QAPI Program Utilization_Manual

PERSONAL FILES AUDIT FORM Employee Name: ____________________________________ Position: __________ Date of Hire: __________ Audit conducted by: ______________________________________________________ Date: ______________ 9 Initial Interview 9 Conflict of Interest 9 Board of Director Members (Annually signature of Conflict of Interest) 9 Position Application 9 Dated and signed All Statements (General tables) 9 Verification of citizenship or authorization to work in the US (I-9 Form) 9 Reference Checks (two(2) for all staff, including office, owners, etc) 9 Personnel credentialing, license, education (Diploma if required) 9 Ethic Conduct form (Licensure verification at hire and annually, Verification of Qualifications) 9 Hepatitis B vaccination or declination 9 Job Description (signed by employee and supervisor, dated) 9 Alzheimer’s Initial information 9 Valid Motor Vehicle Insurance, declaration page if available 9 Valid Driver license 9 Zero fraud tolerance form 9 Policy during the Absence of the Administrator and DON 9 National Sex Offender check 9 OIG’S exclusion List check 9 CPR Card 9 OSHA Certificate 9 Personnel Policies Review or receipt of Employee Handbook with signature 9 Social Sec. Copy 9 Orientation (topics per the discipline) 9 Confidentiality Agreement, HIPAA oath 9 Competency Assessments all disciplines (writing/practice at hire, practice part annually) 9 (2) Glucometer Competencies 9 HHA (75 hrs)/CNA (40 hrs) Training hours verification 9 Valid Professional Insurance copy 9 IRS Forms 9 W-4 (Direct Employee) 9 W-9 Independent Contractor ( 9 Tax Exception Form) 9 Agreement/Contract, signed, dated 9 Affidavit of Compliance with background screening Confidential: 9 Criminal Background Check (at hire and every 5 years) 9 Physical Exam/TB Screening (At hire and 9 Medical Questionnaire annually Medical Certificate) Evaluations: 9 Probation Period (90 days) (use first page of Evaluation, all disciplines, including Office staff) 9 Goals settings/met date 9 Annual Evaluation: 9 Joint Visit by DON or qualified designee (Annual observation of job duties) 9 Practical Part of Competency (Reflect Positive and/or Negative Outcomes) 9 Self Evaluation (by each employee) 9 Goals settings/met date 9 Discussion Job Description, duties, responsibilities 9 Other ____________________ 9 If leader, leader evaluation (Administrator and Alternate Competency) In-Service ORIENTATION REQUIREMENTS 9 Compliance Program (fraud and abuse) In-service (annual) 9 Patient’s Rights (initial and annual) 9 Advance Directives, Grievance, Complaints (annual) 9 Board of Director Orientation 9 Regulations members Orientation 9 Non-Clinical Staff Orientation 9 Additional training for special populations, community served, cultural background, diversity (annual) 9 Ethical issues (annual) 9 Position Change In-service (if applicable) 9 Infection Control, TB precautions, OSHA requirements, safety and infection control plan, Handwashing, Nursing Bag, Bloodborne pathogens (annual) 9 Supervisor training 9 Medical Device, Orientation to equipment safety (annual) 9 Biomedical Waste Protocol (annual DOH requirement) 9 Orientation no conveying charges, Service Agreement (annual) 9 Safety issues relating to building, personnel, equipment, patient/family safety and security in the home and work environment, fire, Office Equipment safety, Personal safety techniques relating to in home care/service safety 9 Emergency plan, Disaster Drill (annual) 9 Home Care Professional Boundaries 9 Office Staff training required (8 hrs annual) 9 Office Staff Safety training 9 Personal Care staff (12 hrs) 9 Other: __________________________________________________ Required by License, State regulations (12 hrs annually) 9 CPR as required 9 HIV (lifetime) 9 Medical Errors Prevention, safety as required 9 Domestic Violence as required 9 Medical Record Documentation and Legal Aspects as required 9 Communication with Cognitively Impaired Clients as required 9 Alzheimer’s 2 hrs training curriculum (lifetime, AHCA approved training only) Comments: ___________________________________________________________________________________ ____________________________________________________________________________________________ Auditor Signature:____________________________________________________ Date: ___________________ 129