ANNUAL EVALUATION - PN System

1 EVALUATIONYear: _____Sample 1-855-PNSystemSample 1-855-PNSystemEMPLOYEE EVALUATION SHEET - PROBATION PERIOD / ANNUAL * (circle)Name of Employee: _____Date of Employment: _____ Position/Title: _____Immediate Supervisor: _____EVALUATIONITEM DiscussedExceptional SatisfactoryNon-SatisfactoryImprovement NeededPersonal appearance/ Code of conduct/ BehaviorPunctuality/Visits Frequency complianceAttitude to work /Attitude to other workers and staff Acknowledgment/ Contract-Agreement reviewedAttitude-Communication with patients/familyResponsibility, JOB DESCRIPTION Discussion in details,follow Physician Plan of Care.

2 Updates as guidelinesInitiative/Duties/Abilities/QA -QI-PI/Agency Evaluationprogram participation/learning experienceMorals/Ethics/Courtesy/Conflic t of interestAbility to record relevant notes, delivery on time,documentation guidelines complianceAbility to communicate in legible, professional manner,participation in Case Conference, follow standardsprecautions, Infection control of professional procedures, , Participation in continue education, In-servicesprogram, Reporting guidelines (Agency, Physician). Ability to relate to patient, doctor, community, patient sfamily and other professionalsOverall impression regarding quality of careGOALS SETTINGS:_____Achievement Date: _____Comments: _____Employee/Contractor Signature: _____ Date: _____ _____ Signature of Administrator/DON/Evaluator Date* ANNUAL EVALUATION include: 9 Self EVALUATION /Input 9 Joint Visit 9 Competency 9 Job Description discussion 9 GOALS setting (Managers/Administrators staff: 9 Leader EVALUATION , PAC members.)

3 9 PAC EVALUATION )Sample 1-855-PNSystemEMPLOYEE RESPONSE INPUT (Self EVALUATION )(To improve our services to our patients we need your input and concern, please fil out the following form , andreturn it to our Agency.)Employee Name and Title: _____Date: _____* ANNUAL Competency Skill, EVALUATION SELF EVALUATION As per your ANNUAL skill and/or EVALUATION , we identified:Area that need Improvement: _____Please indicate how you will improve your skill and services, planning and goals setting:_____Plan of care compliance, career development : _____Initiative/Duties/Family-Patient rapport _____* ANNUAL Joint visit on site, Supervisor/Title: _____ Signature: _____As per our joint supervisory visits, we identified the following improvement needed.

4 _____Please indicate how you will improve your services, treatment and procedures:_____Please indicate any concern and suggestion to improve our services, and our relation with youand with our patients/community:_____Employee Signature: _____ Date: _____Sample 1-855-PNSystemHOME HEALTH AIDE/CNA COMPETENCY TEST (PRACTICAL PART)Competency shall be determined through Observation of the Aide s Performance of each ActivityHHA/CNA Name: _____ObservedDateCompetentDateComments/I nitials1- Demonstrate Vital Signs Reading andRecording: Temperature - Oral(adult/pediatric), Pulse - Apical - Radial,Blood Pressure, Respirations2- Observation, reporting and documentationof patient status and the care or servicefurnished3- Appropriate and safe techniques inpersonal hygiene and grooming that include:Bath, Shampoo, Foot, Nail and skin care, Oralhygiene, Toileting and elimination.

5 Assistwith dressing4- Adequate nutrition, feeding, diet and fluidintake5- Basic infection control procedures6- Demonstrate Safe Techniques for Assistingwith Ambulation, ROM, Positioning, Transfer7- Assisting with self administration ofMedication. Medication Demonstrate Safe Techniques for Assistingwith Personal Care & ADL s, including alltypes of baths: Bed, Sponge, Tub, Shower,Chair9- Demonstrate Use of Assistive Devices:Cane, crutches, walker, W/C, Hoyer lift(optional)10- Communications skills, Reportingguidelines to supervisor/Agency11- Maintenance of a clean, safe, and healthyenvironment12- Recognizing emergencies and knowledgeof emergency procedures13- The physical, emotional, anddevelopmental needs of and ways to workwith the populations served, including theneed for respect for the patient, his or herprivacy and his or her Demonstrate Proper Body Mechanics:Transferring self, Transferring patient15- Weight, Pain Management16- Record Intake/Output.

6 Light housekeeping, wash clothesComments:_____DON/Qualified RN Signature: _____Employee Signature:_____ACTIVITYDone in the Patient's Home Office/Dummy PtSample 1-855-PNSystemSample 1-855-PNSystemEvaluating Hand Hygiene TechniqueObservation Audit ToolObservation form to be completed for every contact with the patient/near patient environment for total visit durationPatient Visit date: _____ GRADE/RESULTS: __ Excellent __ Good __ Fair __ Need ImprovementActivity (described in full, handled bedclothes, urinary catheter, wound care):Hands decontaminatedProductTime (in seconds)Surfaces decontaminatedDryingPedal binGloves wornSharpsComments/Recommendations:Activ ities classified as clean or dirtyYes ___ No ___Alcohol base formulation: ____ Hibisol___ Hibiscrub___ Soap___ None _____Dorsal ___ Palmar ___ Interdigital ___Thorough ___Not thorough ___ Not dried___ N/A___Used correctly ___ Not used correctly ___N/A ___Yes ___ No ___Sterile ___Not sterile___Recapped ___ Not recapped ___ N/A ___Staff Name/Title: _____Evaluation Date.

7 _____(Must be completed in Joint visit, assesing a patient, at initial visist, and the annually)Evaluator/Supervisor Name/Title: _____Staff Signature: _____ Evaluator Signature: _____(Results must be addedd to the Agency Aggregated data hand hygiene effectivesness summary report)(Monitoring of the staff at key points in time such as: before patient contact; after contact with blood, body fluids, after contact with contaminated surfaces (even if gloves are worn); before invasive procedures; after removing gloves, after touching patient or patient sorroundings)Sample 1-855-PNSystemHAND HYGIENE KNOWLEDGE ASSESSMENT QUESTIONNAIRE(Use this questionnaire to annually survey clinical staff about their knowledge of key elements of hand hygiene)Staff Name/Title: _____ Evaluator Name/Title: _____ Date: _____1.

8 In which of the following situations hygiene be performed?A. Before having having direct contact with a patientB. Before inserting an invasive device ( , intravascular catheter, foley catheterC. When moving from a contaminated body site to a clean body site during an episode of patient careD. After haven direct contact with a patient or with items in the immediate vicinity of the patient or with a patient orwith items in the immediate vicinity of the patientE. After removing glovesMark the number for the answer:1. B and E2. A, B and D3. All of the above2. If hands are not visible soiled or visible contaminated with blood or other proteinaceous material, which of the followingregimens is the most effective for reducing the number of pathogenic bacteria on the hands of personnel?)

9 Mark the letter corresponding to the single best answer:A. Washing hands with plain soap and waterB. Washing hands with an antimicrobial soap and waterC. Applying ml to 3 ml of alcohol-based hand rub to the hands and rubbing hands together until they feel dry 3. How are antibiotic-resistant pathogens most frequently spread from one patient to another in health in health care settings?Mark the letter corresponding to the single best answer:A. Airborne spread resulting from patients coughing or sneezingB. Patients coming in contact with contaminated equipmentC. From one patient to another via the contaminate hands of clinical staffD.

10 Poor environmental maintenance 4. Which of the following infections can be potentially transmitted from patients to clinical staff if appropriate glove use andhand hygiene are not performed?Mark the letter corresponding to the single best answer:A. Herpes simplex virus infection B. Colonization or infection with methicillin-resistant Staphylococcus aureus C. Respiratory syncytial virus infectionD. Hepatitis B virus infectionE. All of the above5. Clostridium difficile (the cause of antibiotic-associated diarrhea) is readily killed by alcohol-based hand hygiene products True False6.