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