # 3mDisposal of infectious waste Policy # 3mTransport of blood/body fluids Policy #, unit learning

resources3m

TB control, fit check Policy # 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


Immunizations PPD yearly (mandatory)* Flu vaccination

Policy # 3m

Use of personal protectiveequipment (PPE)

Policy # 3m

D. RESOURCE MANAGEMENTTour of supply room(s) & stor-age areas

Guided tour 3m

E. RESPIRATORY MANAGEMENTSupplemental O2 therapies* Manual 3mOperation of oxygen equip-ment, tank, regulator*


Oxygen safety Unit learning resources 3mF. NUTRITIONAL MANAGEMENTEnteral Tubes (gastrostomytubes), dressing care

Manual 3m

Oral feedings Unit learning resources 3mG. ELIMINATION MANAGEMENTIntermittent/indwelling catheter(male & female)

Policy # 3m

Oral feedings Policy # 3mH. USE OF EQUIPMENTHumidifier Direct observation,skills lab 3mManual BP cuffs Direct observation,skills lab 3mThermometers Direct observation,skills lab 3mLift scales Direct observation,skills lab 3mHospital bed/side rails Direct observation,skills lab 3mStanding scales Direct observation,skills lab 3mFeeding pump operation Direct observation,skills lab 3mWheelchairs & walkers Direct observation,skills lab 3mSplints (hand, AFOs) Direct observation,skills lab 3mBath chair/shower chair Direct observation,skills lab 3mStethoscope Direct observation,skills lab 3mHoyer lift P&P manual, section # 3mTransfer bench Direct observation,skills lab 3mTrapeze bar Direct observation,skills lab 3mPressure relief devices/mat-tresses

Direct observation,skills lab 3m

Sliding board Direct observation,skills lab 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


I. CARE OF PARTICIPANTSAirway management P&P manual, section # 3mHealth care wishes P&P manual, section # 3m Vial of life P&P manual, section # 3m ”911” system P&P manual, section # 3m

Emergency plan of care P&P manual, section # 3mEmergency intervention Mock codes, situation

analysis6m

Cardiopulmonary arrest* Policy # 6mJ. PARTICIPANT SPECIFIC COMPETENCIES Age specific* Self-study module 3m Cultural diversity* Self-study module 3m Latex allergy* Self-study module 3m

Review of participants’ rights* P&P manual, mandatory in-service training

3m

K. MANAGEMENT OF INFORMATIONHome care nursing technician documentation

Medical record manual 3m

Reporting of significant obser-vations to home care coordi-nator, RN

Direct observation, precep-tor

3m

Participant confidentiality* Policy #, P&P manual 3mReview of marketing policy toinclude prohibited marketingpractices*


3m

L. UNIT SPECIFICBasic skills Direct observation, skills lab 3m Bathing Direct observation, skills lab 3m Oral hygiene Direct observation, skills lab 3m Skin care, monitoring Direct observation, skills lab 3m Nail care/hands & feet Direct observation, skills lab 3m Urinal Direct observation, skills lab 3m Bedpan Direct observation, skills lab 3m Bedmaking-occupied bed Direct observation, skills lab 3m Dressing reinforcement Direct observation, skills lab 3m Range of motion exercises Direct observation, skills lab 3m Ambulation Direct observation, skills lab 3m Positioning/body

alignmentDirect observation, skills lab 3m

CRSP










ABCDEFG


TimeFrame

Met Notmet


Transfer Direct observation, skills lab 3m Special support stockings Direct observation, skills lab 3m Vital signs monitoring Direct observation, skills lab 3m

Seizure safety Direct observation, skills lab 6m

Ostomy/fistula care Direct observation, skills lab 6mAdvanced skills Direct observation, skills lab 3m Sterile, clean dressing

changeDirect observation, skills lab 3m

Dressing wafer to non-infected wound

Direct observation, skills lab 3m

Bolus tube feeding Direct observation, skills lab 3m Fleets enema Direct observation, skills lab 3m

M. QUALITY IMPROVEMENTStandard precautions monitor Policy # 3mQI committee Site QI meeting minutes 3m

CRSP



INTAKE COORDINATOR ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr


Policy # 1 yr

Cultural respect Self-study module 1 yrLatex allergy Self-study moduleAge specific Self-study module 1 yrAssessment, PACE docu-mentation

Policy #

CPR every 2 years Policy #, competency testinglab

2 yr

Disaster/fire drills Policy #, participation 1 yrDepartment manuals Tour 1 yrCorporate compliance Video & class 1 yrInfection control P&P manual, in-service

training1 yr



CRSP



INTAKE COORDINATOR COMPETENCY PROFILE




Name: Date of hire:



License renewal date: Specialty certification (if applicable):Expiration date:

BLS renewal date (every two years)*:

Other:

CRSP




ABCDEFG


TimeFrame

Met Notmet




Dress code Policy # 3mClock-in/out or sign in/out Policy # 3mBeeper paging Preceptor orientation 3mTelephone & intercom system Tour, policy # 3mLocation of manuals Guided tour 3mDepartment meetings (staff, in-service)


Log Books Grievance log Maintenance log CLIA-waived testing log*

Preceptor orientation 3m

Review Organizational chart Preceptor orientation 3mReview personnel proceduresfor travel, tardiness, absen-teeism, leave requests, incident& accident reports, employeescreening requirements, payprocedures, supplies

Review policies & proce-dures

3m



3m

Review of emergency procedures and equipment, both medical and non-medical* Fire safety procedure* Disaster manual, P&P 3m Disaster plan, evacuation

plan*Disaster manual, P&P 3m

Location of safety manuals* Guided tour 3m MSDS notebook-agents

used*Hazardous materials manual 3m

Hazardous waste precautions*


CPR/basic life support (every 2 years)*

Policy # 6m

“911” system Preceptor/guided tour 3m Use of restraints* Policy # 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


C. INFECTION CONTROLHandwashing Infection control manual 3mStandard precautions* Infection control manual 3mLocation and use of personalprotective equipment (PPE)


3m

Immunizations PPD yearly (mandatory)* Flu vaccination

Policy # 3m

D. RESOURCE MANAGEMENTHR management of intake specialist

P&P manual 3m

Ordering of supplies Preceptor 3mScheduling of home visits Preceptor 3mCoordination/scheduling ofintake presentations

Preceptor 3m

E. ASSESSMENT OF PARTICIPANTSIntake and enrollment policies& procedures

P&P manual, (State)Medicaid program hand-book, (PACE program)enrollment handbook

3m

Explanation of PACE concept “, PACE manual 3m

Screening criteria “ 3m Age “ 3m Geographical location “ 3m Financial resources (State) Medicare &

Medicaid, private pay eligi-bility guidelines

3m

Level of care determination Form # 3m Certification of level of care Form #, preceptor 3m

Home visit Preceptor 3m Explanation of benefits and

coverage(PACE program) handbook 3m

Explanation of exclusions and limitations of coverage

(PACE program) handbook 3m

Explanation of contracts with other community resources & agencies


Explanation of charges & payment


CRSP




ABCDEFG


TimeFrame

Met Notmet


Explanation of emergencyplan including out-of-state care


Explanation of participant rights


Explanation of participant and caregiver responsibilities


Ineligibility for enrollment (PACE program) handbook 3m Appeal rights (PACE program) handbook 3m

Referral to other resources 6mPresentation of new intakes tointerdisciplinary care teams

Preceptor 3m

Signing of enrollment agree-ment


Team denial of enrollment (PACE program) handbook 3mJ. PARTICIPANT SPECIFIC COMPETENCIES Age specific* Self-study module 3m Cultural diversity* Self-study module 3m Latex allergy* Self-study module 3m

K. MANAGEMENT OF INFORMATIONReferral information Completion of telephone

referral form3m

Communication of assessmentfindings to potential participant& caregiver

Preceptor 3m

Maintenance of intake record Preceptor 3mParticipant confidentiality* P&P manuals 3mRelease of medical information P&P manuals 3mCompletion of PACE data P&P manuals 3m Intake study information P&P manuals 3m Biographical information P&P manuals 3m (State) information P&P manuals 3m

Participants’ rights P&P manuals 3mReview of marketing policy toinclude prohibited marketingpractices*

P&P manuals 3m

L. UNIT SPECIFICAdministrative call P&P manual, section # 6mManagement team P&P manual, section # 3mBilling P&P manual, section # 6m

CRSP










ABCDEFG


TimeFrame

Met Notmet


M. QUALITY IMPROVEMENTChart review QI manual 3mQI committee Site QI meeting minutes 3m

CRSP



INTAKE SPECIALIST COMPETENCY PROFILE




Name: Date of hire:



Driver’s license renewal date: Specialty certification (if applicable): Expiration date:

Other:

CRSP




ABCDEFG


TimeFrame

Met Notmet




Dress code Policy # 3mClock-in/out or sign in/out Policy # 3mBeeper paging Preceptor orientation 3mTelephone & intercom system Tour, policy # 3mLocation of manuals Guided tour 3mPACE training PACE manual, P&P manual,

preceptor orientation3m

Review organizational chart Review P&P 3mReview personnel proceduresfor travel, tardiness, absen-teeism, leave requests, incident& accident reports, employeescreening requirements, payprocedures, supplies

Review policies & proce-dures

3m



3m



Location of safety manuals* Guided tour 3m Hazardous materials* Hazardous materials manual 3m Body mechanics* Policy #, PT orientation 6m

C. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3mImmunizations: PPD (mandatory)* Flu vaccination (counseling)

Policy # 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


D. RESOURCE MANAGEMENTOrdering of supplies Preceptor 3mScheduling of home visits Preceptor 3mCoordination/scheduling ofintake presentations

Preceptor 3m

E. ASSESSMENT OF PARTICIPANTSIntake and enrollment policies &procedures

P&P manual, (State)Medicaid program hand-book, (PACE program)enrollment handbook

3m

Explanation of PACE concept “, PACE manual 3m

Screening criteria “ 3m Age “ 3m Geographical location “ 3m Financial resources (State) Medicare &

Medicaid, private pay eligi-bility guidelines

3m

Explanation of benefits andcoverage


Explanation of exclusions and limitations of coverage


Explanation of contracts with other community resources & agencies


Explanation of charges & payment


Explanation of emergencyplan including out-of-statecare


Explanation of participant rights


Explanation of participant and caregiver responsibilities


Ineligibility for enrollment (PACE program) handbook 3mReferral to other resources (PACE program) handbook 6mHome visit Assesses Medicaid eligibility

and completes Medicaid applications as appropriate


CRSP










ABCDEFG


TimeFrame

Met Notmet


F. PARTICIPANT SPECIFIC COMPETENCIES Age specific* Self study module 3m Cultural diversity* Self study module 3m Latex allergy* Self study module 3m Limitation of participant

movement*Self study module 3m

G. MANAGEMENT OF INFORMATIONReferral information Completion of telephone

referral form3m

Maintenance of intake record Preceptor 3mParticipant confidentiality* P&P manuals 3mRelease of medical information P&P manuals 3mMaintenance of PACE data P&P manuals 3m Intake study information P&P manuals 3m Biographical information P&P manuals 3m (State) information P&P manuals 3m

Review of participants’ rights* P&P manuals 3mReview of marketing policy toinclude prohibited marketingpractices*

P&P manuals 3m

H. QUALITY IMPROVEMENTChart review P&P manual 3mQI committee Meeting minutes 3m

CRSP



LICENSED PRACTICAL NURSE ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr


Policy # 1 yr

Cultural respect Self-study module 1 yrLatex allergy Self-study moduleAge specific Self-study module 1 yrAssessment, PACE docu-mentationCPR every 2 years Policy #, competency testing

lab2 yr

Disaster/fire drills Policy #, participation 1 yrDepartment manuals Tour 1 yrCorporate compliance Video & class 1 yrInfection control P&P manual/ in-service

training1 yr


Mandatory Training Video and post-test 1 yr

CRSP



LICENSED PRACTICAL NURSE COMPETENCY PROFILE




Name: Date of hire:



Driver’s license renewal date: Specialty certification (if applicable)Expiration date:

Other:

CRSP




ABCDEFG


TimeFrame

Met Notmet




Dress code Policy # 3mClock-in/out or sign in/out Policy # 3mBeeper paging Preceptor orientation 3mTelephone & intercom system Tour, policy # 3mLocation of manuals Guided tour 3mPACE training PACE manual, P&P manual,


Log books Grievance log Emergency equipment log Maintenance log

Guided tour, preceptor orien-tation

3m

B. DEPARTMENT SAFETY PROCEDURESAnnual mandatory safety training(includes corporate compliance)*


3m



Location of safety manuals* Guided tour 3m Hazardous waste precautions* Hazardous materials manual 3m Body mechanics* PT program 3m CPR/basic life support (every

2 years)*Policy # 6m

“911” system, emergency drugbox*

Policy #, preceptor 3m

Use of restraints* Policy #, restraint P&P 3mMSDS notebook-agents used* Hazardous materials manual 3mSecure guard system Manufacturer’s instructions,

preceptor3m

Fall precautions/participant safety* Nursing P&P 3mC. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


Disposal of infectious waste Policy # 3mImmunizations PPD yearly (mandatory)* Flu vaccination (counseling)

Policy # 3m



3m

Toilet liners Manufacturer’s instructions,preceptor

3m

D. RESOURCE MANAGEMENTTour of supply room(s) Guided tour 3mOrdering of supplies Preceptor 3m Requisition 3m

Medication administration Policy # 3mPharmacy orders P&P manual, section # 3mNarcotics responsibility P&P manual, section # 3mE. ASSESSMENT OF PARTICIPANTSIntake and enrollment policies &procedures


Assists with admission process-assessment (health history)

Medical records manual,section #, preceptor

3m

Disenrollment criteria P&P manual 3mF. PHYSICAL ASSESSMENT DATAIdentifies both normal andabnormal findings and reportsthem to RN

Unit learning resources, preceptor

3m

G. RESPIRATORY MANAGEMENTSpO2 monitoring (pulse oxime-try)

Policy # and direct observation

3m

Operation of oxygen equipment,tank, regulator & O2 concentrator*

Policy # 3m

Tracheostomy care Policy # 3mSuctioning (oral, tracheal, nasotra-cheal, endotracheal)*

Policy # and manufacturer’smanual

3m

H. NUTRITIONAL MANAGEMENTNasogastric tubes Policy # 3mEnteral tubes (gastrostomytubes, PEG’s)

P&P manual 3m

Continuous/bolus feedings, kangaroo pumps

P&P manual, manufacturer’smanual

3m

Oral feedings P&P manual 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


I. ELIMINATION MANAGEMENTIntermittent/indwelling catheter(male and female)

P&P manual 3m

Suprapubic catheter P&P manual 3mCondom catheter P&P manual 3mLarge volume enemas P&P manual 3mSmall volume enemas P&P manual 3mIncontinent care Policy # 3mJ. USE OF EQUIPMENTSuction devices P&P manual 3mInfusion pumps Manufacturer’s manual 3mBP cuff P&P manual 3mAuto-cuffs (Dinemapp machine) P&P manual 3mThermometers/IVACs P&P manual 3mDoppler P&P manual 3mLift scales P&P manual 3mStanding scales P&P manual 3mPressure relieving devices P&P manual 3m

Glucometer use and calibration P&P manual 3mCentrifuge P&P manual 3mNebulizer P&P manual 3mWheelchairs P&P manual 3m

Splints (hand, AFOs) P&P manual 3mIce packs P&P manual 3mK. CARE OF PARTICIPANTSAirway management P&P manual 3mIV therapy P&P manual 3m Venous (peripheral) P&P manual 3m Venipuncture P&P manual 3m

Immunization administration P&P manual 3mEmergency intervention Mock codes 6mSpecimen collection P&P manual 3mLab procedures Lab manual 3mOstomy P&P manual 3mDeath and dying (including postmortem management)

Policy # 6m

CRSP










ABCDEFG


TimeFrame

Met Notmet


L. PATIENT SPECIFIC COMPETENCIES Age specific* Self-study module 3m Latex allergy information* Self-study module 3m Cultural sensitivity/diversity* Self-study module 3m

M. MANAGEMENT OF INFORMATIONUnit nursing documentation Medical records manual 3mPatient confidentiality* Policy #, P&P manual 3mReview of participants’ rights* P&P manual, mandatory in-

service training3m

Review of marketing policy toinclude prohibited marketingpractices*

P&P manual, mandatory in-service training

3m

N. QUALITY IMPROVEMENTQuality control checks 3m Emergency equipment

checksPolicy # 3m

Refrigerator checks P&P manual 3mQI committee Meeting minutes 3mSerious occurrence reportingIncident reportingAdverse drug reaction reporting

Policy # 3m

CRSP



MARKETING AND PLANNING COORDINATOR ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet


Fire safety procedure* P&P manual, disaster manual


P&P manual, disaster manual

Location of safety manuals*

Unit tour

Immunizations (PPD yearly)*

Policy #

Age specific competency Self-study moduleLatex allergy competency Self-study moduleCultural sensitivity/diversity Self-study module

CRSP



MARKETING AND PLANNING COORDINATOR COMPETENCY PROFILE




Name: Date of hire:


Other: Evaluation date:

CRSP




ABCDEFG


TimeFrame

Met Notmet




Dress code Policy # 3mSign in/out Policy # 3mBeeper paging Preceptor orientation 3mTelephone & intercom system Tour, policy # 3mLocation of manuals Guided tour 3mLocation of complaint/concern log Guided tour 3mDepartment & in-service meetings Direct observation 3mReview of participants’ rights* P&P manual, mandatory in-

service training3m



3m



Location of safety manuals* Guided tour 3m Emergency procedures-”911”

systemP&P manual, preceptor ori-entation

3m

C. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3mDisposal of infectious waste Policy # 3mImmunizations PPD yearly* Flu vaccination counseling

Policy # 3m

D. USE OF EQUIPMENTFacsimile operation Policy #Digital camera Policy #

CRSP




ABCDEFG


TimeFrame

Met Notmet


Publishing software Policy # 3mKnowledge of graphics, zipdrive, camcorder, scanner

Policy # 3m

Computer and printer (color andlaser)

Policy # 3m

E. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3mCultural sensitivity/diversity* Self-study module 3mF. MANAGEMENT OF INFORMATIONParticipant confidentiality* Policy #, P&P manual 3m

Knowledge of prohibited PACE marketing guidelines including:* Discrimination of any kind,

except that marketing may be directed to individuals eligible for (PACE program)by reason of their age*

PACE protocol, P&P manu-al, section #

3m

Activities that could mislead or confuse potential partici-pant or misrepresent (PACE program) or the (State)Medicaid agency *


3m

Gifts or payments to induce enrollment


3m

Contracting outreach efforts toindividuals or organizations whose sole responsibility involves direct contact with theelderly to solicit enrollment*


3m

Unsolicited door-to-door marketing*


3m

Knowledge of (PACE program)marketing guidelines

P&P manual 3m

Knowledge of Medicare +Choice guidelines

Preceptor 3m

Knowledge of legislative issueseffecting (PACE program)

Preceptor 6m

Preparation of marketing strate-gy for programs

P&P manual, preceptor 6m

CRSP




ABCDEFG


TimeFrame

Met Notmet


Preparation of a strategic market-ing/advertising plan

Job description 6m

Knowledge of PACE coverage including: Lock-in Participants’ handbook 6m Access to emergency care Participants’ handbook 6m Urgently needed out-of-area

careParticipants’ handbook 6m

Written, understandable description of benefits, rules,procedures, services provided

Participants’ handbook 6m

How and where to obtain services


Restrictions on coverage Participants’ handbook 6m Normal and expedited appeal

proceduresParticipants’ handbook 6m

Moves and extended absences for participants wholeave the coverage area


Any other information necessary to enable potential participants to make informed decisions about enrollment


Submission of all marketingmaterials for approval before dis-tribution

Preceptor 6m

Coordinates media events Job description 6mDevelops internal and externalcommunications (newsletter,brochures, presentation, etc.)

Job description 6m

Coordination of participant satis-faction survey

Job description, preceptor 6m

Facilitates consumer advisorycouncil meetings and activities

Preceptor 6m

Facilitates fund-raising activitiesper PACE protocol

PACE regulations, preceptor 6m

CRSP










ABCDEFG


TimeFrame

Met Notmet


Builds and maintains collabora-tive relationships with area agen-cies which provide senior careservices and serves as a publicrelations representative for(PACE program)

Job description 6m

Acts as liaison between (PACEprogram) and general publicthrough exhibits and speakers’bureau

Preceptor 6m

G. QUALITY IMPROVEMENTParticipation in program QI projects

Management team and/orQI meeting minutes

3m

Concern/complaint logs Site supervisor/designee,preceptor

3m

CRSP



MEDICAL SOCIAL WORKER ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr

Immunizations (PPD yearly)

Policy # 1 yr

Cultural respect Self-study module 1 yrLatex allergy Self-study moduleAge specific Self-study module 1 yrAssessment, PACE docu-mentationCPR/basic life support Policy #, competency testing

lab2 yr

Disaster/fire drills Policy #, participation 1 yrDepartment manuals Tour 1 yrCorporate compliance Video & class 1 yrInfection control P&P manual/ in-service

training1 yr



CRSP



MEDICAL SOCIAL WORKER COMPETENCY PROFILE




Name: Date of hire:




BLS renewal date:

Other:

CRSP




ABCDEFG


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour 3mKnowledge of (PACE program)operations, history

Preceptor 3m

Dress code Policy # 3mActive participation in teamprocess


Knowledge of chain of command P&P manual 3mTelephone & intercom system Tour, policy # 3mMorning meeting attendance &participation

P&P manual, direct observa-tion

3m

Staff meeting attendance & partici-pation


3m

IDT meeting attendance & partici-pation


3m

B. DEPARTMENT SAFETY PROCEDURESEmergencies, drills, “911” system Disaster manual 3mCPR/basic life support Policy #, competency testing

lab3m

Mandatory training Policy #, preceptor 3m

Fall precautions Policy #, restraint P&P 3mHazardous materials management Hazardous materials manual 3mRestraint use/precautions P&P manual 3m

Location of safety manuals Guided tour 3mC. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3mAnnual PPD/X-ray Policy # 3mImmunizations (PPD yearly) Policy # 3mD. ASSESSMENT OF PARTICIPANTS/FAMILIESAbility to conduct a comprehen-sive biopsychosocial assessment


6m

Knowledge of family dynamics P&P manual, direct observa-tion

6m

Knowledge about illnesses andmedications and their psychoso-cial sequelae


6m

CRSP




ABCDEFG


TimeFrame

Met Notmet


E. LEADERSHIPQuality improvement participa-tion


Presentations-inside and outside(PACE program)


F. COMMUNITY & RESOURCE MANAGEMENTAbility to work with a variety ofprofessionals, agencies and sys-tems


Ability to mobilize an array ofcommunity resources and servic-es


Ability to identify gaps in commu-nity services and alternativeresources


Ability to identify, coordinate, uti-lize and develop communityresources


Knowledge of current Medicare& Medicaid rules, regulationsand benefits


G. PROFESSIONAL DEVELOPMENT & APPLICATIONCEU’s Professional practice stan-

dardsAbility to educate professionalstaff and community providersregarding psychosocial factorsand family dynamics impactingresponse to treatment

Professional practice stan-dards, direct observation

Knowledge of population char-acteristics to include cultural,ethnic and religious diversity

Direct observation

Knowledge and application ofdevelopment theory and agespecific issues

Direct observation and self-study packet

Skills in communication Direct observationSkills in advocacy Direct observationSkills in counseling to facilitatelife changes

Direct observation

Skills in conflict managementand mediation

Direct observation

CRSP










ABCDEFG


TimeFrame

Met Notmet


H. PARTICIPANT SPECIFIC COMPETENCIES Age specific* Self-study module 3m Cultural diversity* Self-study module 3m Latex allergy* Self-study module 3m

I. MANAGEMENT OF INFORMATIONCommunication of transfer anddisenrollment information


Medical record documentation Medical records manual 3mDataPACE P&P manual 3mConfidentiality P&P manuals 3mJ. UNIT SPECIFIC COMPETENCIESAlzheimer’s or other dementiacare


K. QUALITY IMPROVEMENTParticipation in QI process Direct observation 3m

CRSP



NURSE PRACTITIONER COMPETENCY PROFILE




Name: Date of hire:



License renewal date: Specialty certification:Expiration date:

BLS renewal date: Hospital Nursing CBO completed: yes/noDate:

Other: Competency testing score:

CRSP




ABCDEFG


TimeFrame

Met Notmet




Dress code Policy # 3mSign in/out Policy # 3mBeeper paging Preceptor orientation 3mTelephone & intercom system Tour, policy # 3mLocation of manuals Guided tour 3mLog books Guided tour 3mDepartment meetings (staff, in-service)

Preceptor, center manager 3m

Unit nurse practitioner protocols Griffith’s 5 Minute ClinicalConsult

3m

Current APN certification (State) board of nursingmandates

3m

Current prescriptive authority (State) board of nursingmandates

3m

Recognition by (State) board oflabor and licensing

(State) board of nursingmandates

3m



3m



Location of safety manuals* Guided tour 3m MSDS notebook-agents used* Hazardous materials manual 3m Hazardous waste precautions* Hazardous materials manual 3m Body mechanics* PT program 3m Emergency procedures-”911”


3m

Use of restraints* Policy #, restraint P&P 3m CPR/basic life support (every

2 years)Policy # 3m

Fall precautions/participant safety* Nursing P&P 3mSecure guard system Preceptor, center manager 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


C. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3mDisposal of infectious waste Policy # 3mImmunizations PPD yearly (mandatory)* Flu vaccination (counseling)

Policy # 3m

Transport of blood/body fluids Policy # 3mLocation and use of personal pro-tective equipment (PPE)*


3m

Toilet liners Product instructions 3mD. RESOURCE MANAGEMENTTour of supply room(s) Guided tour 3mPharmacy orders Medication dispensing 3m Monthly cycle fill medications (State) board of pharmacy

guidelines3m

Over the counter medications

(State) board of pharmacyguidelines

3m

Dispensing of floor stock medications

(State) board of pharmacyguidelines

3m

E. ASSESSMENT OF PARTICIPANTSIntake and enrollment policies P&P manual 3m

Medical evaluation form Medical records manual 3m

Disenrollment policy P&P manual 3m

Management of episodic illness P&P manual 3m

Clinic visits (well care) P&P manual 3m

F. PHYSICAL ASSESSMENT DATAWeight Griffith’s 5 Minute Clinical

Consult3m

Height Griffith’s 5 Minute ClinicalConsult

3m

Vital signs Griffith’s 5 Minute ClinicalConsult

3m

Visual acuity Griffith’s 5 Minute ClinicalConsult

3m

Hearing screen Griffith’s 5 Minute ClinicalConsult

3m

Problem focused exam Griffith’s 5 Minute ClinicalConsult

3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


G. RESPIRATORY MANAGEMENTSupplemental O2 therapies* P&P manual 3mSpO2 monitoring (pulse oxime-try)

P&P manual 3m

Operation of oxygenequipment/tank/regulator

P&P manual 3m

Suctioning (oral, tracheal, naso-tracheal, endotracheal)*

P&P manual, manufacturer’smanual

3m

H. NUTRITIONAL MANAGEMENTEnteral tubes (gastrostomytubes, gastrostomy buttons)

P&P manual 3m

Continuous/bolus feedings P&P manual 3mOral feedings P&P manual 3mNasogastric tubes P&P manual 3mI. ELIMINATION MANAGEMENTIntermittent/indwelling catheter(male and female)

P&P manual 3m

Small volume enemas P&P manual 3mLarge volume enemas P&P manual 3mIncontinent care Policy #, skin care resource

book3m

J. USE OF EQUIPMENT Equipment manual, situational analysis, unit learning resourcesSuction devices P&P manual 3mInfusion pumps Manufacturer’s manual 3mOtoscope/ophthalmoscope P&P manual 3mAuto-cuffs (dinemapp machine) P&P manual 3mThermometers/IVACs P&P manual 3mLift scales (hoyer/maxi lift) P&P manual 3mStanding scales P&P manual 3mNebulizer Policy # 3mFeeding pump Manufacturer’s manual 3mSplints (hand, AFOs) P&P manual 3mK. CARE OF PARTICIPANTSOperation of EKG machine Manufacturer’s manual 3m

Airway management P&P manual 3mIV therapy Policy # 3m Venous (peripheral/central) Policy # 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


Venipuncture Policy # 3m IVADs Policy # 3m PICCs Policy # 6m

Emergency intervention Mock codes, situation analy-sis

6m

Specimen collection P&P manual 3m

Lab procedures Lab manual 3mOstomy/fistula care P&P manual 3mDeath and dying (including postmortem management)

Policy # 6m

Wheelchair Manufacturer’s manual 3mL. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3mLatex allergy information* Self-study module 3mCultural sensitivity/diversity* Self-study module 3mM. MANAGEMENT OF INFORMATIONUnit nursing documentation Medical records manual 3mParticipant confidentiality* Policy #, P&P manual 3mReview of participants’ rights* P&P manual, mandatory in-

service training3m

Review of marketing policy toinclude prohibited marketingpractices*


3m

Informed consent Policy # 3mDeath notification Policy # 3mFamily Policy # 3mPhysician Policy # 3mCoroner Policy # 3mSCOPA Policy # 3mMedical documentation Medical records manual 3mMedical orders Medical records manual 3mDocumentation of pharmaceuti-cal management

Medical records manual 3m

Authorization of services Medical records manual 3m

CRSP










ABCDEFG


TimeFrame

Met Notmet


N. UNIT SPECIFIC Immunization administration P&P manual 3mSeizure precautions/manage-ment

P&P manual 3m

Ear irrigation P&P manual 3mVision screening Griffith’s Five Minute Manual 3mO. QUALITY IMPROVEMENTQuality control checks P&P manuals 3m Emergency equipment

checksP&P manuals 3m

Refrigerator checks P&P manuals 3m Chart review P&P manuals 3m Glucometer and other CLIA-

wavered equipment testingDirect observation 3m

QI committee Meeting minutes 3mSerious occurrence reportingIncident reportingAdverse drug reaction reporting

Policy # 3m

CRSP



NURSING TECHNICIAN ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr


Policy # 1 yr

Cultural respect Self-study module 1 yrLatex allergy Self-study module 1 yrAge specific Self-study module 1 yrCPR/basic life support Policy #, competency testing

lab2 yr

Disaster/fire drills Policy #, participation 1 yrCorporate compliance Video & class 1 yrInfection control P&P manual/ in-service

training1 yr



CRSP



NURSING TECHNICIAN COMPETENCY PROFILE




Name: Date of hire:




BLS renewal date:

Other:

CRSP




ABCDEFG


TimeFrame

Met Notmet




Dress code Policy # 3mClock in/out, sign in/out Policy # 3mBeeper paging Preceptor orientation 3mTelephone & intercom system Tour, policy # 3mLocation of manuals Guided tour 3mLog books Grievance log Maintenance log

Guided tour, direct observa-tion

3m

Department meetings (staff, in-service)




3m



Location of safety manuals* Guided tour 3m MSDS notebook-agents used* Hazardous materials manual 3m Hazardous waste precautions* Hazardous materials manual 3m Body mechanics* PT program 3m Emergency procedures-”911”


3m

Use of restraints* Policy #, restraint P&P 3m CPR/basic life support (every

2 years)Policy # 6m

Fall precautions/participant safety* Nursing P&P 3mSecure guard system Preceptor, center manager 3mC. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3mDisposal of infectious waste Policy # 3mTransport of blood/body fluids Policy # and unit learning

resources3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


Toilet liners Manufacturer’s instructions,preceptor

3m

Immunizations PPD yearly (mandatory)* Flu vaccination (counseling)

Policy # 3m



3m

D. RESOURCE MANAGEMENTTour of supply room(s)/storageareas

Guided tour 3m

E. RESPIRATORY MANAGEMENTOperation of oxygen equipment,tank, regulator*

Unit learning resources,P&P manual

3m

Suctioning (oral) P&P manual 3m

F. NUTRITIONAL MANAGEMENTEnteral tubes (gastrostomytubes)

P&P manual 3m

Continuous, bolus feedings P&P manual 3mOral feedings P&P manual 3mG. ELIMINATION MANAGEMENTIntermittent/indwelling catheter(male and female)

Policy # 3m

Incontinent care Policy # and skin careresource book

3m

H. USE OF EQUIPMENTReview of all emergency equip-ment *

Policy # and skin careresource book

3m

Suction devices* Policy #, skin care resourcebook, P&P manual

3m

Manual BP cuff Policy #, skin care resourcebook, P&P manual

3m

Auto-cuffs (dinemapp machine) Policy #, skin care resourcebook, P&P manual

3m

Thermometers/IVAC’s Policy #, skin care resourcebook, P&P manual

3m

Lift scales Policy #, skin care resourcebook, P&P manual

3m

Standing scales Policy #, skin care resourcebook, P&P manual

3m

Feeding pump (kangaroo) Policy #, skin care resourcebook, P&P manual

3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


Wheelchairs Manufacturer’s instructions,preceptor

3m

Splints (hand, AFOs) Manufacturer’s instructions,preceptor

3m

Bath chair/shower chair Manufacturer’s instructions,preceptor

3m

Stethoscope Manufacturer’s instructions,preceptor

3m

Hoyer/maxi lift Manufacturer’s instructions,preceptor

3m

Pressure relieving devices Manufacturer’s instructions,preceptor

3m

I. CARE OF PARTICIPANTSAirway management P&P manual 3mEmergency intervention Mock codes, situation analy-

sis6m

Cardiopulmonary arrest P&P manual 3mOstomy/fistula care P&P manual 3mRange of motion exercises Physical/occupational thera-

py in-service (patient specif-ic)

3m

Patient hygiene needs/foot care Unit learning resources 3mVital signs Unit learning resources,

P&P manual3m

Simple wound care Unit learning resources 3mAssist recreation therapy staffwith age appropriate activities


J. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3m

Latex allergy* Self-study module 3mCultural respect* Self-study module 3mK. MANAGEMENT OF INFORMATIONNursing technician documenta-tion


Reporting of significant observa-tions to supervising RN

Preceptor 3m

Participant confidentiality* Policy #, P&P manual 3mReview of marketing policy toinclude prohibited marketingpractices*


3m

CRSP










ABCDEFG


TimeFrame

Met Notmet


L. UNIT SPECIFICReview of participants’ rights* P&P manual, mandatory in-

service3m

Management of wandering par-ticipants


M. QUALITY IMPROVEMENTGrievance log P&P manual 3mQI committee QI meeting minutes 3mStandard precautions monitor P&P manual 3m

CRSP



OCCUPATIONAL THERAPY ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr


Policy # 1 yr


lab2 yr

Disaster/fire drills Policy #, participation 1 yrEmergency equipment Direct observation 1 yr

Range of motion Direct observation 1 yr

CRSP



OCCUPATIONAL THERAPY COMPETENCY PROFILE




Name: Date of hire:




BLS renewal date:

Other:

CRSP




ABCDEFG


TimeFrame

Met Notmet




Dress code Policy # 3mClock in/out Policy # 3mBeeper paging Preceptor orientation 3mTelephone system Tour, policy # 3mLocation of manuals Guided tour 3mStandards of practice 3mDepartment meetings (staff, in-service)


B. DEPARTMENT SAFETY PROCEDURESFire safety procedure* Disaster manual, P&P 3mDisaster plan, evacuation plan* Disaster manual, P&P 3m

Location of safety manuals* Guided tour 3mMSDS notebook-agents used* Hazardous materials manual 3mHazardous waste precautions* Hazardous materials manual 3mBody mechanics* PT program 3mBalance precautions Unit learning resources 3mUse of restraints* Policy #, restraint P&P 3mCPR/basic life support (every 2years)

Policy # 6m

C. INFECTION CONTROLHandwashing Policy # 3mUniversal precautions* Policy # 3mDisposal of infectious waste Policy # 3mTB control/fit check Policy # 3mImmunizations (PPD yearly) Policy # 3mD. RESOURCE MANAGEMENTTour of supply room(s) Guided tour 3mDurable medical equipment P&P manual, preceptor 3mScheduling of therapy appoint-ments

Preceptor 3m

Ordering of supplies Routine supplies Purchase order requisitions

Unit learning resources, pre-ceptor

3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


E. ASSESSMENT OF PATIENTSImmunizations PPD yearly (mandatory)* Flu vaccination (counseling)

Policy # 3m



3m

D. RESOURCE MANAGEMENTIntake and enrollment policies Unit learning resources 3mDisenrollment policy Unit learning resources 3mE. PHYSICAL ASSESSMENT DATARange of motion measurement Unit learning resources 3mManual muscle testing Unit learning resources 3mSensory/perceptual testing Unit learning resources 3mActivities of daily living assess-ment


Neuromotor functioning Unit learning resources 3mAppropriateness of currentassistive/adaptive/orthoticdevices


F. USE/MAINTENANCE OF EQUIPMENTWheelchair Manual Power

Unit learning resources,manufacturer manual

3m

Hoyer lift Unit learning resources,manufacturer manual

3m

Walker Unit learning resources,manufacturer manual

3m

Crutches Loft strand Standard

Unit learning resources,manufacturer manual

3m

Ankle foot orthosis (AFOs) Unit learning resources 3mKnee ankle foot orthosis(KAFOs)


Knee immobilizers Unit learning resources 3mSplints Unit learning resources 3mG. CARE OF PATIENTSNeurodevelopment treatment Unit learning resources 3mSensory integration treatment Unit learning resources 3mMuscle stretching Unit learning resources 3mRange of motion exercises Unit learning resources 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


Positioning Unit learning resources 3mSplints fabrication Unit learning resources 3mBath chair/shower chair Manufacturer’s instructions,

preceptor3m

Emergency intervention Mock codes, situation analy-sis

3m

H. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3mLatex allergy* Self-study module 3mCultural respect* Self-study module 3mI. MANAGEMENT OF INFORMATIONUnit therapy documentation Medical records manual 3mDocuments teaching Medical records manual 3mParticipant confidentiality* Policy #, P&P manual 3mCompletion of physician orders Medical records manual 3mParticipation in IEPs Unit learning resources 3mJ. UNIT SPECIFICTherapy attendance policy P&P manual 3mWheelchair maintenance policy,contract

P&P manual 3m

Seizure precautions, manage-ment

Module 3m

Hip, shoulder dislocation pre-cautions


3m

K. QUALITY IMPROVEMENTTherapy equipment checks Policy # 3mChart review Policy # 3mUniversal precautions monitor Policy # 3mQI committee Meeting minutes 3m

CRSP





I understand that it is my responsibility to notify my immediate supervisor if at any time I am unable to perform the basic competencies required to practice in my assigned clinical area.




CRSP



PERSONAL CARE ATTENDANT COMPETENCY PROFILE




Name: Date of hire:

Certification expiration date: Employee number:

Other:

CRSP





TimeFrame

Met Notmet

SkillsImprovement

A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour 3mDress code Policy # 3mClock in/out, sign in/out Policy # 3mTelephone system Tour, policy # 3mLocation of manuals Guided tour 3mComplaint log book Guided tour, direct observation 3mDepartment meetings (staff, in-service)


B. DEPARTMENT SAFETY PROCEDURESFire safety procedure* Disaster manual, P&P 3mDisaster plan, evacuation plan* Disaster manual, P&P 3mLocation of safety manuals* Guided tour 3mMSDS notebook-agents used* Hazardous materials manual 3mHazardous waste precautions* Hazardous materials manual 3mBody mechanics* PT program 3mEmergency equipment*, “911”system

Policy # 3m

Use of restraints* Policy #, restraint P&P 3mCPR/basic life support Policy # 6mFall precautions, participant safety Nursing P&P 3mC. INFECTION CONTROLHandwashing Policy # 3mUniversal precautions* Policy # 3mDisposal of infectious waste Policy # 3mD. RESOURCE MANAGEMENTTour of supply room(s) Guided tour 3mE. RESPIRATORY MANAGEMENTOperation of oxygenequipment/tank/regulator


Suctioning (oral) Direct observation 3mF. NUTRITIONAL MANAGEMENTEnteral tubes (gastrostomy tubes) Direct observation 3mContinuous/bolus feedings Direct observation 3mOral feedings Direct observation 3mG. ELIMINATION MANAGEMENTIntermittent/indwelling catheter(male and female)

Policy # 3m

Incontinent care Policy #, direct observation 3m

CRSP





TimeFrame

Met Notmet


H. USE OF EQUIPMENTSuction devices Direct observation 3mManual BP cuff Direct observation 3m

Stethoscope Direct observation 3m

Thermometers/IVAC’s Direct observation 3mLift scales Direct observation 3m

Standing scales Direct observation 3m

Feeding pump Direct observation 3m

I. CARE OF PARTICIPANTSAirway management Direct observation 3mEmergency intervention Mock codes, situational

analysis6m

Cardiopulmonary arrest Policy # 6mOstomy/fistula care Policy # 3mPatient hygiene needs/foot care Direct observation 3mVital signs Policy # 3mSimple wound care Policy # 3mAssist recreation therapy staffwith appropriate activities


J. PARTICIPANT SPECIFIC COMPETENCIESAge specific 3mLatex allergy 3mCultural respect 3mK. MANAGEMENT OF INFORMATIONNursing technician documentation Direct observation 3mReporting of significant observa-tions to supervising RN


Participant confidentiality P&P manual 3mL. UNIT SPECIFICManagement of wandering partic-ipants


M. QUALITY IMPROVEMENTOccurrence report Preceptor training 3mConcern/complaint log P&P manual 3mStandard precautions monitor P&P manual 3mQI committee QI meeting minutes 3m

CRSP









CRSP



PHARMACIST ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr


Policy # 1 yr


lab2 yr


Department manuals Direct observation 1 yr

Corporate compliance Video & class 1 yr


Infection control Video & class 1 yr

Mandatory training Video & class 1 yr

CRSP



PHARMACIST COMPETENCY PROFILE




Name: Date of hire:




BLS renewal date:

Other:

CRSP



Task/Behavior References:A. Review policy/procedureB. Direct observationC. Video reviewD. Competency testing labE. Written testF. Self-study packet

ABCDEF


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Direct observation 3mDress code P&P 3mSign in/out P&P, direct observation 3mBeeper paging Direct observation 3mTelephone & intercom system Direct observation 3mMeeting schedule Direct observation 3mB. DEPARTMENT SAFETY PROCEDURESFire safety procedure* P&P, video review 3mDisaster plan, evacuation plan* P&P 3mLocation of safety manuals* Direct observation 3mHazardous waste precautions* P&P 3mBody mechanics* Direct observation 3mCPR/basic life support Direct observation, compe-

tency 6m

Sharps P&P 3mC. INFECTION CONTROLHandwashing Infection control manual 3mStandard precautions* Infection control manual 3mTB control/fit check Policy # 3mImmunizations (PPD yearly) Policy # and unit learning

resources3m

D. RESOURCE MANAGEMENTDrug cost control P&P, direct observation 3mE. USE OF EQUIPMENTGlucometer P&P, direct observation 3mNebulizer P&P, direct observation 3mLocation of all emergency equip-ment

P&P, direct observation 3m

F. MANAGEMENT OF INFORMATIONComputer access P&P 3m E-mail P&P 3m Intranet P&P 3m Internet P&P 3m Other P&P 3m

CRSP




ABCDEF


TimeFrame

Met Notmet


ConfidentialityCharting P&P, direct observation 3m Forms P&P, direct observation 3m Re-evals P&P, direct observation 3m Intakes P&P, direct observation 3m Orders P&P, direct observation 3m Lab review P&P, direct observation 3m Flowsheets P&P, direct observation 3m MARs P&P, direct observation 3m

G. QUALITY IMPROVEMENTQI committees P&P, direct observation 3mRecord review P&P, direct observation 3mPrimary care P&P, direct observation 3mOccurrence reporting P&P, direct observation 3mIncident P&P, direct observation 3mAdverse drug reactions P&P, direct observation 3mEquipment/serious incidents P&P, direct observation 3mH. PARTICIPANT CAREDoctorate in pharmacy Direct observation, written

test3m

License in pharmacy Direct observation, writtentest

3m

Management of medications forpatients with chronic conditionsin an outpatient setting

Direct observation, writtentest

3m

Input into functional assessmentand maintenance


Assistance with pain management


Management of polypharmacy Direct observation 3m

I. COMMUNICATION AND TEAM SKILLSOral & written communicationwith peers, other staff , partici-pants, families and public


Working cooperatively in smallgroups


Conflict resolution skills P&P, direct observation 3mTeam dynamics P&P, direct observation 3m

CRSP









CRSP



PHYSICAL THERAPY ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr


lab2 yr


Corporate compliance Video & class 1 yr


Infection control Video & class 1 yr

Mandatory training Video & class 1 yr

Splinting Direct observation 1 yr

CRSP



PHYSICAL THERAPY COMPETENCY PROFILE




Name: Date of hire:



License renewal date:

BLS renewal date:

Other:

CRSP




ABCDEF


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour 3mDress code Policy # 3mSign in/out P&P manual, direct observa-

tion3m

Beeper paging Policy # 3mTelephone & intercom system Policy # 3mLocation of manuals Guided tour 3mDepartment meetings (staff, in-service)

3m

Standards of practice 3mB. DEPARTMENT SAFETY PROCEDURESFire safety procedure* Disaster manual 3mDisaster plan, evacuation plan* Disaster manual 3mLocation of safety manuals* Guided tour 3mHazardous waste precautions* MSDS manual 3mBody mechanics* General CBO 3mCPR/basic life support Policy # 6mUse of restraints* Policy #, P&P manual 3mBalance Precautions Unit learning resources 3mC. INFECTION CONTROLHandwashing Infection control manual 3mStandard precautions* Infection control manual 3mTB control/fit check Policy # 3mImmunizations (PPD yearly) Policy # 3m

D. RESOURCE MANAGEMENTTour of supply room(s) Guided tour 3mDurable medical equipment P&P manual, preceptor 3mScheduling of therapy appoint-ments

Preceptor 3m

Ordering of supplies Routine supplies Purchase order requisitions


3m

E. ASSESSMENT OF PARTICIPANTSIntake and enrollment policies P&P manual 3mInitial PT evaluation Unit learning resources 3mCognition/dementia assessment Unit learning resources 3m

CRSP




ABCDEF


TimeFrame

Met Notmet


Fall risk assessment Unit learning resources 3mBalance/posture assessment Unit learning resources 3mHome assessment Unit learning resources 3m

Disenrollment policy P&P manual 3mF. PHYSICAL ASSESSMENT DATANormal/abnormal changes in theelderly


Range of motion measurement Unit learning resources 3m Active Active/assisted Passive


Manual muscle testing Unit learning resources 3mSensory/perceptual testing Unit learning resources 3mNeuromotor functioning Unit learning resources 3mAppropriateness of current assis-tive/adaptive/orthotic devices

Unit learning resources,preceptor

3m

G. THERAPEUTIC SKILLSRange of motion (A/AA/PROM) Unit learning resources 3mContracture management Unit learning resources 3mModalities Hot packs


Cold packs Unit learning resources 3m Paraffin Unit learning resources 3m Analgesic cream Unit learning resources 3m Electrotherapy Unit learning resources,

manufacturer manual3m

Wheelchair positioning and adap-tive devices


Wheelchair mobility training Unit learning resources 3mEdema control Unit learning resources 3mGross motor coordination exercises Unit learning resources 3m

Gait training Unit learning resources 3m

H. USE/MAINTENANCE OF EQUIPMENTWheelchairs Manual Power

Unit learning resources,manufacturer manuals

3m

Reclining wheelchair Unit learning resources,manufacturer manual

3m

CRSP




ABCDEF


TimeFrame

Met Notmet


Walker Unit learning resources 3m

Rolling walker Unit learning resources 3mHemi-walker Unit learning resources 3mPlatform walker Unit learning resources 3mWedge Unit learning resources,

manufacturer manual3m

Hoyer lift Unit learning resources,manufacturer manual

3m

Crutches Loft strand Standard


Straight cane Unit learning resources 3mQuad cane Unit learning resources 3mAbove knee prosthesis Unit learning resources 3mBelow knee prosthesis Unit learning resources 3mShort leg brace (double upright) Unit learning resources 3mAnkle foot orthosis (AFOs) Unit learning resources 3mKnee ankle foot orthosis (KAFOs) Unit learning resources 6mKnee immobilizers Unit learning resources 3mSplints Unit learning resources 3mI. CARE OF PARTICIPANTSNeurodevelopmental treatment Unit learning resources 3mAmputee management Unit learning resources 3mMuscle stretching Unit learning resources 3mRange of motion exercises Unit learning resources 3mGait training Unit learning resources 3mOrthopedic precautions Unit learning resources 3mPositioning Unit learning resources 3m

Emergency intervention Mock codes, situationalanalysis

3m

J. PATIENT SPECIFIC COMPETENCIESAge specific* Self-study module 3mLatex allergy* Self-study module 3mCultural respect* Self-study module 3m

CRSP










ABCDEF


TimeFrame

Met Notmet


K. MANAGEMENT OF INFORMATIONUnit therapy documentation Medical records manual 3mTeaching documents Medical records manual 3mPatient confidentiality Policy #, P&P manual 3mCompletion of physician orders Medical records manual 3m

Participation in MDC Unit learning resources, preceptor

3m

L. UNIT SPECIFICTherapy attendance policy P&P manual 3mWheelchair maintenancepolicy/contract

P&P manual 3m

Seizure precautions/management Module 3mM. QUALITY IMPROVEMENTTherapy equipment checks Preceptor 3mChart review Preceptor 3mStandard precautions monitor Preceptor 3m

QI committee Meeting minutes 3m

CRSP



PHYSICIAN ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr

Cultural respect Self-study module 1 yrLatex allergy Self-study module 2 yrsAge specific Self-study module 1 yrDisaster/fire drills Direct observation 1 yrEmergency equipment P&P, direct observation 1 yr

Corporate compliance Video 1 yr

Emergency equipment P&P, direct observation 1 yr

Infection control P&P, direct observation 1 yr

Mandatory training Video & post test 1 yr


Policy # 1 yr

BLS renewal P&P, direct observation, com-petency testing

1 yr

CRSP



PHYSICIAN COMPETENCY PROFILE




Name: Date of hire:



License renewal date: Specialty certification:Expiration date:

BLS renewal date:

Other:

CRSP




ABCDEF


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Direct observation 1mDress code P&P 1mTime P&P, direct observation* 1mBeeper paging Direct observation 1mTelephone & intercom system Direct observation 1mMeeting schedule Direct observation 1mB. DEPARTMENT SAFETY PROCEDURESFire safety procedure* P&P, video 3mDisaster plan, evacuation plan* P&P 3mLocation of safety manuals* Direct observation 3mHazardous materials P&P 3mBody mechanics Direct observation 3mCPR/basic life support Direct observation, compe-

tency testing3m

Sharps P&P 3mC. INFECTION CONTROLHandwashing Infection control manual 3mStandard precautions* Infection control manual 3mTB control/fit check Policy # 3mImmunizations (PPD yearly) Policy # 3mManagement of communicablediseases

P&P

D. RESOURCE MANAGEMENTPharmacy Direct observation 3mE. USE OF EQUIPMENTWheelchair P&P, direct observation 3mEKG machine P&P, direct observation 3mGlucometer P&P, direct observation 3mCentrifuge P&P, direct observation 3m Suction machine P&P, direct observation 3m Oxygen P&P, direct observation 3m Ophthalmoscope P&P, direct observation 3m Otoscope P&P, direct observation 3m Nebulizer P&P, direct observation 3m IVAC P&P, direct observation 3m Location of all emergency equip-ment


CRSP




ABCDEF


TimeFrame

Met Notmet


F. MANAGEMENT OF INFORMATIONComputer Access E-mail P&P, direct observation 3m Intranet P&P, direct observation 3m Internet P&P, direct observation 3m Other P&P, direct observation 3m

ConfidentialityCharting P&P, direct observation 3m Forms P&P, direct observation 3m Re-evals P&P, direct observation 3m Intakes P&P, direct observation 3m Orders P&P, direct observation 3m Lab review P&P, direct observation 3m Flowsheets P&P, direct observation 3m DataPACE or successor P&P, direct observation 3m

G. QUALITY IMPROVEMENTQI committees P&P, direct observation 3mRecord review P&P, direct observation 3mPrimary care P&P, direct observation 3mOccurrence reporting P&P, direct observation 3m Incident P&P, direct observation 3m Adverse drug reactions P&P, direct observation 3m Equipment/serious incidents P&P, direct observation 3m

H. PARTICIPANT CAREKnowledge of diseases & manage-ment


on-going

Completion of approved residencyin IM or FP


on-going

Board certification or Board eligibili-ty and pursuing certification


on-going

Patient management in acute caresetting (inpatient and ER)


on-going

Medical staff privileges at hospital Direct observation, writtentest

on-going

Patient management in LTC setting Direct observation, writtentest

on-going

CRSP




ABCDEF


TimeFrame

Met Notmet


I. PARTICIPANT SPECIFIC COMPETENCIESKnowledge and skills related tomanagement of specific issues ingeriatric care


on-going

CAQ in geriatrics; successful com-pletion of fellowship, demonstratedknowledge of:


on-going

Management of chronic conditions in outpatient setting


on-going

Functional assessment and maintenance


on-going

Geriatric preventive care issues-primary, secondary andtertiary


on-going

Diagnosis and management ofgeriatric syndromes


on-going

Ability to effectively address issuesaround death and dying


on-going

Establishing advance directives(formal and informal)


on-going

Comfort care, palliative care, pain management


on-going

Judicious consultant use Direct observation, writtentest

on-going

I. CARE OF PARTICIPANTSOral and written communicationwith peers, other staff, participants,families and public


Working cooperatively in smallgroups


Conflict resolution skills P&P, direct observation 6mTeam dynamics P&P, direct observation 6m

CRSP









CRSP



RECEPTIONIST COMPETENCY PROFILE




Name: Date of hire:


BLS renewal date (every 2 years): Evaluation date:

Other:

CRSP




ABCDEF


TimeFrame

Met Notmet




Dress code Policy # 3mClock in/out, sign in/out Policy # 3mBeeper paging Direct observation 3mTelephone & intercom system Policy # 3mTelephone etiquette Direct observation 3mDepartment & in-service meetings Direct observation 3mRecording of telephone messages Direct observation 3mLocation of manuals Guided tour 3mLog books Grievance log Maintenance log Emergency equipment log

Guided tour 3m



3m



Location of safety manuals* Guided tour 3m MSDS notebook-agents used* Hazardous materials manual 3m Hazardous waste precautions* Hazardous materials manual 3m Body mechanics* PT program 3m ”911” system Preceptor, guided tour 3m Use of restraints* Policy #, restraint P&P 3m CPR/basic life support (every

2 years)Policy # 6m

Fall precautions/participant safety* Nursing P&P 3mC. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3mDisposal of infectious waste Policy # 3mImmunizations PPD yearly (mandatory)* Flu vaccination (counseling)

Policy # and unit learningresources

3m

Location and use of personal pro-tective equipment (PPE)*


3m

CRSP





I understand that it is my responsibility to notify my immediate supervisor if at any time I am unable to performthe basic competencies required to perform in my assigned area.





ABCDEF


TimeFrame

Met Notmet


D. USE OF EQUIPMENTTwo way radio Instruction guide, preceptor

supervision3m

Multi-line telephone Instruction guide, preceptorsupervision

3m

Computer and printer Instruction guide, preceptorsupervision

3m

E. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3mCultural sensitivity/diversity* Self-study module 3mLatex allergy information* Self-study module 3mF. MANAGEMENT OF INFORMATIONDaily participant log Preceptor instructions 3mDaily employee attendance roster Preceptor instructions 3mUtilization sheets Preceptor instructions 3mMedication log Preceptor instructions 3mParticipant confidentiality* Policy #, safety training

manual & video, mandatoryin-service

3m

Review of participants’ rights* P&P manual, mandatory in-service training

3m

Review of marketing policy toinclude prohibited marketing prac-tices*


3m

G. (PACE CENTER) SPECIFIC“No available family” procedure Preceptor/center manager 3mOutside appointments Preceptor/center manager 3mH. QUALITY IMPROVEMENTParticipation in QI projects QI meeting minutes 6mGrievance log Preceptor/center manager 3m

CRSP



RECREATION THERAPY ASSISTANT COMPETENCY PROFILE




Name: Date of hire:


License number (if applicable): Evaluation date:

License renewal date: Specialty certification (if applicable): Expiration date:

BLS renewal date (every 2 years):

Other:

CRSP




ABCDEF


TimeFrame

Met Notmet




Dress code Policy # 3mClock in/out, sign in/out Policy # 3mBeeper paging Direct observation 3mTelephone & intercom system Policy # 3mLocation of manuals Guided tour 3mLog books Grievance log Maintenance log

Guided tour 3m



Standards of practice National Council forTherapeutic RecreationCertification (NCTRC)

3m



3m



Location of safety manuals* Guided tour 3m MSDS notebook-agents used* Hazardous materials manual 3m Hazardous waste precautions* Hazardous materials manual 3m Body mechanics* PT program 3m ”911” system Preceptor, guided tour 3m Use of restraints* Policy #, restraint P&P 3m CPR, basic life support (every

2 years)Policy # 6m

Fall precautions, participant safety* Nursing P&P 3mC. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3mDisposal of infectious waste Policy # 3mImmunizations PPD yearly (mandatory)* Flu vaccination (counseling)


3m

CRSP




ABCDEF


TimeFrame

Met Notmet


D. RESOURCE MANAGEMENTTour of supply room(s), cabinets Guided tour, scavenger

hunt3m

Ordering supplies, purchasing P&P manual 3mAssists with specific therapeuticprograms to include recreational &social activities

P&P manual 3m

E. ASSESSMENT OF PARTICIPANTSAdmission criteria P&P manual 3mAdmission process-assessment P&P manual 3mTransfer, intraprogram: receiving P&P manual 3mTransfer, intraprogram: sending P&P manual 3mReassessment P&P manual 3mF. USE OF EQUIPMENTWheelchair Orientation equipment

checklist3m

Van lifts Orientation equipmentchecklist

6m

Seat belts Orientation equipmentchecklist

6m

Tie downs Orientation equipmentchecklist

6m


Safety training manual &video, unit tour

3m

G. CARE OF PARTICIPANTSNeurodevelopment therapy P&P manual 6mSensory integration therapy P&P manual 6mRange of motion activities P&P manual 6mEducational activities P&P manual 6mCommunity outings P&P manual 6mCultural events P&P manual 6mReality orientation P&P manual 6mCounseling, leisure, education P&P manual 6mSocial games & events P&P manual 6mE. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3mCultural sensitivity, diversity* Self-study module 3mLatex allergy information* Self-study module 3mF. MANAGEMENT OF INFORMATIONParticipant confidentiality* P&P manual 3mParticipants’ bill of rights* P&P manual 3m

CRSP










ABCDEF


TimeFrame

Met Notmet




3m

Volunteer documentation P&P manual 3mMedical records Medical records manual 3mIntraprogram transfer report (verbal) P&P manual 3mAssessment, reassessment docu-mentation

P&P manual 3m

Service utilization PACE manual, P&P manual 3mSupply requisition P&P manual 3mCatering requests P&P manual 3mJ. CENTER SPECIFICImplements specific therapeuticprograms to include recreational &social activities

P&P manual 3m

Alzheimer’s dementia P&P manual 3mH. QUALITY IMPROVEMENTParticipation in QI projects QI meeting minutes 3mGrievance log Center manager, preceptor 3mOccurrence reports P&P manual, Policy # 3m

CRSP



RECREATION THERAPY COMPETENCY PROFILE




Name: Date of hire:


License number (if applicable): Evaluation date:


BLS renewal date (every 2 years):

Other:

CRSP




ABCDEF


TimeFrame

Met Notmet





Guided tour 3m



Standards of practice National Council forTherapeutic RecreationCertification (NCTRC)

3m



3m




2 years)Policy # 6m

Fall precautions, participant safety*

Nursing P&P 3m



3m

CRSP




ABCDEF


TimeFrame

Met Notmet


D. RESOURCE MANAGEMENTTour of supply room(s), cabinets Guided tour, scavenger

hunt3m

Ordering supplies, purchasing P&P manual 3mDevelops specific therapeutic pro-grams to include recreational &social activities

P&P manual 3m

E. ASSESSMENT OF PARTICIPANTSAdmission criteria P&P manual 3mAdmission process-assessment P&P manual 3mTransfer, intraprogram: receiving P&P manual 3mTransfer, intraprogram: sending P&P manual 3mReassessment P&P manual 3mF. PHYSICAL ASSESSMENT DATABehavioral Admission criteria &

medical records manual3m

Musculoskeletal Admission criteria & medical records manual

3m

Neurological Admission criteria & medical records manual

3m

Cognitive ability Admission criteria & medical records manual

3m

Identifies both normal and abnormal findings

Admission criteria & medical records manual

3m

Motor development Admission criteria & medical records manual

3m

Tactile senses Admission criteria & medical records manual

3m

Exercise physiology Admission criteria & medical records manual

3m

G. USE OF EQUIPMENTWheelchair Orientation equipment

checklist3m

Van lifts Operating manual, precep-tor

6m

Seat belts Operating manual, precep-tor

6m

Tie downs Operating manual, precep-tor

6m


Safety training manual &video, unit tour

3m

CRSP




ABCDEF


TimeFrame

Met Notmet


H. CARE OF PARTICIPANTSNeurodevelopmental therapy P&P manual 3mSensory integration therapy P&P manual 3mRange of motion activities P&P manual 3mEducational activities P&P manual 3mCommunity outings P&P manual 3mCultural events P&P manual 3mReality orientation P&P manual 3mCounseling, leisure, education P&P manual 3mSocial games & events P&P manual 3mI. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3mCultural sensitivity, diversity* Self-study module 3mLatex allergy information* Self-study module 3mJ. MANAGEMENT OF INFORMATIONParticipant confidentiality* P&P manual 3mParticipants' bill of rights* P&P manual 3mReview of marketing policy toinclude prohibited marketing prac-tices*


3m

Volunteer documentation P&P manual 3mMedical records P&P manual 3mIntraprogram transfer report (verbal)

P&P manual 3m

Assessment, reassessment docu-mentation

P&P manual 3m

Service utilization P&P manual 3mSupply requisition P&P manual 3mCatering requests P&P manual 3mK. CENTER SPECIFICDevelops specific therapeutic pro-grams to include recreational &social activities

P&P manual 3m

Alzheimer’s dementia 3mL. QUALITY IMPROVEMENTParticipation in QI projects P&P manual 3mGrievance log Center manager, preceptor,

P&P manual3m

Occurrence reports Policy # 3m

CRSP









CRSP



REGISTERED DIETITIAN COMPETENCY PROFILE




Name: Date of hire:


Registration number: Evaluation date:

BLS renewal date (every 2 years): Specialty certification (if applicable): Expiration date:

Other:

CRSP




ABCDEF


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour 3mDress code Policy # 3mSign in/out Policy # 3mBeeper paging Direct observation 3mTelephone & intercom system Policy # 3mLocation of manuals Guided tour 3mLocation of complaint/concern log Guided tour 3mDepartment & in-service meetings Clinical ladder manual 3mStandards of practice P&P manual, Gerontological

Nutritionists Standards ofProfessional Practice per theADA (July, 1999)

3m

B. DEPARTMENT SAFETY PROCEDURESFire safety procedure* Disaster manual, P&P 3mDisaster plan, evacuation plan* Disaster manual, P&P 3mLocation of safety manuals* Guided tour 3mMSDS notebook-agents used* Hazardous materials manual 3mHazardous waste precautions* Hazardous materials manual 3mBody mechanics* PT program 3mEmergency procedures-”911” system

Preceptor, guided tour 3m

Use of restraints* Policy #, restraint P&P 3mCPR/basic life support (every 2years)

Policy # 6m

Fall precautions/participant safety* Nursing P&P 3mC. INFECTION CONTROLHandwashing Policy # 3mStandard precautions* Policy # 3mDisposal of infectious waste Policy # 3mImmunizations PPD yearly (mandatory)* Flu vaccination (counseling)


3m

TB control/fit testing Policy # 3mD. RESOURCE MANAGEMENTTour of centers and storage areas Guided tour 3mExplains the cost differencebetween various types of nutritionsupplements and tube feedingsavailable and explains how thisinformation can be utilized tomake cost effective nutrition rec-ommendations

Preceptor 3m

CRSP




ABCDEF


TimeFrame

Met Notmet


Understands the method of charg-ing for nutrition supplies per facilitypolicy


Orders supplements, supplies Owens & minor forms Warehouse Special requisition forms (SFRF)

P&P manual 3m

E. CLINICAL NUTRITION ASSESSMENTDemonstrates the ability to accu-rately assess participants utilizingstandards of care

Preceptor, direct observa-tion

3m

Identifies age-related factors thatmay influence nutritional assess-ment for geriatric specialty


3m

Accurately calculates protein, calo-rie and fluid requirements for nor-mal and specific disease states


6m

Accurately calculates nutrientbreakdown of tube feedings


6m

Verbally defines the differencesbetween the nutritional supplementson the enteral formulary and imple-ments appropriate supplementationinto care plan


6m

Makes appropriate recommenda-tions for enteral tube feedings orparenteral nutrition changes, asappropriate, based on assessmentof participants


3m

Includes religious, cultural and eth-nic preferences when completingnutrition assessments


3m

Appropriately identifies nutrient,drug interactions and is knowledge-able of resources to use when infor-mation is not readily available


3m

Monitors monthly weight changeswith development of appropriateinterventions


3m

Sets nutritional goals in care planprocess


3m

Completes caloric intake assessments and appropriatelysummarizes the results


3m

CRSP




ABCDEF


TimeFrame

Met Notmet


F. PARTICIPANT, FAMILY, STAFF & COMMUNITY EDUCATIONExplains the importance of assess-ing participant and family educa-tional needs and potential barriersto learning when conducting nutri-tion education


3m

Appropriately incorporates knowl-edge of therapeutic diets whenconducting participant educationsessions


3m

Identifies religious, cultural, motiva-tional and other barriers that mayimpact a participant’s ability to learn


3m

Identifies and utilizes resourcesavailable in the facility, such asinterpreters, that can be used whenlanguage barriers exist


3m

Evaluates competencies andpotential to comply with nutritioncounseling


3m

G. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3mCultural sensitivity, diversity* Self-study module 3mLatex allergy information* Self-study module 3mH. MANAGEMENT OF INFORMATIONDocuments in the participant’smedical record using appropriatecharting methods for the facility


Completes transfer report betweencenters


Completes initial assessment data Medical records manual 3mCompletes periodic reassessmentdata


Evaluates progress toward careplan goals


Respects participant confidentiality P&P manual 3m

I. IMPROVING ORGANIZATIONAL PERFORMANCEParticipates in interdisciplinaryteams assigned center


3m

CRSP





I understand that it is my responsibility to notify my immediate supervisor if at any time I am unable toperform the basic competencies required to practice in my assigned clinical area.





ABCDEF


TimeFrame

Met Notmet


Defines internal and external cus-tomers and demonstrates the abilityto address customers’ needs to main-tain satisfaction


3m

Explains importance of using thesatisfaction survey or client surveyin monitoring participant satisfaction


3m

Observes oral intake at noon mealand follows up on identified prob-lems


3m

Explains the JCAHO, OBRA andstate standards that impact the roleof the clinical dietitian


3m

States the PACE organization’smission statements and definesthem in everyday language


3m

J. QUALITY IMPROVEMENTMonitors monthly weights; evalu-ates quarterly reports for monthlychanges to meet criteria for nutri-tional quality of care


3m

Prepares quarterly report for man-agement team


3m

Participates in QI councils Preceptor, direct observa-tion

3m

Participates in CQI plans asrequested by center manager andgathers needed data


3m

Explains the CQI process and itsrole in improving organizationalperformance


3m

CRSP



REGISTERED NURSE COMPETENCY PROFILE




Name: Date of hire:



License renewal date: Hospital nursing CBO completed: yes/noDate:

BLS renewal date (every 2 years): Specialty certification (if applicable): Expiration date:

ACLS renewal date (if applicable): Competency testing score:

Other renewal date (if applicable):

Other:

CRSP




ABCDEFG


TimeFrame

Met Notmet

Self-needsAssess-ment

A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour G 3mPACE training PACE manual, P&P manual,

preceptor orientationA 3m

Dress code Policy # A,G 3mClock in/out, sign in/out Policy # A,G 3mBeeper paging Direct observation A,G 3mTelephone & intercom system Policy # A,G 3mLocation of manuals Guided tour G 3mDepartment meetings (staff, in-service)

Clinical ladder manual A,G 3m

Log books1. Grievance log2. Emergency equipment log3. Glucometer log4. Maintenance log

Guided tour GGGGG

3m

Standards of practice ANA Standards and Scopeof Gerontological NursingPractice

A 3m

B. DEPARTMENT SAFETY AND EMERGENCY (MEDICAL AND NON MEDICAL) PROCEDURESAnnual mandatory safety training* Safety training manual &

videoA,C,E

3m

Fire safety procedure* Disaster manual, P&P man-ual, fire drill participation

A,C,E,G

3m

Review of all emergency equip-ment*

Safety training manual &video, manufacturer’s manuals

A,B,C,D,E,G

3m

Disaster plan, evacuation plan* P&P and disaster manuals “ 3mLocation of safety manuals* Guided tour G 3mMSDS notebook-agents used* Hazardous materials manual A,G 3mHazardous waste precautions* Hazardous materials manu-

al, safety training manual &video

A,C,E

3m

Body mechanics* PT program, safety trainingmanual & video, NursingProcedures, 3rd Edition (NP)p. 60

A,C,D,E,

G

3m

CPR/basic life support (every 2years)*

Policy # A,D,G

3m

“911” system, emergency drugbox*

Preceptor, guided tour G 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


Use of restraints* Lap buddy Y-strap Wrist restraints Hand mittens Other types of restraints

Policy #, restraint P&P,“Respect and non-discrimi-nation”, annual mandatoryin-service

A,G 3m

Fall precautions, participant safety Nursing P&P A,G 3mC. INFECTION CONTROLHandwashing Policy # A,G 3mStandard precautions* Policy #, safety training

manual & videoA,C,E,G

3m

Disposal of infectious waste Policy # A,G 6mIsolation protocols Infection control manual A,G 6mTB control, fit check Policy # A,G 6mImmunizations (PPD yearly) Policy # A,G 3mLocation and use of personal pro-tective equipment (PPE)*

Safety training manual &video, guided tour

A,C,G

3m

D. RESOURCE MANAGEMENTTour of supply room(s), cabinets Guided tour G 3mOrdering supplies Requisition


G 3m

E. ASSESSMENT OF PARTICIPANTSAdmission criteria Manual section # A 3mAdmission process-assessment(health history/physical assess-ment)

Medical records manual A,G 3m

Transfer, intraprogram: receiving P&P manual A,G 3mTransfer, intraprogram: sending P&P manual A,G 3mDisenrollment criteria P&P manual A 3mBaseline assessment (beginning ofshift)

Charting tools, policy # A,G 3m

Assessment re-evaluation Medical records and P&Pmanual

A,G 3m

PACE assessment P&P manual A,G 3mPhysical assessment data Policy # A,G 3m Neurological Policy # A,G 3m Behavior Policy # A,G 3m Respiratory Policy # A,G 3m Cardiovascular Policy # A,G 3m Integumentary and altered skin

conditionsPolicy # A,G 3m

Gastrointestinal Policy # A,G 3m

CRSP



Task/Behavior References:A. Review policy/procedureB. Manufacturer’s manualC. Video reviewD. Skills labE. Written testF. Self-study packetG. Direct Observation

ABCDEFG


TimeFrame

Met Notmet


Renal, urinary Policy # A,G 3m Reproductive (date of last PAP,

mammogram through age 70)Policy # A,G 3m

Identifies both normal and abnormal findings, including changes in the elderly

Policy # A,G 3m

Gastric suctioning Policy # A,G 3mF. USE OF EQUIPMENT Suction devices* Equipment manuals, situa-

tional analysis, unit learningresources

A,B,G

3m

Infusion pumps “ “ 3mAuto-cuffs (Dinemapp machine) “ “ 3mThermometers, IVACs “ “ 3mBP cuff “ “ 3mPulse oximeter “ “Doppler “ “ 3mFoot pump “ “ 3mPacemaker check “ “ 3mPressure relieving devices “ “Glucometer* “ “ 3mUrine test strips* “ “ 3mHemocult testing* “ “ 3mEKG machine “ “ 3mKangaroo pump “ “ 3mCentrifuge “ “ 3mMultipodus splints “ “ 3mIce packs “ “ 3mWaffle boot “ “ 3mWaffle wheelchair, head cushion “ “ 3mHoyer, maxi lift “ “ 3mWheelchair “ “ 3mScales “ “ 3mSecure guard system “ “ 3mOtoscope “ “ 3mOphthalmoscope “ “ 3mSterilizer “ “ 3mToilet liners Product instructions G 3m

CRSP




ABCDEFG


TimeFrame

Met Notmet


G. CARE OF PARTICIPANTSAirway management P&P manual A,G 3mPain management Situation analysis A,G 3mEpidural management Policy # A,G 1yrIV therapy Policy # A,G 3mVenipuncture Policy # A,G 3mIVADs* Policy # A,G 6mPICCs Policy # A,G 6mTPN/PPN Policy # A,G 6mEmergency intervention Situation analysis A,G 6mCardiopulmonary arrest* Policy # A,G 6mSpecimen collection Policy # A,G 3mRemoval of sutures, staples P&P manual A,G 3mDrains (JP’s, hemovac, lumbar) P&P manual A,G 3mOstomy, fistula care P&P manual A,G 3mPressure ulcers Policy # A,G 3mEye care Policy # A,G 1yrDeath and dying (including postmortem management)

Policy # A,G 6m

Medication administration Policy #, ASCP video, Medpass observation

A,C,G

3m

Narcotics responsibility P&P manual A,G 3mRespiratory ManagementSupplemental O2 therapies P&P manual A,G 3mOperation of oxygen equipment,including O2 concentrator*

P&P manual A,G 3m

Tracheostomy care P&P manual A,G 3mNebulizer Policy # A,G 3mSuctioning (oral, tracheal, nasotra-cheal)*

P&P manual A,G 3m

Nutritional ManagementNasogastric tubes Policy # A,G 3mEnteral tubes (gastrostomy tubes,PEGs, caluso tubes)

P&P manual A,G 3m

Continuous feedings, bolus feed-ings, kangaroo pump

P&P manual, equipmentmanual

A,B,G

3m

Elimination ManagementIntermittent/indwelling catheter(male and female)

Policy # A,G 3m

Nephrotomy tube P&P manual A,G 1yr

CRSP




ABCDEFG


TimeFrame

Met Notmet


Intraperitoneal catheter Policy # A,G 1yrSuprapubic catheter Policy # A,G 1yrCondom catheter Policy # A,G 3mContinuous bladder irrigation Policy # A,G 1yrIntermittent bladder irrigation Policy # A,G 1yrLarge volume enemas Policy # A,G 3mSmall volume enemas Policy # A,G 3mIncontinent care Policy #, skin care resource

bookA,G 3m

Continuous ambulatory PD Policy # A,G 1yrAV fistula graft, dialysis catheter Policy # A,G 3mH. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module E,F 3mLatex allergy* Self-study module, safety

training manual & videoA,C,E,F

3m

Cultural diversity* Self-study module E,F 3mI. MANAGEMENT OF INFORMATIONMedical record Medical records manual A 3mParticipant confidentiality* Policy #, safety training

manual & video, mandatoryin-service

A,C,E

3m



A 3m

Informed consent Policy # A 3m

Death notification Policy # A,G 3m Family Policy # A,G Physician Policy # A,G 3m Coroner Policy # A,G 3m SCOPA Policy # A,G 3m

QI council participation Meeting minutes G 3mDocumentation of teaching, disen-rollment instructions

Policy #, P&P manual A,G 3m

J. UNIT SPECIFICStump care P&P manual A,G 6mCast, splint care P&P manual A,G 6m

Application and maintenance ofslings

P&P manual A,G 6m

CRSP





I understand that it is my responsibility to notify my immediate supervisor if at any time I am unable to perform the basic competencies required to practice in my assigned clinical area.





ABCDEFG


TimeFrame

Met Notmet


Immobilizers, cervical collars, braces P&P manual A,G 6mNeurovascular checks P&P manual D,G 6mK. GENERALAuthorizations Authorization manual A,G 1yrPACE documentation Unit PACE manual A,G 1yrDiabetic foot care P&P manual A,G 3mManagement of participants whowander

P&P manual G 3m

Review of participants’ rights(mandatory)*

P&P manual, mandatory in-service training

A 3m

Corporate compliance* Safety training manual &video

A,C,E 1yr

L. NEUROSCIENCESeizure precautions, use of anti-convulsants (action & side effects)

Resource book: TheClinical Practice ofNeurological &Neurosurgical Nursing **

A,G 3m

Evaluation of LOC (appropriateactions in caring for participant andnotifying MD)

Resource book **, P&Pmanual

A,C,E,F

3m

Care of head injuries, aneurysms,brain tumors

Resource book** E,F 3m

Quality control checks P&P manual A,C,E 3m Emergency drug box checks Policy # A 3m Refrigerator checks Direct observation, equip-

ment manualA 3m

Chart review P&P manual A,G 3m Glucometer checks Direct observation, equip-

ment manualA,G

Serious occurrence reporting,*Incident reporting, Adverse drug reaction reporting

Policy # A,G 3m

CRSP



RESTORATIVE ASSISTANT COMPETENCY PROFILE




Name: Date of hire:


BLS renewal date (every 2 years): Evaluation date:

Other: Hospital orientation completed: yes/noDate:

CRSP




ABCDEF


TimeFrame

Met Notmet





Guided tour 3m





3m




2 years)Policy # 6m

Fall precautions, participant safety*

Preceptor 3m



3m



3m

CRSP




ABCDEF


TimeFrame

Met Notmet


D. RESOURCE MANAGEMENTTour of supply room(s), cabinets Guided tour, preceptor 3mDurable medical equipment (DME) P&P manual, preceptor 3mOrdering of linen Preceptor 3mUR book Unit learning resources,

Preceptor3m

Scheduling of therapy appoint-ments

Preceptor 3m

E. THERAPEUTIC SKILLSAssistance with treatment plans for: 3m Wheelchair positioning and

adaptive devicesUnit learning resources,preceptor

3m

Wheelchair mobility training Unit learning resources,preceptor

3m

Transfer training Unit learning resources,preceptor

3m

Edema control Unit learning resources,preceptor

3m

Gross motor coordination exercises

Unit learning resources,preceptor

3m

Range of motion Unit learning resources,preceptor

3m

Ambulation Unit learning resources,preceptor

3m

ADL’s Unit learning resources,preceptor

3m

G. USE/MAINTENANCE OF EQUIPMENTWheelchair Manual Power

Unit learning resources,manufacturer manuals, preceptor

3m

Reclining wheelchair “ 3mWalker “ 3mRolling walker “ 3mHemi-walker “ 3mPlatform walker “ 3mWedge “ 3mHoyer lift “ 3mCrutches Loft strand Standard

“ 3m

Straight cane “ 3mQuad cane “ 3m

CRSP




ABCDEF


TimeFrame

Met Notmet


Above knee prosthesis Unit learning resources,manufacturer manuals, preceptor

3m

Below knee prosthesis “ 3mshort leg brace (double upright) “ 3mAnkle foot orthosis (AFOs) “ 3mAdaptive equipment “ 3mHydroculator “ 3mParaffin bath “ 3mKnee ankle foot orthosis (KAFOs) “ 3mKnee immobilizers “ 3mSplints “ 3mG. CARE OF PARTICIPANTSAmputee management Unit learning resources, 3mCVA, stroke management Unit learning resources 3mBalance precautions Unit learning resources 3mNeurological diseases Unit learning resources 3mOrthopedic precautions Unit learning resources 3mSkin integrity Unit learning resources 3mCirculatory diseases Unit learning resources 3mEmergency intervention Mock codes, situational

analysis3m

Balance precautions Unit learning resources 3mH. PARTICIPANT SPECIFIC COMPETENCIESAge specific* Self-study module 3mCultural sensitivity, diversity* Self-study module 3mLatex allergy information* Self-study module 3mI. MANAGEMENT OF INFORMATIONUnit therapy documentation Medical records manual 3mUtilization review Medical records manual,

preceptor3m

Participant confidentiality* Policy #, P&P manual 3mParticipants’ bill of rights* P&P manual 3mReview of marketing policy toinclude prohibited marketing practices*


3m

J. UNIT SPECIFICTherapy attendance policy P&P manual 3mWheelchair maintenance policy,contract

P&P manual 3m

CRSP










ABCDEF


TimeFrame

Met Notmet


K. QUALITY IMPROVEMENTTherapy equipment checks Preceptor 3mStandard precautions monitor Preceptor 3mQI committee Meeting minutes,

attendance3m

CRSP



SPEECH THERAPY ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr

Cultural respect Self-study module 1 yrLatex allergy Self-study module 1 yrAge specific Self-study module 1 yrCorporate compliance Mandatory training 1 yr

CPR/BLS renewal Direct observation and writtentest

2 yrs

Infection control Direct observation 1 yr

Mandatory training Video & post test 1 yr


Policy # 1 yr

CRSP



SPEECH THERAPY ASSISTANT COMPETENCY PROFILE




Name: Date of hire:




BLS renewal date:

Other:

CRSP




ABCDEF


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour 3mDress code Policy # 3mClock in/out, sign in/out Policy # 3mTelephone & intercom system Policy # 3mLocation of manuals Guided tour 3mStaff in-services Guided tour 3mB. DEPARTMENT SAFETY PROCEDURESFire safety procedure* Disaster manual, P&P 3mDisaster plan, evacuation plan* Disaster manual, P&P 3mLocation of safety manuals* Guided tour 3mHazardous materials Hazardous materials manual 3mBody mechanics PT program 3mUse of restraints* Policy #, restraint P&P 3mCPR, basic life support (every 2years)

Policy # 6m

C. INFECTION CONTROLHandwashing Infection control manual 3mStandard precautions* Infection control manual 3mTB control, fit check Policy # 3mImmunizations PPD yearly (mandatory)* Flu vaccination (counseling)

Policy #, unit learningresources

3m

D. RESOURCE MANAGEMENTTour of supply room(s) Guided tour 3mOrdering of supplies P&P manual 3mE. ASSESSMENT OF PARTICIPANTSIntake and enrollment policies P&P manual 3mLanguage (expressive/receptive) P&P manual 3mArticulation P&P manual 3mAuditory processing P&P manual 3mVoice P&P manual 3mFluency P&P manual 3mAural habilitation P&P manual 3mDysphagia, oral-motor P&P manual 3mAugmentative, alternative commu-nication

P&P manual 3m

Appropriateness of current assistive, adaptive devises

P&P manual 3m

CRSP




ABCDEF


TimeFrame

Met Notmet


F. USE AND MAINTENANCE OF EQUIPMENTAugmentative, alternative communication devices Communication notebooks Communication boards

Speech manual 3m

Oral motor facilitation tools Laryngeal mirror

Speech manual 3m

Audiometer Speech manual 3mAssistive listening devices, hear-ing aids

Speech manual 3m

G. CARE OF PARTICIPANTSArticulation treatment Speech manual 3mLanguage treatment Speech manual 3mAuditory processing, cognitivetreatment

Speech manual 3m

Dysphagia/oral-motor treatment Speech manual 3mFluency treatment Speech manual 3mVoice treatment Speech manual 3mH. PARTICIPANT SPECIFICAge specific* Module 3mLatex allergy* Module 3mLimitation of participant movement P&P manual 3mCultural respect* Module 3mI. MANAGEMENT OF INFORMATIONUnit therapy documentation Medical records manual 3mTeaching documents Medical records manual 3mParticipant confidentiality P&P manual 3mCompletion of physician orders Medical records manual 3mJ. UNIT SPECIFICTherapy attendance policy Speech manual 3mReferral process Speech manual 3m Audiological evaluation Speech manual 3m Videofluroscopy Speech manual 3m

K. QUALITY IMPROVEMENTChart review QI manual 3mQI committee Meeting minutes 3m

CRSP









CRSP



STAFF ASSISTANT ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr


CPR/BLS renewal Direct observation and writtentest

2 yrs



Policy # 1 yr

Recording and typing ofmorning meeting and IDTmeeting minutes

Direct Observation 1 yr

Emergency equipment 1 yr

Disaster/fire drills 1 yr

CRSP



TRANSPORTATION COORDINATOR ANNUAL COMPETENCY ASSESSMENT

(PACE program)






ABCDEF


TimeFrame

Met Notmet



P&P manual 1 yr


CPR every 2 years Direct observation and writtentest

2 yrs


Department manuals P&P manual, participation 1 yrImmunizations (PPD everyyear)

Policy # 1 yr

Driver’s license renewal (ifapplicable)

5 yrs

Defensive driving renewal(if applicable)

Defensive driving course 2 yrs

Disaster/fire drills Tour 1 yr


CRSP



TRANSPORTATION COORDINATOR COMPETENCY PROFILE




Name: Date of hire:



License renewal date: Defensive driving renewal date:

BLS renewal date:

Other:

CRSP




ABCDEF


TimeFrame

Met Notmet


A. DEPARTMENT OVERVIEWTour of (PACE program) Guided tour 3mDress code Policy # 3mClock in/out Policy # 3mTelephone & intercom system Policy # 3mBeeper paging Direct observation 3mLocation of manuals Guided tour 3mLocation of complaint, concern log Guided tour 3mDepartment & in-service meetings Direct observation 3mB. DEPARTMENT SAFETY PROCEDURESFire safety procedure* Disaster manual, P&P 3mDisaster plan, evacuation plan* Disaster manual, P&P 3mLocation of safety manuals* Guided tour 3mHazardous materials Hazardous materials manual 3mBody mechanics PT program 3mUse of restraints* Policy #, restraint P&P 3mCPR, basic life support (every 2years)

Policy # 6m

MSDS notebook-agents used* Hazardous materials manual 3mEmergency procedures-”911” system

Disaster manual 3m

Fall precautions P&P manual 3mC. INFECTION CONTROLHandwashing Infection control manual 3mStandard precautions* Infection control manual 3mDisposal of infectious waste P&P manual 3mAnnual mandatory testing* P&P manual 3mImmunizations PPD yearly (mandatory)* Flu vaccination (counseling)


3m

D. USE OF EQUIPMENTOperating van Vehicle manual, defensive

driving course knowledge,preceptor supervision

6m

Van lifts Operating manual, preceptorsupervision

6m

Fire extinguisher Instructions, annual manda-tory in-service

6m

First aid kit Instruction guide, first aidcourse knowledge

6m

CRSP




ABCDEF


TimeFrame

Met Notmet


Seat belts Operating manual, preceptorsupervision

6m

Tie downs Operating manual, preceptorsupervision

6m

Oxygen tank Instructions, preceptorsupervision

6m

Two-way radio Instructions, preceptorsupervision

6m

F. CARE OF PARTICIPANTSLoading/unloading participantson/off vans

Preceptor supervision 6m

Transporting participants Preceptor supervision 6mG. PARTICIPANT SPECIFICAge specific* Module 3mLatex allergy* Module 3mCultural respect* Module 3mH. MANAGEMENT OF INFORMATIONMileage log Transportation manual,

preceptor instructions6m

Daily vehicle checklist Transportation manual, preceptor instructions

6m

Fuel log Transportation manual, preceptor instructions

6m

Daily participant log Transportation manual, preceptor instructions

6m

Daily employee attendance roster Transportation manual, preceptor instructions

6m

Utilization sheets Transportation manual, preceptor instructions

6m

Medication log Transportation manual, preceptor instructions

6m

Participant confidentiality Transportation manual, preceptor instructions

6m

J. UNIT SPECIFICTherapy attendance policy Speech manual 3mReferral process Speech manual 3m Audiological evaluation Speech manual 3m Videofluroscopy Speech manual 3m

K. QUALITY IMPROVEMENTChart review QI manual 3mQI committee Meeting minutes 3m

CRSP










ABCDEF


TimeFrame

Met Notmet


I. UNIT SPECIFICPharmacy, supply, mail pick-ups Transportation manual,

preceptor instructions6m

Van maintenance procedure Transportation manual, preceptor instructions

6m

“No available family” procedure Transportation manual, preceptor instructions

6m

Field trips Transportation manual, preceptor instructions

6m

Saturday respite Transportation manual, preceptor instructions

6m

Outside appointments Transportation manual, preceptor instructions

6m

K. QUALITY IMPROVEMENTParticipation in center QI projects QI meeting minutes 6mConcern, complaint log Site supervisor/designee,

preceptor6m

CRSP



SAMPLE COMPETENCY BASED PERFORMANCE PROGRAM

Rules:Staff competency will be measured against the department job requirements for all new(PACE program) employees and annually for existing employees. The purpose of the com-petency based performance program is to verify that all (PACE program) employees havebeen trained and are capable of achieving job requirements and performance standards asidentified at (PACE program). The program also assists the employee to maintain and toincrease competency through educational programs.

The following definitions apply:

Competency:Characterized by three basic elements:1. an appropriate knowledge base;2. skills in use of equipment and technical aspects of role; and3. behaviors, such as critical thinking and implementation of performance standards, that

are adjusted to the work environment, clinical setting and participants.

Competency testing:A validation process used to verify that each employee has the appropriate knowledge,

skills and behaviors to achieve and maintain job expectations. Each discipline identifies key areas to be assessed incorporating Scope of Care

issues, i.e., age, diagnoses, cultural and religious needs of the participant.

With assistance:An employee must perform a task/behavior with a preceptor/instructor present and

“with assistance” is marked on an employee’s skills checklist or competency profile. Actionplans are developed to assist the employee to perform the action without assistance.

Identifying competency topics/levelCompetency topics/levels are identified in job descriptions, policies and procedures, (PACEprogram) mission statements and the scope of care/service for the Program for All-InclusiveCare for the Elderly (PACE).

Job descriptions identify knowledge requirements, skills and behaviors that are specificto the role of the employee.

Policies and procedures identify current national, state and local standards or requirements.

CRSP



The mission statements and the clinical scope of care/service identify competency requirements including those related to the age population served (those ages 55 years and higher), the cultural, religious and psychological needs of the participant, and the goals/objectives of the participant and the goals/objectives of (PACE program).

Universal competency elements for all employees are identified in the safety, infec-tion control, quality improvement and body mechanics programs.

Measurement of competencyExpected competency outcomes and criteria for competency testing are identified in

performance standards and policies and procedures.References for competency may include: oral or written exams competency testing labs self learning modules charting reviews care plans participant interviews attendance at meetings and/or participation on committees BCL certification

Measurement for competency behavior testing is based on a 1-4 scale. Competencyis satisfactorily met if the employee is 1) able to perform independently or 2) able to performafter a review of information. Competency is not met if the employee 3) achieves thebehavior only if he/she has assistance or 4) is unable to perform the behavior.

The employee’s performance will be documented on the competency profile sheet.This sheet is kept at the (PACE program), accessible to the employee and the supervisor.Competency profiles will be used as a reference for clinical assignments.

An action plan is generated by the supervisor for an employee who does not achievethe required competency level within a specified time frame.

Frequency of competency testingAll new employees complete the competency based orientation program to verify

knowledge, skills and behaviors required in their role.The Frequency-Risk Grid (del Bueno, 1987) is used to identify topics for on-going,

periodic testing. The grid is also used to determine the frequency of testing. Topics that are identified as high risk-low frequency may be tested on a frequent

basis, i.e. monthly, quarterly or every six months. Topics identified through routine competency testing as areas in need of improve-

ment are targeted for more frequent evaluations until such time as satisfactory and consistent competency testing results are documented.

CRSP



Mandatory topics, such as safety classes, standard precautions, infection control, bodymechanics or BLS will be included in mandatory annual competency achievement programs.If deficiencies are noted, more frequent review may be needed.

Skills proficiency labs may be held to facilitate equipment and procedure reviews andtesting depending on identified need.

Educational offerings and/or workshops may also be held on universal topics such asage-specific issues, cultural, religious and common needs of all participants.

CommunicationA summary of the competency testing results will be completed and maintained by

(PACE program) center managers and forwarded to the (PACE program) director and the(PACE program) quality improvement coordinator.

An annual report regarding the (PACE program) competency based performance pro-gram trends and patterns will be provided for the director of geriatric services and the (PACEprogram) board of directors.

CRSP



SAMPLE COMPETENCY PROFILE ACTION PLAN

Date: _________________ Satisfactory completion required by: _________________

Plan:

Employee Signature: _________________ Instructor Signature: _________________


Plan:

Employee Signature: _________________ Instructor Signature: _________________


Plan:

Employee Signature: ________________ Instructor Signature: __________________

CRSP



SAMPLE INITIAL COMPETENCY SELF-ASSESSMENT

1. At the time of hire, each staff person will be required to complete a “Competency Self-Assessment” form. This form will provide supervisory staff with an assessment of the staff’s ability to perform each skill and activity required by their position.

2. In the event of noted deficiencies in one or more areas of competencies, supervisory staff will develop and implement a plan for correcting deficiencies. The plan will include the training and education necessary for the staff person to become competent in the skills required for the position.

CRSP



(PACE PROGRAM)INITIAL COMPETENCY SELF-ASSESSMENT: (TITLE OF POSITION)

Rate your competency to perform each skill or activity with an A, B, C as follows:A. I feel completely competent in this skill/activity.B. I feel that I could become competent in this skill/activity with some additional training.C. I am unfamiliar with this skill/activity and require education to become competent.

Employee signature: __________________________________________________ Date: __________

Preceptor Signature: __________________________________________________ Date: __________

Name: Department: Date of hire:

Plan to correct deficiencies (including timeframe):

CRSP



SAMPLE PERFORMANCE EVALUATION SAMPLE POLICY

Purpose:To provide an objective basis on which to evaluate the performance of employees so that salary adjust-ments are properly substantiated.

Scope:All (PACE program) employees.

Policy: Supervisors and employees are strongly encouraged to discuss job performance and goals on an

informal, day-to-day basis. For performance evaluations/development plans are generally con-ducted at the end of an employee’s initial period in any new position. This period, known as theintroductory period, allows the supervisor and the employee to discuss the job responsibilities, standards and performance requirements of the new position. Additional formal performance evaluations are generally conducted to provide both supervisors and employees the opportunityto discuss job tasks, identify and correct weaknesses, encourage and recognize strengths and discuss positive, purposeful approaches for meeting goals.

Performance evaluations are generally scheduled approximately every 12 months, coinciding generally with the anniversary of the employee’s original date of hire.

Merit-based pay adjustments may be awarded by (PACE program) in an effort to recognize truly superior employee performance. The decision to award such an adjustment is dependentupon numerous factors, including the information documented by this formal performance evaluation process.

Core Set for PACE CRSP - National PACE Association

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Transcript of Core Set for PACE CRSP - National PACE Association