Monthly Administrator Evaluation

• Conducted on

  Date

• Prepared by

• Location
  Address

Environmental Rounds:

• Were there any odors present?

  Compliant

  Non-Compliant

  N/A

• Were hallways cluttered?

  Compliant

  Non-Compliant

  N/A

• Appearance of outside of buidling?

  Compliant

  Non-Compliant

  N/A

• Carpets and flooring - stain free, appears clean, no major issues?

  Compliant

  Non-Compliant

  N/A

• Room audits - walls damaged by beds and ceiling tiles

  Compliant

  Non-Compliant

  N/A

• Test Tray Audit - Temperature, Quality and presentation

  Compliant

  Non-Compliant

  N/A

Quality of Care/Clinical

• Quality Measures - increase in points, trending in the right direction?

  Compliant

  Non-Compliant

  N/A

• Proper SRI investigations

  Compliant

  Non-Compliant

  N/A

• Falls - did facility meet monthly goal?

  Compliant

  Non-Compliant

  N/A

• Wounds - Exclude Unavoidable inhouse - Goal is 0 inhouse

  Compliant

  Non-Compliant

  N/A

• Morning meeting process is in place and white board updated"

  Compliant

  Non-Compliant

  N/A

• Evidence that UR and Focus in place and being followed

  Compliant

  Non-Compliant

  N/A

• Evidence that Kardex rounds are being done

  Compliant

  Non-Compliant

  N/A

• Completion of weekly and monthly kitchen/sanitation audits. Are results acceptable?"

  Compliant

  Non-Compliant

  N/A

• Nurse aide verifications being completed on ALL staff?

  Compliant

  Non-Compliant

  N/A

• Recent survey? If so, acceptable outcome?

  Compliant

  Non-Compliant

  N/A

• Align and ITM survey results acceptable? are Customer Service rounds being completed?

  Compliant

  Non-Compliant

  N/A

• Sprenger Hospice utilization (excludes MW and SC)

  Yes

  No

  N/A

• DON and Administrator night shift/off hours rotation being done?

  Compliant

  Non-Compliant

  N/A

Financial Performance:

• Is census target being met?

  Compliant

  Non-Compliant

  N/A

• Is case mix target being met?

  Compliant

  Non-Compliant

  N/A

• Part B Revenue targets being met?

  Compliant

  Non-Compliant

  N/A

• AR accounts - evidence of weekly internal AR meeting and Days Sales Outstanding (Primeview)

  Compliant

  Non-Compliant

  N/A

• Quality measures and quality points being managed appropriately?

  Compliant

  Non-Compliant

  N/A

• Is PDPM process being managed appropriately?

  Compliant

  Non-Compliant

  N/A

Expense Control:

• Are rentals being managed appropriately?

  Compliant

  Non-Compliant

  N/A

• Pharmacy bill being managed appropriately?

  Compliant

  Non-Compliant

  N/A

• Spend down sheets in place and evidence of

  Compliant

  Non-Compliant

  N/A

• Labor hours (Nursing, Dietary, H/L) in line and within budget

  Compliant

  Non-Compliant

  N/A

• Overtime % and dollar amount being spent per month

  Compliant

  Non-Compliant

  N/A

• No agency

  Compliant

  Non-Compliant

  N/A

• Employee Retention - turnover rates - below State average?

  Compliant

  Non-Compliant

  N/A

• Is PBJ being reviewed daily/weekly/quarterly for accuracy?

  Compliant

  Non-Compliant

  N/A

• Timely approval of invoices and CC receipt processing?

  Compliant

  Non-Compliant

  N/A

Marketing

• Attendance at community groups IE chamber, rotary, etc.

  Compliant

  Non-Compliant

  N/A

• Is marketing plan updated and being followed?

  Compliant

  Non-Compliant

  N/A

• "Physician and hospital relations going well, things being followed through on relationships being maintained?"

  Compliant

  Non-Compliant

  N/A

• "Is administrator rounding with case manager in the hospitals on a regular basis?"

  Compliant

  Non-Compliant

  N/A

• Tour conversions

  Compliant

  Non-Compliant

  N/A

Other Misc

• Timely completion of employee evaluations

  Compliant

  Non-Compliant

  N/A

• Relias completion percentages for all staff

  Compliant

  Non-Compliant

  N/A

• Are all staff meetings in place on a regular basis?

  Compliant

  Non-Compliant

  N/A

Sign Off

• Administrator Name and Signature

  Sign

• Regional Name and Signature

  Sign