Staff Application Pack
(For all disciplines)
(Minimum order 5 / discipline)
Ready to use, updated as required, only $ 2.59 each
(For all disciplines)
(Minimum order 5 / discipline)
Ready to use, updated as required, only $ 2.59 each
Renew License Form: 60 days before to expiration date. CLIA application form
New CoPs: HHA/CNA Competency (new practical part)
Staff Agreement: Staff Agreement
Clinical Manager JD (Add to DON): Job Description
QAPI staff Job Description: Job Description DON JD: DON JD
Compliance Officer JD Job Description
Administrator Clarification: Administrator JD add (add to Administrator JD)
All Agency Job Descriptions: Job Descriptions
Staff Family Medical Leave Request Leave Request
Inactive/Active Staff: Inactivation Form
Staff Chart Audit Form (at least Annually to all field and office staff):
ADMINISTRATOR/HR: Staff Chart Audit Result Report to BD (Quarterly):
Quarterly Report for Chart Audits presented to BD meeting
If needed, to complete competencies for Professional Staff (PT, OT, ST, MSW), the Agency need a participation of a member of the same discipline, if no staff is available, the Agency must contract a same discipline member Consultant to do the competencies in any discipline needed:
Prof. Consultant Contract (External contract, if needed for competencies)
Initial prospective staff Interview Exit staff Interview
Initial Interview Exit Interview
Disciplinary warning: Staff warning Software Secury:Software Security
Staff survey: Staff Survey Staff Concern/report incident: Staff Concern
During Absence of Administrator Form During Absence of DON Form
(This forms must be filed in each employee chart Administrator/DON and their alternates)
During Absence Administrator During Absence of DON
Position Change Staff Orientation New DON Orientation
(all staff in new position must be trained/oriented in their new duties)
Position Change Orientation DON Orientation
New Alt. DON Orientation
Supervisor Staff Training/Orientation Staff anonymous complaint
Supervisior Training Form Staff Complaint
School Verification if Diploma not available (CHAP only required)
(CHAP Only, not necessary if it is prevented by your Policy)
School Diploma Verification Personnel Licensure Policy
STTAF EVALUATIONS:
90 days/Probation Period (Same for all disciplines)
90 Days/Probation period: Probation period eval
Annual Evaluations:
Executive Staff Evaluations:
Administrator Competency Alt. Administrator Competency
DON Evaluation ADON Evaluation
Field Staff:
Registered Nurse or Licensed Practical Nurse Home Health Aide (HHA or CNA)
RN or LPN Annual Evaluation HHA or CNA Annual Evaluation
Psychiatric/IV/Pediatric Nurse, you must add this competency (Initial/Annual):
Pshyc RN Compentency IV Therapy Compentency
Pediatric RN Compentency Chemotherapy Compentency
Physical Therapist or Assistant Occupational Therapist or Assistant
Physical Therapist or Assistant OT or OTA Annual Evaluation
Speech Therapist or Assistant Social Worker
ST or STA Annual Evaluation MSW Annual Evaluation
Glucometer Competency
(Nursing Staff-Annual) The patient's glucometer must be verified before to be used staff:
Glucometer 2 Competencies Glucometer use verification
( Also must have literature about the Glucometer manufacturer guidelines)
CoaguChek PT-INR Tests (Nursing Staff-Annual)
CoaguCheck Competency 1 CoaguCheck Competency 2
Bag Technique Competency Hand Hygiene knowledge assessment
(Initial-Annual) (all field staff) (Initial-Annual)
Bag Technique Competency Hand Hygiene Knowledge
Handwashing (initial/Annual): Handwashing Competency
Hand Hygiene Staff Survey Hand Hygiene Staff Survey (annual)
Bag tech., Pt Assessment, Handwashing procedures documentation:
Bag Assesment/Handwashing (share with your staff)
Yearly BP Gauges Check Log Vissual Inspection of BP Equipment
BP Gauges Check Log (annual) BP equipment inspection
Cardiovascular Disease Best Practice Competency CVD Competency
TB risk assessment questionnaire: TB risk assessment questionnaire
Non Clinical staff:
Office Staff (Non-Clinical Staff) Safety Culture Survey (all staff)
Non-Clinical Annual Evaluation Safety Culture survey
After Survey Staff training form (generic form to be completed as proof of training received after deficiency noted during a survey)
Staff Training after Survey (part of the Plan of correction (POC))
ADMINISTRATOR: Influenza Vaccine Rate Compliance Goal LOG
(must be posted in the Agency's Board) (Initial-Annual)
Influenza Vaccine Goal Log Influenza Staff data
ADMINISTRATOR/HR: Staff Influenza Declination Analyzes, Report to BD (Quarterly):
Influenze Declination Analyzes
CALENDAR of In-services (must be posted in the Agency's Board)
STTAF VERIFICATIONS:
Florida Verify License:
(Prof. staff & referral physicians) OIG (Office Inspector General
FL Prof. License (hire/annual) OIG Verify Medicare Exclusion (hire/monthly)
Sex Offender: (at hire)
AHCA Background Screening
Sex Offender Registry
AHCA Background Screening
E-Verify: E-Verify (Legal Status)
Florida School Verification (Verify that the School is Licensed)
Live Scan Providers: Live Scan Providers (for background check)
Florida: Alzheimer's Educator Registration App: Alzheimer's Educator
Approved Schools/trainer: Alzheimer's Schools HCAF Approved Training
Texas: Pennsylvania:
TX Verify License PA Verify License
Driver License check:
FL Drive License Check
TX Background Screening
TX Driver License Check PA Background Check
Disclaimer: Every template is only your Guide/Agenda to complete each report, your Agency Officials must assure that the meeting/evaluation occur, the quorum is acceptable, and every member had active participation in the discussion and confection of the Reports, Evaluations/Competencies, Documents.
The 24 hours must include two (2) hours on Prevention of Medical Errors. HIV/AIDS is now a one-time, 1-hour CE requirement to be completed prior to the first renewal. Domestic Violence (DV) CE is now a 2-hour requirement every third renewal. Since Domestic Violence (DV) is a 2-hour requirement, the licensee will have 26 hours of CE during the renewal period when DV is taken. For example, if you renew your license on July 31, 2008 and completed DV during the 2006-2008 licensure cycle, you are required to complete the Domestic Violence CE before the July 31, 2014 renewal.
CPR: must be with life person (not on-line)
All home health aides employed by home health agencies must complete an HIV/AIDS training course (lifetime). They also are required to obtain and maintain a current certificate in cardiopulmonary resuscitation (CPR). Home health aides employed by Medicare and Medicaid home health agencies are required to have a total of 12 hours of in-service training during each 12-month period (this can be a calendar year or based on the date of hire). The HIV/AIDS training and CPR training may be counted toward meeting the 12 hours of in-service training.
All CNAs must complete a minimum of 12 hours of in-service training each calendar year. Every 2 years, in-service training hours shall include, but are not limited to, the following areas: Bloodborne Pathogens, Infection Control, Domestic Violence, Medical Record Documentation and Legal Aspects Appropriate to Nursing Assistants, Resident Rights, Communication with cognitively impaired clients, CPR skills, Medical Error Prevention and Safety
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