ADON OR DON Skills Checklist
   LAST 4 OF SSN      
I hereby certify that ALL information I have provided on this skills checklist and all other documentation, is true and accurate. I understand and acknowledge that any misrepresentation or omission may result in disqualification from employment and/or immediate termination.  
Instructions: This checklist is meant to serve as a general guideline for our client facilities as to the level of your skills within your nursing specialty. Please use the scale below to describe your experience/expertise in each area listed below.  
Proficiency Scale: 1 = No Experience
2 = Need Training
3 = Able to perform with supervision
4 = Able to perform independently

Rating Stars (Click) Leadership Domain 1 2 3 4  
Communicates effectively with residents, families, significant others and other team members  
Communicates effectively with peers, physicians, and State agencies  
Coordinates resident care to the multidisciplinary team via “at risk meetings, QA and A, rehab meetings, etc.  
Provides updated resident information to physician, resident, family, legal, consultants, State agencies in accordance with regulations and/or BHC standards  
Knowledgeable and able to execute human resource policies as applicable to a variety of people issues.  
Delegates as appropriate  
Actions demonstrate excellent customer service skills and builds relationships with families and associates.  
Monitors the progress of others and associates are held accountable  
Enforces regulatory and employee law compliance  
Rating Stars (Click) Technical Domain 1 2 3 4  
Assesses and monitors staff compliance of infection control and safety programs  
Demonstrates excellent technical skills and judgment, as evidenced by: Daily Start up execution, Follow-up 24 hour report, Computer reports, Medicare Reports, 672/802  
Assess and monitors accuracy of Facility Scorecard and CMS quality indicator data and initiates corrective action as indicated  
Actively participants and contributes to facility QA &A meetings, QR/QRFU and process improvement activities  
Promotes survey preparedness at all times  
Demonstrates basic working knowledge of Computer i.e. ADT, PO’s, MDS modules and management reports  
Demonstrates basic understanding of quality event investigating and reporting process  
Maintains a current knowledge of LTC Federal, state regulations including Medicare, Medicaid and JCAHO as applicable  
Ensure that RAI functions are completed timely for all residents, i.e. concurrent review, State submissions, careplan meetings, etc  
Assess and ensure execution of Facility standards, protocols and policies  
Provides and monitors the effectiveness of clinical orientation and ongoing training to all associates  
Actively participates in recruiting, hiring and orientation of all associates  
Rating Stars (Click) Problem Solving Domain 1 2 3 4  
Utilizes the nursing process to structure care to individual resident ‘s needs  
Demonstrates the ability to assess and interpret data about the resident’s status and ensure timely interventions are executed  
Collaborates with DNS/ Consultants on identified areas of noncompliance and implements necessary corrective actions  
Effectively troubleshoots and ensure allocation of staffing resources to meet the needs of the residents/patients  
Demonstrates understanding of census as it relates to HOL, expense control and budgeted PPD, i.e. nursing supplies  
Assess and monitors discharge, rehospitalization patterns and implements corrective actions as indicated  
Rating Stars (Click) Age Specific Competencies 1 2 3 4  
Infant (Birth - 1 year)  
Preschooler (ages 2-5 years)  
Childhood (ages 6-12 years)  
Adolescents (ages 13-21 years)  
Young Adults (ages 22-39 years)  
Adults (ages 40-64 years)  
Older Adults (ages 65-79 years)  
Elderly (ages 80+ years)