RN/LPN/LVN

INITIAL COMPETENCY CHECKLIST
RN/LPN/LVN
NAME
RN
LPN
Date and RN’s signature indicates that the nurse has been checked off on the procedure.

SKILLS

	Not Satisfied	Satisfied
1. Urinary catheters:
Cleanliness
Responsiveness
Friendliness

Date and RN’s signature indicates that the nurse has been checked off on the procedure.

1. Urinary catheters:SKILLS
SKILLS

3. Enteral Feedings:COMMENTS
YES

b. Suprapubic insertion/removalNO
COMMENTS
COMMENTS
COMMENTS
COMMENTS
COMMENTS
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
DATE & INITIAL
2. Central Cath Lines

c. Removal/insertion PEG tubesCOMPETENT
2. Central Cath Lines
a. Bolus

6. Irrigations:a. Bladder
a. Bolus

5. IV therapy:4. Equipment:
a. Bolus

b. Continuousc. Oxygen concentrator
4. Equipment:

b. Enteral pumps2. Central Cath Lines
4. Equipment:

d. Oxygen tanka. IV pumps
a. IV pumps
a. IV pumps
d. Oxygen tank
d. Oxygen tank
e. Nebulizer

a. Peripheral/INTb. Adm fluids/meds
e. Nebulizer
5. IV therapy:

e. Nebulizerc.Dressing change
Initial Competency Checklist RN/LPN/LVN (continued)
Initial Competency Checklist RN/LPN/LVN (continued)
Initial Competency Checklist RN/LPN/LVN (continued)
COMMENTS
INITIAL
INITIAL
INITIAL
INITIAL
INITIAL
INITIAL
INITIAL
INITIAL
INITIAL
INITIAL
INITIAL
INITIAL
INITIAL
b. Oral
c. Tracheal
8. Tracheostomy Care
a. Administration
b. Labs
c. Starting/stopping
d. Additives
a. Aseptic technique
b. Sterile technique
b. Sterile technique
a. Gloves
b. Gowns
c. Masks/goggles
d. Shoe covers
Observer Signature/Title
ORIENTATION CHECKLIST
ORIENTATION CHECKLIST
EMPLOYEE
POSITION

ORIENTATION TO

	1. Basic Home Safety: bathroom, electrical, environmental and fire	N/A	SIGNATURE/DATE	-

a.Risks within Agency and patient’s home
b. Actions to eliminate, minimize or report risks
c. Incident reporting and procedures to follow
d. Reporting processes for common problems, failures and user errors.
3.Storage/handling/access to/transport of supplies/medical gases/drugs
4.ID/handling/disposal of infectious wastes (Blood and Body Fluids/Precautions)
5.ID/handling/disposal of hazardous waste (cytotoxic/chemotherapy drugs)

YES
6.Infection Control and Prevention
ORIENTATION TO
ORIENTATION TO
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
SIGNATURE/DATE
b. Fire safety – fire escape, fire alarm system, fire extinguishers and prevention

N/Ab. Fire safety – fire escape, fire alarm system, fire extinguishers and preventionYES20. Pt rights/responsibilities, including conveying charges for care21. Agency complaint mechanism/Medicare state hotline # and purpose24. Ethical aspects of care, treatment and services and process to address ethical issues25. Philosophy/mission/purpose/vision/goals/conflict of interest26. Interpreters/communicating with hearing/speech/ visually impairedc. Security – Personal safety during home visitsSIGNATURE/DATE28. Physical safety (e.g., body mechanics and safe lifting)ORIENTATION TO23. On-call and answering service32. Organizational structure, lines of authority and responsibility; supervision process; Corporate Integrity Plane. Responding to emergencies27. Sentinel event policy/process29. Cultural diversity and sensitivity34. Documentation requirements, including OASIS, if applicable31. Family/State Medical Leave Act22.QAPI program and role30. Role of the health team36. Equal Employment Opportunity Act35. Medical Device Reporting Act33. Hours of work; benefits39. Unemployment and Workers’ Compensation38. Salary/hourly wage reimbursement37. Sexual Harassment Act41. Assessing and managing pain.40. Malpractice coverage(Note: See Job-specific Competency Checklist for Skills)DateDateOtherPolicies and Procedures Manual for Home Health Care © 2000 MED-PASS, Inc. (Revised October 2017)Employee Signature4.13A.4Supervisor Signatured. Utilities7677787980818283848586878889
24. Ethical aspects of care, treatment and services and process to address ethical issues
25. Philosophy/mission/purpose/vision/goals/conflict of interest
26. Interpreters/communicating with hearing/speech/ visually impaired
28. Physical safety (e.g., body mechanics and safe lifting)
32. Organizational structure, lines of authority and responsibility; supervision process; Corporate Integrity Plan
32. Organizational structure, lines of authority and responsibility; supervision process; Corporate Integrity Plan
34. Documentation requirements, including OASIS, if applicable
35. Medical Device Reporting Act
36. Equal Employment Opportunity Act
Date
Date
Date
Date
Date
PERFORMANCE APPRAISAL/EVALUATION
PERFORMANCE APPRAISAL/EVALUATION
PERFORMANCE APPRAISAL/EVALUATION
PERFORMANCE APPRAISAL/EVALUATION

as per Agency policy.

	Provides those services requiring substantial specialized nursing skills.	Makes the initial evaluation visit and regularly reevaluates the	summaries of care conferences on his/her patients in a timely manner	Prepares clinical and progress notes for each patient visit and
Provides services in accordance with the plan of care.
patient’s nursing needs.
Initiates the plan of care and necessary revisions.

Initiates appropriate preventive and nursing procedures.

Coordinates services.

Informs personnel of changes in the condition and needs of the patient.Counsels with the patient and family in meeting nursing and relatedProcesses orders and notifies physician of patient needs and changesCompletes comprehensive assessments within forty-eight (48) hours.
needs.

Completes certification/recertification orders as specified in policy.Implements and documents in nursing notes actions/interventions asDetermines the amount and type of nursing needed for the patient.Initiates individualized care plans based on admission assessment and
in condition.

Reviews, evaluates and updates the care plan based upon assessments.
outlined in the plan of care.

Involves the patient/family in developing the plan of care.
outlined in the plan of care.

Prepares discharge summaries which reflect the care provided and
outlined in the plan of care.

Refers to PT, OT, SLP and MSW those patients requiring their
Reviews, evaluates and updates the care plan based upon assessments.

Choice13
outcomes.

Supervises and teaches other nursing personnel.
outcomes.

Provides appropriate information regarding the patient to otherDirects and supervises performance of LPN as specified, and reportsphysician orders according to Agency policy.
Refers to PT, OT, SLP and MSW those patients requiring their

Choice4
Supervises and teaches other nursing personnel.

Choice7
Provides appropriate information regarding the patient to other

Choice6
Directs and supervises performance of LPN as specified, and reports

Choice1
Supervises HHA’s work every fourteen days, either in the presence of

outlined in the plan of care.agencies/individuals involved in the patient’s care.Supervises HHA’s work every fourteen days, either in the presence ofor absence of the HHA, and completes supervisory visit form.PERFORMANCE APPRAISAL/EVALUATIONParticipates in after hour on-call duty as assigned.in condition.Registered Nurse (RN)Coordinates services.as per Agency policy.specialized skills.Policies and Procedures Manual for Home Health Care © 2000 MED-PASS, Inc. (Revised March 2018)Provides total patient care as needed.findings as appropriate.4.17J.25outcomes.1 - Does Not Meet Standards 3 - Meets Standardsneeds.18192021222324252627282930313233343536373839404142434445464748495051525354
Supervises HHA’s work every fourteen days, either in the presence of

Choice1
Provides total patient care as needed.

Choice3
Agency2344R
Agencyphone2345R
Observes confidentiality, safeguards all patient related information.

Choice1Choice321
Attends staff meetings and patient care conferences as scheduled.

Choice2Choice332
resumptions of care, discharges and significant change in condition in

Choice4Choice31
Completes documentation and paperwork in a timely manner per

Choice10Choice313
Immediately reports to Clinical Manager/Director of Clinical Services

Supervisor SignatureCompletes and submits OASIS assessments, reassessments, transfers,resumptions of care, discharges and significant change in condition inObserves confidentiality, safeguards all patient related information.Attends staff meetings and patient care conferences as scheduled.Completes documentation and paperwork in a timely manner perPerformance Appraisal/Evaluation – Registered Nurse RN continuedObtains knowledge and supervised practice of new skills.Understands and adheres to established policies/procedures.Adheres to Agency standards and consistently interprets andany patient incidents/variances or complaints.Maintains acceptable attendance status, per Agency policy.Maintains acceptable level of tardiness, per Agency policy.Appropriately utilizes ICD-10 codes.accordance with Agency defined time frames.accurately performs all assigned responsibilities.Demonstrates effective time management skills through dailyDemonstrates sound judgment and decision making.Maintains clean and neat work environment.established procedures.Maintains current CPR certification, if required.Services/Clinical Manager.Performs other duties as assigned.Agency policy.2 - Needs Improvement 4 - Exceeds Standardsgroomed.Policies and Procedures Manual for Home Health Care © 2000 MED-PASS, Inc. (Revised March 2018)Date4.17J.26Comments1 - Does Not Meet Standards 3 - Meets StandardsEmployee Signature323334353637383940414243
any patient incidents/variances or complaints.

Reports all incomplete work assignments to Director of ClinicalImmediately reports to Clinical Manager/Director of Clinical ServicesDateDemonstrates competent performance of technical skills according toParticipates in peer review and QAPI activities as requested.Participates in inservice programs and presents inservices as assigned.Appearance is always within Agency standard; is clean and welldocumentation and infrequent overtime for routine assignments.
Demonstrates competent performance of technical skills according to

Choice14Choice15324657
Participates in peer review and QAPI activities as requested.

2435
Understands and adheres to established policies/procedures.

0123
Adheres to Agency standards and consistently interprets and

Choice18Choice313
Maintains acceptable attendance status, per Agency policy.

Choice20Choice313
Maintains acceptable level of tardiness, per Agency policy.

Choice19Choice332
Appearance is always within Agency standard; is clean and well

Choice9Choice31
Participates in inservice programs and presents inservices as assigned.

Choice12Choice313
Maintains clean and neat work environment.

Choice5Choice313
Demonstrates sound judgment and decision making.

Choice13Choice313
Maintains current CPR certification, if required.

Choice6Choice313
Performs other duties as assigned.

Choice6Choice313
Should be Empty:

YES