IN - Consumer Specific Competency Training Form

1. Does the individual have any High Risk Plans? If so, for what risk areas? (Please select all that apply and if your client has a risk not listed you must select other and add it) *All of the consumer's risk plans must be selected / added under other option to pass this question. *

Consumer has No High Risks Allergies Assistive Technology Asthma Baclofen Pump Chemotherapy Choking Constipation Communication Constipation Coumadin Deep Vein Thrombosis Dehydration Diabetes Dining Dysphagia Elopement Excoriation (Skin Picking) Fall Hearing Impairment Hoyer Lift Hypertension (BP) Hypospadias Kidney Disease Medication Administration MRSA Multi Story Escape Osteoporosis Pressure Ulcers PRN Medication Psychotropic Medication Scoliosis Seizures Shower Chair Suicidal Risk Toileting Tracheostomy Transfer / Lifting Visual Impairment VNS

2. Which of these documents would provide information regarding whether or not the consumer has approved alone time? *

NOA PCISP CSC None of these

3. All risk plans provide history / baseline information regarding the consumer's individual risks. What other categories of information can you find on the Bridges consumer high risk plan? *

Supervision, Redirection and Documentation info Monitoring, Intervention and Documentation info Redirection and Intervention None of these options

4. Risk Plans include baseline information for all areas of risk specific to individual consumers, which is meant to provide staff with picture of the consumer's current status or what is usual for the consumer daily behavior. If your consumer exhibited behavior that was unusual but not life threatening / medically concerning during your shift but at other times displayed completely usual behavior. How should you respond? *

Continue to observe consumer throughout shift, it is not necessary to report or document unless it is threatening to the consumer's health and safety. Refer to the consumer's High Risk Plan and follow intervention, notification and documentation steps contained in the risk plan as you were trained Immediately call 911 Immediately call the 911 and the consumer's guardian (if applicable), case manager, BMAN and CSFS

5. Who do you call if you do not know how to implement a High Risk plan or do not have equipment or supplies to implement the plan? *

Case Manager Consumer Lead Client Services Field Supervisor (CSFS) Guardian

6. How often are you required to complete CSC training which includes training on the consumer high risk plans? *

Only when you initially begin employment Upon Hire and Annually Only Upon Hire, Annually or when there is a change to a consumer's individual needs / risks. Only annually

7. Who is responsible for conducting consumer specific training with direct support professional staff? *

Consumer Lead Client Services Field Supervisors (CSFS) Behavior Clinician (BMAN) Other DSP staff currently trained to work with the consumer

8. DSP staff are required to enter their time within 24 hours of working their shift. The correct documentation for each shift is REQUIRED to include at least one * shift note task element and at least one consumer specific goal task element. *

True False

9. Which of the following is not a prohibited intervention. *

Aversive Technique Prone (lying face down) Restraint Restraint used for discipline Mechanical Restraint (except when Dr. Ordered) Psychotropic Medication

10. What is the most important reason to be alert and responsive to changes in your consumers status. (ie noticing changes in their usual behavior) *

Early Identification of a change can save a person's life Staff turnover will decrease Major change in status can be difficult to handle

Employee Signature Date

Date

Employee Signature *

Score (This should be number of correct responses)

Based on Score did employee Pass / Fail? (MUST HAVE 8 / 10 OR HIGHER TO PASS) *

Pass Fail

Trainer Signature Date

Date

Signature of Trainer Below indicates that the employee has demonstrated the expected level of competency in the skills areas check marked above as well as received a passing score of 80% or better on the written compentency test.

Trainer Signature / Credentials *

Consumer Specific Competency Training with Competency Test

Competency Testing

Score / Trainers Acknowledgement