All Staff Group Activities Competency Checklist

All Staff Group Activities Competency Checklist

Name:______________________________ Title: ___________________________ Hire Date:_______________

Skill Area		Evaluation (Check One)		Method of Evaluation (Check One) D = Skills Demonstration O = Performance Observation W = Written Test V = Verbal Test				Verification (Initials/Date)
		Competency Demonstrated/ Meets Standards	Needs Additional Training
		Competency Demonstrated/ Meets Standards	Needs Additional Training	D	O	W	V
All Staff	Staff verbalize the protocol to follow when assisting a resident to do an activity in their room
	Staff monitors and verbalizes how to coach residents in proper use of facial coverings
	Staff monitors and verbalizes how to coach residents in proper completion of hand hygiene
	Staff verbalizes understanding of when group activities will not be performed
	Staff verbalizes residents who would be able to participate in group activities
	Staff verbalizes understanding of small group programming and ways to promote attendance
	Staff knows where the designated small group activity locations are
	Staff assist residents to participate in small groups
	Staff are observed assisting residents to pursue activities of interest
	Proper cleaning and disinfection processes are followed as needed
	Staff document resident activity participation and engagement
	Staff demonstrate PPE application and removal and purpose for type of precaution needed
	Staff know how, when and to whom personal and resident symptoms of COVID-19 are reported
Other (Describe)
Other (Describe)

*I certify that I have received orientation in the above-mentioned areas.

*Employee:

___________ _______________________________________ ____________

Initials Signature Date

Evaluator/Trainer:

___________ _______________________________________ ____________

Initials Signature Date

(PLACE IN EMPLOYMENT FILE)

References:

Centers for Disease Control and Prevention. “Using Personal Protective Equipment (PPE). Updated Aug. 19, 2020: https://www.cdc.gov/coronavirus/2019-ncov/hcp/using-ppe.html

Centers for Medicare and Medicaid Services (CMS) State Operations Manual, Appendix PP-Guidance to Surveyors for Long Term Care Facilities. (Rev. 173, 11-22-17): https://www.cms.gov/Regulations-and-Guidance/Guidance/Manuals/downloads/som107ap_pp_guidelines_ltcf.pdf
Centers for Medicare & Medicaid Services. “Nursing Home Reopening Guidelines for States and Local Officials”; May 18, 2020, Revised 09/28/2020; QSO- 20-30-NH; https://www.cms.gov/files/document/qso-20-30-nh.pdf-0
Centers for Medicare & Medicaid Services. “Interim final Rule (IFC), CMS-3401-IFC, Additional Policy and Regulatory Revisions in Response to the COVID-19 Public Health Emergency related to Long Term Care (LTC) Facility Testing Requirements and Revised COVID-19 Focused Survey Tool”; August 26, 2020; CMS QSO Memo 20-38-NH; https://www.cms.gov/files/document/qso-20-38-nh.pdf
Centers for Medicare & Medicaid Services. “Nursing Home Five Star Quality Rating System update, Nursing Home Staff Counts, Frequently Asked Questions” (revised); April 24, 2020 CMS QSO 20-28-nh; https://www.cms.gov/files/document/qso-20-28-nh.pdf
Centers for Medicare and Medicaid Services. “Nursing Home Visitation-COVID-19”; September 17, 2020; https//: cms.gov/files/document/qso-20-39-NH.pdf