ANNUAL OSHA/HIPPA Checklist

ANNUAL OSHA/HIPAA CHECKLIST
Name
Date

Month Day Year
Date
Key: *All Staff ♦ Must be completed Annual + As Required

Modules	Completed	Date/Initials of Trainer
SAFETY (*, ♦)		LM
Ergonomics/Clinical and Clerical Settings Basic Home Safety – Bathroom, Electrical, Environmental, Fire Personal Safety	Emergency Preparedness Plan – Environmental – Fire Plan OSHA

Modules	Completed	Date/Initials of Trainer
EMPLOYEE HEALTH/INFECTION CONTROL (*, ♦)		LM
Medical Personnel File Requirements Identification/Reporting of Infections Bloodborne Pathogens and Standard Precautions Exposure Control Plan Special Disease Management	Work Practice Policies Equipment Cleaning and Quality Care Personal Protective Equipment (PPE) Sharps Handling & Disposal of Special Waste

Modules	Completed	Date/Initials of Trainer
ADVANCE DIRECTIVES (*, ♦)		LM
Directive to Physician Out of Hospital Do Not Resuscitate (OOHDNR)	Death and Dying Medical Power of Attorney

Modules	Completed	Date/Initials of Trainer
COMPLIANCE (*, ♦)		LM
Zero Tolerance Fraud and Abuse	Code of Conduct Patient Privacy – HIPAA Regulation

Modules	Completed	Date/Initials of Trainer
HIPAA (*)	Certified/Licensed/PAS/Hospice	LM
Origin and Intent of HIPAA Implementation Timelines	Goals and Policies Security Rule and Privacy rule

Statement Of Completion for Annual Inservice

STATEMENT	EMPLOYEE INITIALS	Date/Initials of Trainer

I have read and understand the required orientation modules. I have completed the comprehensive quizzes and have been given the opportunity to practice, ask and have questions answered.		LM
I have completed the OSHA, HIPAA and Infection Control Policy review and understand my responsibilities.
I understand policies that are specific to the license category in which I am employed.  Certified  Licensed  PAS
I have been offered protective equipment
My personal patient care equipment has been quality checked and entered into the log. (Blood Pressure Cuff)
I have been educated in the Emergency Preparedness Plan for my location and made aware of my role in the disaster plan.
I understand that CPR certification is not required.
RESPONSIBILITIES REGARDING UNDERSTANDING OF FRAUD AND ABUSE I understand the principles of fraud and abuse. I have been educated specifically about what constitutes fraud and abuse. I understand that no form of fraud and abuse will be tolerated by Beacon Home Health Agency, LLC. I will immediately report to my supervisor or the Compliance Officer any suspicion of fraud and abuse.

Employee Name

First Name Last Name
Employee Signature

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Initials blanks
Trainer Signature

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Trainer Signature

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Trainer Signature

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Supervisor/Staff Development Signature

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Date

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