ADON/DON Checklist

NAME

LAST 4 OF SSN

Date of application

E-MAIL

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.

Ranking: 0%

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)