IN HOME SUPERVISION

 

Employee Name:   Empl ID #:   Employee Title:  HHA,  PCA

   
  Date: 
    Time In:   Time Out:

 

Competency Method of evaluation Topic
Wearing ID badge
Wearing mask if declined flu vaccination
Punctual, clocks in and out and is appropriately dressed
Able to communicate with patient and comprehend the plan of care
Good rapport with patient/family
Demonstrates competence and good judgement in carrying out assignments and following the POC. Able to recognize, and report incidents and accidents, unusual or emergency events to the appropriate person
Knowledgeable in use of DME
Understands role in assisting with medications
Understands their role in reporting changes in patient needs, conditions, and emergencies
Provides oral hygiene/Denture care
Bathing: Bed/Tub/Shower
Grooming: Shampoo/Shave/Nail Care
Maintains safe environment and safety practices. Demonstrates good transfer technique
Knowledgeable about skin care and measures to prevent and reduce impaired skin integrity
Practices universal precautions and infection control measures including hand hygiene
Prepare/serve meals and special diet in accordance with the Plan of care and patient’s preferences
Maintains clean kitchen/bedroom/bathroom
Runs errands for patients and escorts to doctors appointments as necessary
Maintains strict patient confidentiality, HIPAA, demonstrates understanding of False Claims Act and Corporate Compliance policies and procedures.
Encourages and engages patient in diversional activities
Quality of care

 

Special Competency
N/A Competency Method of evaluation Topic
Hoyer lift
Ostomies
 
Medication reconciliation done: Yes No
 
DRUG NAME DOSE/FORM AMOUNT FREQ ROUTE COMMENTS
 
 
Aide Comments:
Patient/family Comments:
Progress/General Note:
Nurse signature:

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Aide Signature:

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