Policy Manual sample

MDT Home Health Care Agency, Inc. EMPLOYEE EVALUATION SHEET - PROBATION PERIOD / ANNUAL * (circle) Name of Employee: _______________________________________________________________________________ Date of Employment: _________________ Position/Title: ________________________________________________ Immediate Supervisor: _____________________________________________________________________________ EVALUATION ITEM Discussed Excepti onal Satisfa ctory Non-Satisfactory Improvement Needed Personal appearance/ Code of conduct/ Behavior Punctuality/Visits Frequency compliance Attitude to work /Attitude to other workers and staff Acknowledgment/ Contract-Agreement reviewed Attitude-Communication with patients/family Responsibility, Job Description Discussion in details, Confidentiality/Privacy/HIPAA guidelines Initiative/Duties/Abilities/QAPI/Evaluation program Morals/Ethics/Courtesy/Conflict of interest Ability to record relevant notes, delivery on time, Ability to communicate in legible, professional Knowledge of professional procedures, equipments- Ability to relate to patient, doctor, community, Overall impression regarding quality of care Goals settings:_____________________________________________________________________________ ____________________________________________________________________________________________ Achievement Date: __________________________ Comments: _______________________________________________________________________________ _________________________________________________________________________________________ Employee/Contractor Signature: ___________________________________ Date: ____________ ______________________________________________ _________________ Signature of Administrator/DON, Clinical Manager/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) Home Health Agency. - - Personnel/Operations Policies B-19