Program/Site Specific Section

Program Name: Residential

R9-20-204 completion date: ______________________
R9-20-206 completion date: ______________________

Site: __________________
Driver training observation date: ____________

| Shifts and schedules

DESCRIPTION

VERIFICATION SIGNATURE

TITLE/CRED

DATE

TITLE/CRED

DATE

Knowledge of employees current work schedule and all shift schedules

Knowledge of staff scheduling software/posted schedules
Knowledge of A shift Responsibilities (7 am 3:30 pm)
Knowledge of B shift Responsibilities (3 pm 11:30 pm)
Knowledge of C shift Responsibilities (11:15 7:15 am)
Knowledge of lunch breaks and staff breaks
Knowledge of client and petty cash policy and procedure
Knowledge of mail, staff mailboxes, and interoffice mail
Knowledge of job description and scope of practice
Monitoring property/perimeter at various times (Interior and Exterior)
Knowledge of NextGen Bedboard/Hourly attendance sheet
Knowledge of Policies and Procedures (E-Learning and Physical binders)
Knowledge of on-call procedure and location of posted crisis protocol

| Rules/Tones
DESCRIPTION
Thorough Description of House Rules and Tones
Knowledge of assigning chores and kitchen duties to clients in NextGen
Knowledge of Transportation procedures and forms
Knowledge of client appointments and entering pass requests in NextGen
Knowledge of activity schedule (groups, phones & TV times)
Knowledge of appropriate TV shows and movies
Knowledge of contraband and room search protocol
Introduction and Knowledge of check-ins and debriefing protocol
Introduction and Knowledge of In house Visitation
Introduction and Knowledge to Off-Site Passes and Activities
Introduction and Knowledge to Off-site Activities
Introduction and Knowledge of Client Privileges
Introduction and Knowledge to Client Accountability /Behavioral Contracts/ Site
Retreat
Introduction and Knowledge of Caffeine Policy
Knowledge of Commissary requests

VERIFICATION SIGNATURE

| Programming
DESCRIPTION

VERIFICATION SIGNATURE

TITLE/CRED

DATE

TITLE/CRED

DATE

TITLE/CRED

DATE

Knowledge of Group Schedule

Knowledge of CA/Clinician groups
Introduction and Knowledge of facilitating groups/promoting group process
Introduction and knowledge of 12 step programs and site protocol
Visual Observation and Interaction of Staff Member Facilitating a Group

| Documentation
DESCRIPTION

VERIFICATION SIGNATURE

Knowledge of Incident Reporting and Event Notification

Knowledge of LSS logs including Nursery Log, Medication Log, and Site Log.
Documentation of NextGen shift prog notes
Documentation of Contact Notes in NextGen
Documentation of Group Notes in NextGen
Documentation of Individual Notes in NextGen
Documentation of Site log notes
Knowledge of ROIs in NextGen
Knowledge of CA Shift Change Report
Knowledge of online shared network files and forms (DC2)
Knowledge of filing forms in binders
Knowledge of filing in client charts and location

| Clinical knowledge and competence

DESCRIPTION
Knowledge of ancillary services: clinics, case managers, advocates, guardians,
probation/parole officers, ACT teams, CPS
General Confidentiality Laws as it relates to Telephone
Procedures/Facebook/Twitter/Email
General Confidentiality Laws as it relates to Client Records & Information
Knowledge of Client treatment that Promotes Client Dignity, Independence,
Individuality, Strengths, Privacy, and Client Choices
Knowledge of Client Treatment that Promotes Client Choices
Understanding of scheduled time for Clinical Supervision and utilizing online
Supervision Form
Understanding of Continuing Education Hours and Lifewell required annual
trainings
Knowledge of concurrent review process with RBHA and entering authorizations on
NextGen

VERIFICATION SIGNATURE

| Intakes/Discharges
DESCRIPTION

VERIFICATION SIGNATURE

TITLE/CRED

DATE

TITLE/CRED

DATE

TITLE/CRED

DATE

Knowledge of Intake process on NextGen/policy,procedure/protocol

Knowledge of Releases of Information on NextGen
Knowledge of referral process
Knowledge of RBHA communication
Introduction and Knowledge of approved items
Knowledge of storing client items in storage, safe
Introduction and Knowledge of Client Elopement Procedures
Knowledge of donation items
Knowledge of preparing and sanitizing dorm rooms for a new client
Knowledge of discharge protocol and discharge summary on NextGen

| Nursery/CPS/Child visits
DESCRIPTION

VERIFICATION SIGNATURE

Introduction and knowledge of staffs role in the nursery

Policies and procedures to ensure safety of children on site including keeping
chemical s out of childrens reach and other potential hazards
Knowledge of procedures regarding child visits when an S.O. is on property
All children entering the nursery need a wellness check by nursery staff to note any
scars, bruises and injuries
Knowledge of Universal precautionary measures including wearing gloves when
diapering, cleaning bodily fluids
Knowledge of not laying infants on their tummy
Knowledge of monitoring children in the bathroom
Completion of nursery orientation with nursery supervisor
Knowledge of nursery curriculum Parenting and Nurturing
Knowledge of different procedures for supervised CPS visits, unsupervised CPS visits,
child visits from 0-12 and visits from 13 to 18
Knowledge of CPS based role in clients treatment
Knowledge of child ratio to staff
Knowledge of crisis protocol for child onsite
Knowledge of medical protocol for child onsite
Knowledge of medication protocol for children

| Safety/Crisis
DESCRIPTION
Knowledge of Fire Extinguisher Locations
Knowledge of Exit Evacuation Protocol/ Routes and Plans
Knowledge of Emergency/Crisis numbers and protocol
Knowledge of vehicle accidents/crisis protocol
Knowledge of Smoking procedure/protocol and smoking locations

VERIFICATION SIGNATURE

| Inspections
DESCRIPTION

VERIFICATION SIGNATURE

TITLE/CRED

DATE

TITLE/CRED

DATE

Knowledge of Inspection forms, binders, posted assignments, and procedures

Completion and documentation of emergency lighting inspection
Completion and documentation of exit lighting inspection
Completion and documentation of smoke detector inspection
Completion and documentation of water heater inspection
Completion and documentation of ice machine inspection
Completion and documentation of air filter inspection
Completion and documentation of fire extinguisher inspection
Completion and documentation of electrical panel inspection
Completion and documentation of daily/weekly vehicle inspection
Completion and documentation of quarterly internal inspection
Completion and documentation of environmental review

| Environmental compliance
DESCRIPTION
Are the site grounds free of debris/cigarette butts/ paper?
Are the furnishings in good repair?
Are the furnishings and premises free of odors?
Are the furnishings and premises free of insects, bedbugs, and rodents?
Are the furnishings and premises free of trash or refuse?
Are the furnishings and premises free of hazards?
Is the room temperature between 65 and 85 degrees? Has the thermostat been
tampered with?
Is water available and accessible to the client at all times?
Is the hot water maintained between 90 and 120 degrees?
Do the Lamps have Light Bulbs to provide sufficient lighting?
Are toxic and cleaning materials labeled in a locked area away from food and
clients?
Are trash and refuse stored in covered containers or plastic bags?
Are trash and refuse removed from the premises at least once a week?
Are designated smoking area signs conspicuously posted? Are nonsmoking signs
posted?
Is the premise accessible to mobility impaired clients?
Does the bathroom have soap for hand washing?
Does the bathroom have paper towels or air hand dryers?
Does the tub or shower have a slip resistance surface?
Does the bathroom have ventilation or a window that opens?
Are there any cracked electrical outlet faceplates?
Are there outlet covers for all unused electrical outlets?
Are any of the light covers cracked or dirty?
Is the property free of electric cords?

VERIFICATION SIGNATURE

| Medication Forms and Procedures

DESCRIPTION

VERIFICATION SIGNATURE

TITLE/CRED

DATE

TITLE/CRED

DATE

Knowledge and use of Lifewell Standing order form and Over the Counter
Medications
Knowledge of processing Medical/Psychiatric Transportation Sheet (Referral form)
Knowledge and use of Prescription Fax Form to Pharmacy for filling medications
Knowledge and use of Prescription Log Form
Knowledge and use of Narcotics Form and Narcotic Prescription Protocol
Knowledge of Quarterly Inspection Report Form
Knowledge and use of Monthly Medication Sheet and Transcribing instructions from
medication container to Medication Sheet
Knowledge of Flow Sheet from Health Care Provider
Knowledge of Medication Abbreviations
Knowledge of Medication Times
Knowledge of Proper Storage of Current Medications (internal and external)
Knowledge of Proper Storage of Overflow Medications
Knowledge of Proper Storage of Over the Counter Medications
Knowledge of Proper Storage of non-oral Medications
Awareness of Medication Errors and Adverse Reactions
Knowledge of Psychotropic Medications and Side Effects
Knowledge of Informed Consent and Client Refusal to take Meds
Knowledge of Procedure for Filling Medications
Knowledge of Pharmacies used
Knowledge of weekend Prescriptions
Introduction to Medical Director and Contact Information and knowledge of contact
script form
Knowledge of Procedure for contacting Medical Director when Narcotics are
brought in during intake and /or prescribed
Knowledge of Vital Signs (Blood Pressure, Temperature, Weight)
Documentation of Insulin Testing Results
Knowledge of clients taking medications with a FULL glass of water

| Medications in NextGen
DESCRIPTION
Knowledge of UA rules procedures and documentation in NextGen
Knowledge and performance of entering new medications in the medication module
on NextGen
Knowledge and performance of assigning medication times in NextGen
Knowledge and performance of receiving medications in NextGen
Knowledge and performance of discontinuing medications in NextGen
Knowledge and performance of destroying medications in NextGen
Monitoring self administration of medications- Observation #1
Monitoring self administration of medications- Observation #2
Monitoring self administration of medications- Observation #3

VERIFICATION SIGNATURE

| Kitchen Health and Sanitation

DESCRIPTION

VERIFICATION SIGNATURE

TITLE/CRED

DATE

Knowledge of foodborne illness and contamination prevention techniques

Knowledge of labeling leftovers 7 days out and reheating leftovers
Knowledge of food storage
Knowledge of receiving invoices and orders from vendors
Knowledge of food temperatures and thermometer calibration
Knowledge of thawing frozen foods
Knowledge of cutting board colors
Knowledge of staffs role in the kitchen
Knowledge of client kitchen chore rotation and expectations
Knowledge of food handling techniques
Knowledge of portion control and nutritional expectations
Knowledge of modeling table etiquette
Knowledge of sanitation techniques using bleach water solution
Knowledge of refilling juice and sanitizing drink containers
Knowledge and demonstration of 3 compartment sink dish washing process and air
drying dishes
Knowledge and demonstration of using bleach strips to test bleach solution used for
dish and appliance sanitation
Knowledge and demonstration of labeling, refilling, and storing chemicals
Knowledge of trash and recycling
Knowledge of client clearance to work in the kitchen including current TB test and
client kitchen test
Knowledge of wearing hair nets, gloves, and aprons in the kitchen
Knowledge of storing food including keeping food at least 6 inches off the floor and
15 inches from the ceiling

Comments:_______________________________________________________

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Employee Signature

Job Title

Credentials

Date

Direct Supervisor Signature

Job Title

Credentials

Date

Site Supervisor Signature

Job Title

Credentials

Date