Policy Manual sample

MDT Home Health Care Agency, Inc. STAFF CONCERN (Form) I. General information 1. Date of incident _____________________ 2.Time of incident _________________ 3. Place of incident ___________________________________________________________ 4. Name of individual(s) involved in incident ________________________________________________ 5.Date this staff concern form completed _____________ 6.Time this staff concern form completed ________________ II. Objective narrative description of incident ________________________________________________________________________________ ________________________________________________________________________________ Ill. Description of identified problems resulting from incident ________________________________________________________________________________ ________________________________________________________________________________ IV. Corrective action implemented __ Yes __ No (Explain) _______________________________________ V. Date corrective action implemented ________________ VI. Description of implemented corrective action ________________________________________________________________________________ ________________________________________________________________________________ FOLLOWING SECTION TO BE COMPLETED BY Director of Nursing, Clinical Manager VII. Review of incident documentation Review date of this completed Staff Concern form _____________ Review time of this completed Staff Concern form _____________ VIII. Description of incident investigation: ________________________________________________________________________________ ________________________________________________________________________________ ________________________________________________________________________________ IX. Additional corrective action implemented __ Yes __ No (Explain) ________________________________________________________________________________ ________________________________________________________________________________ X. Description of implemented additional corrective action: ________________________________________________________________________________ ________________________________________________________________________________ ______________________________________________ _______________ Signature of individual completing this form Date _____________________________________________________________ Signature of Director of Nursing, Clinical Manager Date _____________________________________________________________ Signature of Administrator Date Home Health Agency. - - Personnel/Operations Policies B-62