ADON/DON CheckList

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.

Proficiency Scale:

1 = No Experience

2 = Need Training

3 = Able to perform with supervision

4 = Able to perform independently

Leadership Domain Rating Stars (Click) 1 2 3 4  
Communicates effectively with residents, families, significant others and other team members 
Communicates effectively with peers, physicians, and State agencies 
Coordinates resident care to the multidisciplinary team via “at risk meetings, QA and A, rehab meetings, etc. 
Provides updated resident information to physician, resident, family, legal, consultants, State agencies in accordance with regulations and/or BHC standards 
Knowledgeable and able to execute human resource policies as applicable to a variety of people issues. 
Delegates as appropriate 
Actions demonstrate excellent customer service skills and builds relationships with families and associates. 
Monitors the progress of others and associates are held accountable 
Enforces regulatory and employee law compliance 
Technical Domain Rating Stars (Click) 1 2 3 4  
Assesses and monitors staff compliance of infection control and safety programs 
Demonstrates excellent technical skills and judgment, as evidenced by: Daily Start up execution, Follow-up 24 hour report, Computer reports, Medicare Reports, 672/802 
Assess and monitors accuracy of Facility Scorecard and CMS quality indicator data and initiates corrective action as indicated 
Actively participants and contributes to facility QA &A meetings, QR/QRFU and process improvement activities 
Promotes survey preparedness at all times 
Demonstrates basic working knowledge of Computer i.e. ADT, PO’s, MDS modules and management reports 
Demonstrates basic understanding of quality event investigating and reporting process 
Maintains a current knowledge of LTC Federal, state regulations including Medicare, Medicaid and JCAHO as applicable 
Ensure that RAI functions are completed timely for all residents, i.e. concurrent review, State submissions, careplan meetings, etc 
Assess and ensure execution of Facility standards, protocols and policies 
Provides and monitors the effectiveness of clinical orientation and ongoing training to all associates 
Actively participates in recruiting, hiring and orientation of all associates 
Problem Solving Domain Rating Stars (Click) 1 2 3 4  
Utilizes the nursing process to structure care to individual resident ‘s needs 
Demonstrates the ability to assess and interpret data about the resident’s status and ensure timely interventions are executed 
Collaborates with DNS/ Consultants on identified areas of noncompliance and implements necessary corrective actions 
Effectively troubleshoots and ensure allocation of staffing resources to meet the needs of the residents/patients 
Demonstrates understanding of census as it relates to HOL, expense control and budgeted PPD, i.e. nursing supplies 
Assess and monitors discharge, rehospitalization patterns and implements corrective actions as indicated 
Age Specific Competencies Rating Stars (Click) 1 2 3 4  
Infant (Birth - 1 year) 
Preschooler (ages 2-5 years) 
Childhood (ages 6-12 years) 
Adolescents (ages 13-21 years) 
Young Adults (ages 22-39 years) 
Adults (ages 40-64 years) 
Older Adults (ages 65-79 years) 
Elderly (ages 80+ years)