Your name
Your Email
Last 4 Of SSN
Date
E-Signature
I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.
Instructions:This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.
1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently
Leadership Domain
Communicates effectively with residents, families, significant others and other team members: 0★★★★−
Communicates effectively with peers, physicians, and State agencies: 0★★★★−
Coordinates resident care to the multidisciplinary team via "at risk meetings, QA and A, rehab meetings, etc.: 0★★★★−
Provides updated resident information to physician, resident, family, legal, consultants, State agencies in accordance with regulations and/or BHC standards: 0★★★★−
Knowledgeable and able to execute human resource policies as applicable to a variety of people issues: 0★★★★−
Delegates as appropriate: 0★★★★−
Actions demonstrate excellent customer service skills and builds relationships with families and associates: 0★★★★−
Monitors the progress of others and associates are held accountable: 0★★★★−
Enforces regulatory and employee law compliance: 0★★★★−
Technical Domain
Assesses and monitors staff compliance of infection control and safety programs: 0★★★★−
Demonstrates excellent technical skills and judgment, as evidenced by: Daily Start up execution, Follow-up 24 hour report, Computer reports, Medicare Reports, 672/802: 0★★★★−
Assess and monitors accuracy of Facility Scorecard and CMS quality indicator data and initiates corrective action as indicated: 0★★★★−
Actively participants and contributes to facility QA &A meetings, QR/QRFU and process improvement activities: 0★★★★−
Promotes survey preparedness at all times: 0★★★★−
Demonstrates basic working knowledge of Computer i.e. ADT, PO's, MDS modules and management reports: 0★★★★−
Demonstrates basic understanding of quality event investigating and reporting process: 0★★★★−
Maintains a current knowledge of LTC Federal, state regulations including Medicare, Medicaid and JCAHO as applicable: 0★★★★−
Ensure that RAI functions are completed timely for all residents, i.e. concurrent review, State submissions, careplan meetings, etc: 0★★★★−
Assess and ensure execution of Facility standards, protocols and policies: 0★★★★−
Provides and monitors the effectiveness of clinical orientation and ongoing training to all associates: 0★★★★−
Actively participates in recruiting, hiring and orientation of all associates: 0★★★★−
Problem Solving Domain
Utilizes the nursing process to structure care to individual resident 's needs: 0★★★★−
Demonstrates the ability to assess and interpret data about the resident's status and ensure timely interventions are executed: 0★★★★−
Collaborates with DNS/ Consultants on identified areas of noncompliance and implements necessary corrective actions: 0★★★★−
Effectively troubleshoots and ensure allocation of staffing resources to meet the needs of the residents/patients: 0★★★★−
Demonstrates understanding of census as it relates to HOL, expense control and budgeted PPD, i.e. nursing supplies: 0★★★★−
Assess and monitors discharge, rehospitalization patterns and implements corrective actions as indicated: 0★★★★−
Age Specific Competencies
Infant (Birth - 1 year): 0★★★★−
Preschooler (ages 2-5 years): 0★★★★−
Childhood (ages 6-12 years): 0★★★★−
Adolescents (ages 13-21 years): 0★★★★−
Young Adults (ages 22-39 years): 0★★★★−
Adults (ages 40-64 years): 0★★★★−
Older Adults (ages 65-79 years): 0★★★★−
Elderly (ages 80+ years): 0★★★★−
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