Employee Self Evaluation Form Sample

ANNUAL EVALUATION

Year: ______

HHA

CNA

EMPLOYEE EVALUATION SHEET - PROBATION PERIOD / ANNUAL

*

(circle)

Name of Employee: _______________________________________________________________________________

Date of Employment: _________________ Position/Title: ________________________________________________

Immediate Supervisor: _____________________________________________________________________________

EVALUATION

ITEM Discussed

Exceptional Satisfactory 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,

follow Physician Plan of Care, Updates as needed.

Confidentiality/Privacy/HIPAA guidelines

Initiative/Duties/Abilities/QA-QI-PI/Agency Evaluation

program participation/learning experience

Morals/Ethics/Courtesy/Conflict of interest

Ability to record relevant notes, delivery on time,

documentation guidelines compliance

Ability to communicate in legible, professional manner,

participation in Case Conference, follow standards

precautions, Infection control compliance.

Knowledge of professional procedures, equipments-med.

device, Participation in continue education, In-services

program, Reporting guidelines (Agency, Physician).

Ability to relate to patient, doctor, community, patient’s

family and other professionals

Overall impression regarding quality of care

GOALS 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: 9 PAC Evaluation)

Lumar's Health Care, Corp.

HHA

CNA

EMPLOYEE RESPONSE INPUT (Self Evaluation)

(To improve our services to our patients we need your input and concern, please fil out the following form, and

return 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 servicesSODQQLQJDQGJRDOVVHWWLQJ:

______________________________________________________________________________

Plan of care complianceFDUHHUGHYHORSPHQW: _________________________________________________

______________________________________________________________________________

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:

______________________________________________________________________________

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 you

and with our patients/community:

______________________________________________________________________________

Employee Signature: ____________________________________ Date: __________________

Lumar's Health Care, Corp.

HOME HEALTH AIDE/CNA COMPETENCY TEST (PRACTICAL PART)

Competency shall be determined through Observation of the Aide’s Performance of each Activity

HHA/CNA Name: ___________________________________________________________________________

Observed

Date

Competent

Date

Comments/Initials

1- Demonstrate Vital Signs Reading and

Recording: Temperature - Oral

(adult/pediatric), Pulse - Apical - Radial,

Blood Pressure, Respirations

2- Observation, reporting and documentation

of patient status and the care or service

furnished

3- Appropriate and safe techniques in

personal hygiene and grooming that include:

Bath, Shampoo, Foot, Nail and skin care, Oral

hygiene, Toileting and elimination

.

Assist

with dressing

4- Adequate nutrition, feeding, diet and fluid

intake

5- Basic infection control procedures

6- Demonstrate Safe Techniques for Assisting

with Ambulation, ROM, Positioning, Transfer

7- Assisting with self administration of

Medication. Medication reminder.

8- Demonstrate Safe Techniques for Assisting

with Personal Care & ADL’s, including all

types of baths: Bed, Sponge, Tub, Shower,

Chair

9- Demonstrate Use of Assistive Devices:

Cane, crutches, walker, W/C, Hoyer lift

(optional)

10- Communications skills, Reporting

guidelines to supervisor/Agency

11- Maintenance of a clean, safe, and healthy

environment

12- Recognizing emergencies and knowledge

of emergency procedures

13- The physical, emotional, and

developmental needs of and ways to work

with the populations served, including the

need for respect for the patient, his or her

privacy and his or her property.

14- Demonstrate Proper Body Mechanics:

Transferring self, Transferring patient

15- Weight, Pain Management

16- Record Intake/Output. Catheter/Ostomy

care.

17- Light housekeeping, wash clothes

Comments:_________________________________________________________________________________

DON/Qualified RN Signature: _______________________________ Employee Signature:_____________________________

ACTIVITY

Done in the Patient's Home

Office/Dummy Pt

Lumar's Health Care, Corp.

Evaluating Hand Hygiene Technique

Observation Audit Tool

Observation— form to be completed for every contact with the patient/near patient environment for total visit duration

Patient no._________________ Visit date: _________________ GRADE/RESULTS: __ Excellent

__ Good __ Fair

__ Need Improvement

Activity (described in full, e.g. handled

bedclothes, urinary catheter, wound care):

Hands decontaminated

Product

Time (in seconds)

Surfaces decontaminated

Drying

Pedal bin

Gloves worn

Sharps

Comments/Recommendations:

Activities classified as clean or dirty

Yes ___ 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: __________

(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)

Lumar's Health Care, Corp.

HAND 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. In which of the following situations hygiene be performed?

A. Before having having direct contact with a patient

B. Before inserting an invasive device (e.g., intravascular catheter, foley catheter

C. When moving from a contaminated body site to a clean body site during an episode of patient care

D. After haven direct contact with a patient or with items in the immediate vicinity of the patient or with a patient or

with items in the immediate vicinity of the patient

E. After removing gloves

Mark the number for the answer:

1. B and E 2. A, B and D 3. All of the above

2. If hands are not visible soiled or visible contaminated with blood or other proteinaceous material, which of the following

regimens is the most effective for reducing the number of pathogenic bacteria on the hands of personnel?

Mark the letter corresponding to the single best answer:

A. Washing hands with plain soap and water

B. Washing hands with an antimicrobial soap and water

C. Applying 1.5 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 sneezing

B. Patients coming in contact with contaminated equipment

C. From one patient to another via the contaminate hands of clinical staff

D. Poor environmental maintenance

4. Which of the following infections can be potentially transmitted from patients to clinical staff if appropriate glove use and

hand 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 infection

D. Hepatitis B virus infection

E. All of the above

5. Clostridium difficile (the cause of antibiotic-associated diarrhea) is readily killed by alcohol-based hand hygiene products

True False

6. Which of the following pathogens readily survive in the environment of the patient for days to weeks?

A. E. Coli

B. Klebsiella spp

C. Clostridium difficile (the cause of antibiotic-associated diarrhea)

D. Methicillin-resistant Staphyloccus aureus (MRSA)

E. Vancomycin-resistant enterococcus (VRE)

Mark the number for the best answer:

1

. A and D

2. A and B 3. C, D, E 4. All of the above

7. Which of the following statements about alcohol-based hand hygiene products is accurate?

Mark the letter corresponding to the single best answer:

A. T

hey dry the skin more than repeated handwashing with soap and water

B. They cause more allergy and skin intolerance than chlorhexidine gluconate products

C. They cause stinging of the hands in some providers due to pre-existing skin irritation

D. They are effective even when the hands are visible soiled

E. They kill bacteria less rapidly than chlorhexidine gluconate and other antiseptic containing soaps

Staff signature: __________________________ Evaluator Signature: ________________________

Lumar's Health Care, Corp.

HANDWASHING

COMPETENCY EVALUATION

Employee Name: ____________________________________________ Title: _________

Items

Yes No N/A

Comments

1. Wets hands and wrists completely:

points fingers downward

2. Applies soap over entire hand/wrist

area; lathers well

3. Scrubs hands and wrists well,

paying attention to fingernails and

between fingers.

4. Rinses well, keeping fingers pointed

Downward

5. Dries hands and wrists completely

Using a paper towel or a clean hand

towel

6. Turns off faucet with the paper towel

or cloth towel

7. If no running water or Handwashing

Facilities not available, uses a

Packaged Handwashing product or

Hand sanitizer

Additional Comments:

Signature/Title of Evaluator:__________________________________ Date:____________

Lumar's Health Care, Corp.

BAG TECHNIQUE

COMPETENCY EVALUATION

Employee Name: __________________________________________ Title: _________

Items Yes No N/A Comments

1. Bag is placed on clean hard surface

2. Barrier is utilized as appropriate

3. Bag is placed out of reach of

children and animals

4. Antiseptic no rinse gel or towelettes is

available for Handwashing if necessary

5. Washes hands before entering the bag

6. Equipment used is cleaned prior

to returning to bag if appropriate

7. Clean and dirty supplies are

maintained separately

8. Supplies are maintained in the bag and

checked for expiration on a regular basis

Additional Comments:

* Never Place the Bag on the Floor or Upholstered Furniture

* Never Take a Bag into a house with bed bug or insect infestation.

* Never take a Bag into a house with MRSA or antibiotic resistant organism.

Signature/Title of Evaluator:________________________________ Date:__________

Lumar's Health Care, Corp.

Fillable Printable Employee Self Evaluation Form Sample

Fillable Printable Employee Self Evaluation Form Sample