Title Page
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Site conducted
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Employee Name
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EID #
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Date
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Location
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Observed by
Validation occurs when the employee can perform the skill safely, correctly and legally with minimal coaching. Any skill or competency that does not apply to the specific service area, can be marked with "N/A"
Hand Hygiene/Glove Removal
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Date
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Describes appropriate hand hygiene technique and opportunities
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Engages in social motivation tactic to ensure proper hand hygiene
Patient Relations/Service Approach
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Date & Time
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Demonstrates a friendly/service approach
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Uses ISIT correctly
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Waits for permission to enter room
Cleaning Practices
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Date
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Prepares and uses chemicals according to policy
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Demonstrates correct and consistent process of cleaning an occupied room
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Demonstrates correct and consistent process of cleaning a restroom
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Demonstrates correct and consistent process of cleaning a discharge room
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Demonstrates correct and consistent process of cleaning an extra area
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Stocks linen according to job description for the designated areas
Isolation Room Cleaning Contact Isolation non C-Diff
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Date
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Demonstrates the proper use of PPE for contact Isolation situations
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Demonstrates the proper use of tools and chemicals for contact Isolation situations
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Demonstrates correct and consistent process of cleaning an occupied room contact precautions
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Demonstrates correct and consistent process of cleaning a Discharge room with contact precautions
Isolation Room Cleaning Contact Isolation C-Diff
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Date
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Demonstrates the proper use of PPE for contact Isolation situations
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Demonstrates the proper use of tools and chemicals for contact Isolation situations
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Demonstrates correct and consistent process of cleaning an occupied room contact precautions
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Demonstrates correct and consistent process of cleaning a Discharge room with contact precautions
Isolation Room Cleaning Droplet Isolation
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Date
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Demonstrates the proper use of PPE for contact Isolation situations
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Demonstrates the proper use of tools and chemicals for Droplet Isolation situations
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Demonstrates correct and consistent process of cleaning an occupied room contact Droplet precautions
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Demonstrates correct and consistent process of cleaning a Discharge room with Droplet precautions
Isolation Room Cleaning Airborne Isolation
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Date
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Demonstrates the proper use of PPE for contact Isolation situations
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Demonstrates the proper use of tools and chemicals for Airborne Isolation situations
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Demonstrates correct and consistent process of cleaning an occupied room contact Airborne precautions
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Demonstrates correct and consistent process of cleaning a Discharge room with Airborne precautions
Suicide Precautions and Violent Patients
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Date
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Demonstrates understanding of policy in proper waster container liners
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Demonstrates understanding of the sharps container placement in the room
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Demonstrates understanding of hand hygiene containers status and placement
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Demonstrates understanding of double red light nurse call light signal in the hallway
Linen Distribution Practices
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Date
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Counts and uses ControlTex according to policy
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Can place a daily linen order with ControlTex/HESI
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Demonstrates correct and consistent process of counting linens in stock & documenting
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Replenishes linen in a neat and orderly way
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Fills carts with established pars according to ControlTex
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Uses safety guidelines when transporting linen (covered/safely stacked)
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Pushes/pulls Metro Carts only with a partner
ScrubEx
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Date
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Stocks scrub cart an organized way
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Evaluates daily scrub needs and communicates those needs, to place accurate scrub orders
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Fills ScrubEx machines accurately and makes deliveries on time
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Completes the filling process using the correct loader board functions
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Can complete limited trouble shooting for issues and begin the repair process
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Can access the IPA Clearview website, assist with staff questions and acquire accurate machine stock levels
Waste and Dirty Linen Processing
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Date
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Demonstrates the proper use of PPE work with waste and dirty linen
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Demonstrates the disposal of sharps container according to policy
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Demonstrates the disposal of Chemo waste container according to policy
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Demonstrates the disposal of black medical waste container according to policy
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Demonstrates the disposal of solid waste according to policy
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Demonstrates the disposal of Bio-Hazard waste
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Demonstrates the proper process of dirty linen
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Demonstrates the proper process for aluminum, newspaper, magazine, and plastic recycling
Fire Safety
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Date
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Can verbalize RACE & PASS
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Identifies the location of the fire pulls & verbalizes how to use the pull
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Identifies the location of the fire exits and fire extinguishers
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Prevent the blocking of any safety equipment: doors, fire pull or extinguishers
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Identifies the use of 9-911
ONE CHART
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Date
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Demonstrates successful access of Bed Board
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Effectively pages staff
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Identifies appropriate actions as a result of a staff call - how to cancel / create a bed request
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Demonstrate a bed hold
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Sign staff into & out of ONE Chart
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Assign a room to staff
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Reassign a room to staff
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Manage staff breaks
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Define Misc. Task Function
Pager, Telephone, iPad, and Computer Use
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Date
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Can access and enter information into the Work Order System
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Responds to the pager in an appropriate and timely way
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Demonstrate successfully the practice of using the pager to "page" someone
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Telephone use: demonstrates appropriate telephone etiquette
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Telephone use: greeting
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Telephone use: problem solving
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Telephone use: transfer calls
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Telephone use: conference calls
Communication
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Date
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Writes communications to share information after shift and when needed
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Communicates changes to staff, HUDDLES & one on one
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Participates in discipline discussions with staff to include termination if requested
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Evaluates staff annually
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Conducts consistent inspections both daily & discharge on staff as needed
I verify this employee has met the ongoing competencies identified for their position
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General Comments:
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Manager/Reviewer E-Signature
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Date Signed
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Employee E-Signature
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Date Signed
