Performance Appraisal Evaluation (CNA s and Med Techs)

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1 Performance Appraisal Evaluation (CNA s and Med Techs) Employee Name: Reviewer: Review Date: Anniversary Date: 1. BASIC SKILLS ADL s SKILL ** COMMENTS Dressing Feeding Transferring (Multiple Types) Toileting Assistance with Walking Bathing (shower or by hand) Other Tasks Cooking Leading Activity Cleaning Laundry Writing Care Notes Initiating Interaction with Resident Handling a Difficult Resident Using ICareManager Using Intranet Completes daily assignment sheet ** See Last Page for Rating Scale Page 1 of 7

2 2. CUSTOMER SERVICE SKILL COMMENTS Is attentive to residents and their families Displays a positive can do attitude Solves Problems creatively to meet residents and family s needs Is flexible and responds well to change Is a team player who works well with others Engages in one-on-one activities with residents Starts group activities when appropriate Professionally represents our company to all visitors, staff and families Warmly greets families and visitors when they arrive; offers assistance 3. COMMUNICATION SKILL COMMENTS Knows how to approach and communicate with cognitively impaired residents Reviews resident information daily Responds appropriately to family s needs and concerns; (doesn t disclose other residents private information) Listens well and accepts constructive feedback from his/her supervisor Speaks in a professional and calm manner Uses ICare Manager to input information during shift Views the Intranet regularly Communicates clearly both written and verbal; easily understandable; good English skills Page 2 of 7

3 Shows respect to all staff and other professionals; handles conflict effectively Reads and responds in the Communications Log regularly Seeks guidance from supervisor regarding concerns, questions or issues 4. WORK HABITS SKILL COMMENTS Correctly punches in and out of ICM each shift Practices safety in all daily tasks Keeps work environment clean and orderly Shows respect for company equipment, furnishings and surroundings Is organized and completes his/her tasks in a timely manner Follows through on tasks with minimum supervision Dresses appropriately for work (i.e., no heels, no jeans, etc.) Does not use cell phone on the floor Proactively seeks ways to improve job performance Remains up to date on all trainings without having to be reminded Follows instructions and asks appropriate questions Follows company s policy and procedures regularly Supports/assists other team members without being asked, particularly with difficult tasks Takes initiative and goes beyond standard work assignments Page 3 of 7

4 5. ATTENDANCE SKILL COMMENTS Is punctual and reliable - can depend on them to show up on time Fills out Leave Request Forms in a timely manner per company s policies Comes to work on assigned days, does not call out frequently or without reason 6. MEDICINE TECHNICIANS (ONLY) SKILL COMMENTS Review of Med Tech Errors minus 1 point for each minor error, minus 5 points for each major error Washes hands prior to preparing medication Identifies resident appropriately Compares the Physician s Medical Order Form (PMOF), the Medication Administration Record (MAR) and the Pharmacy s medication label for agreement Checks for allergies of resident if administering a new medication or if the resident is new to the med tech Checks the expiration date on the label Stops the procedure if the medication has expired Prepares the medication according to directions Reads the label three times Page 4 of 7

5 Measures or counts right dose Administers the right medication Charts the medication(s) by initialing the correct block on the MAR using ink and immediately following medication administration Should the medication be omitted, charts omission accurately and completely Enter medication order onto the MAR accurately and correctly i.e. to include all of the following: medication, patient, time, dose, frequency, route, start date, end date (shift leaders only) ADJUSTMENTS TO PERFORMANCE SCORE: Warnings/Discussions/Trainings/Absence Issues: (Office to Complete) Number of Unexcused Call Outs in past year (Enter as a negative number) Warnings or Discussions (enter number in past year as a negative number) Suspensions (Enter a -2 for each suspension) Total Warning/Unexcused Callouts/Suspensions (Enter sum of 3 lines above) Number of Leave Without Pay Requests in past year (follow policy on LWOP) List of Trainings Past Due (no raise will be effective until these are up to date; next review date will be 12 months from the time raise is effective) Name of Class Date Due Additional Contributions to the Company: (Office to Complete First Two) Activity Team Leader (add up to 5 points based on rating scale) Showed improvement over past year (add 2 points); (compare prior year s total possible point to this year s total) Introduced new idea or better way of doing task (add up to 2 points and explain in comments) Total Additional Contributions (Enter sum of 3 lines above) Page 5 of 7

6 Comments: OBJECTIVES FOR NEXT TWELVE MONTHS Training(s) Desired/Recommended: Skills Growth to Focus On: Employee Goals for Next 12 Months: Employee Comment: Rating Scale: \ 5- Full Mastery = Performs the skill as it should be done with NO outside prompting, direction or correction; would be able to teach the skill correctly to others 4- Acceptable = Performs the skill without direction but could benefit from minor improvements or more selfinitiative (note which in comments); can adjust skill for various types of residents; occasionally needs prompting to perform 3- Developing = Needs direction or prompting to perform the skill correctly 2- Improvement Required = Has difficulty performing the skill even with direction. Requires greater than usual time and attention by supervisor. Improvement is achievable with coaching and training. 1- Probation/Unsatisfactory = Individual performance is consistently below expectations. (Plan of improvement must be written and re-evaluated within 30 days.) Page 6 of 7

7 SCORING (CNA s and Med Technicians Only) (A) Maximum Points (B) Points Received (C) % of Total Received (B) (A) (D) Weighting Factor Basic Skills 80 10% Customer Service 45 20% Communication 55 20% Work Habits 70 20% Attendance 15 15% Med Tech Duties 70 15% 100% (E) Weighted Score (C) x (D) Less: Warnings (enter as a negative) Plus: Contributions (enter as a positive) Total Performance Score ( Total of three lines above) Employee Signature Date Supervisor s Signature: Page 7 of 7

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