Skills/Experience Checklist

Transcription

1 Skills/Experience Checklist Nurse Practitioner This form is a self-assessment of your current skills and abilities upon initial application. This form is also used to document skill demonstration. EMPLOYEE PROFILE Last Name First Name Middle Initial Employee Number Direct Supervisor (Name) CPR/BLS Card expiration date Date Form Initiated NP Previous Experience (Sections NP Must Complete) Place X in appropriate column using the key below: A = I am competent to supervise this skill B = I am competent to perform this skill without supervision C = I need to review this skill D = I need additional instruction on this skill E = I have not performed this skill The instructions below will guide you in completing the form, Review or Skill Demonstration (Sections Supervisor or Preceptor Must Complete) Supervisor: Indicate whether or not a review of policies/procedures or instruction is required then document completion in the appropriate columns. If C or D is selected by the NP, review the instruction and skills demonstration (if applicable) prior to assignment to applicable patients Preceptor: Document completion of skills demonstration or indicates NA as applicable. A date and initials in the Skill Demonstration column indicates competency has been achieved. Where actual hands on is not realistic within orientation time (due to case or patient type unavailable), review policy and provide case scenario and indicate this mode of verification of competency. Do not date or initial until competency is achieved. An additional column is provided for repeat demonstrations. Complete the signature section at the end of this form. All NPs must demonstrate competencies for items in bold text and marked with an asterisk (*) prior to the first assignment requiring those skills. DO Direct observation V Verbalization S Simulation CR Chart Review Preceptor/Manager place # of competency and corresponding letter identifying how competency demonstrated in appropriate column(s) ICE Page 1 of 18 APRIL 2016

2 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Core Competencies 1. Accurately measures a Mid-Arm Circumference (MAC) 2. Accurately calculates Basil Metabolic Index (BMI) 3. Assess and Accurately calculates a Palliative Performance Scale (PPS) 4. Assesses and Accurately calculates a Functional Assessment of Staging for Alzheimer s Disease (FAST) 5. Assesses and Accurately calculates New York Heart Association Classification (NYHA) 6. Utilizes approved scales in the Hospice Eligibility Toolbox (HETB) 7. Obtains complete health history 8. Performs complete physical exam 9. Orders/performs diagnostic tests when appropriate 10. Interprets clinical findings 11. Develops differential diagnosis 12. Develops health care problem list 13. Develops/implements appropriate plan of care 14. Identifies/uses available resources 15. Arranges referrals/consults appropriately where indicated. Consulting with physicians Consulting with pharmacists Consulting with IDG team members: social work, spiritual, bereavement, volunteer, etc, Consulting with family, support system community resources Consult with other therapies nutritionist, speech, occupation etc. 16. Coordinates medical follow-up 17. Develops/implements exacerbation prevention plan 18. Develops/implements injury prevention plan 19. Provide patient/family education and counseling disease specific Review or ICE Page 2 of 18 APRIL 2016

3 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Core Competencies 20. Develops/implements injury prevention plan 21. Provide patient/family education and counseling disease specific 22. Provides patient/family education and counseling regarding end-of-life. 23. Documentation to established standards Review or Vital Signs Neuro 1. Accurately takes an apical pulse for one minute 2. Identifies abnormalities in heart rate and rhythm 3. Demonstrates proper technique of taking a BP and identifying abnormalities (i.e. pulse pressure) 4. Evaluates and interpret vital sign trends 5. Pulse oximetry 1. Assesses Level of Consciousness & orientation 2. Assesses sensation, memory, perception and judgment 3. Utilizes approved scales in the Hospice Eligibility Toolbox (HETB) 4. Identifies vasovagal syncope and implements appropriate plan 5. Utilizes additional neuro-specific assessment (evidenced-based) scales and tests outside of toolbox where appropriate (i.e. mini-mental, finger-to-nose test, etc) 6. Recognizes disease-specific features of the following diseases and how they contribute to prognosis and/or hospice eligibility: Stroke (hemorrhagic vs ischemic) TIAs (transient ischemic attacks) Multiple Sclerosis Parkinson s Traumatic Brain Injuries ALS and other neurodegenerative disease Dementias (Alzheimer s, frontal lobe, senile etc.) Brain Tumors 7. Ability to differentiate between dementias based on clinical findings (i.e. vascular (stroke) vs. Alzheimer s) ICE Page 3 of 18 APRIL 2016

4 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Neuro 8. Ability to differentiate between dementias based on clinical findings (i.e. vascular (stroke) vs. Alzheimer s) Review or Respiratory Assessment 1. Assesses breath sounds and interprets clinical findings appropriately. 2. Recognizes disease-specific features of the following diseases and how they contribute to prognosis and/or hospice eligibility: COPD Asthma Chronic bronchitis Emphysema Lung Cancers Aspiration Pneumonias Pulmonary Fibrosis 3. Identifies interrelationship of varies cardiopulmonary disease processes and their impact on prognosis and/or hospice eligibility. 4. Suctioning Identifies and documents indications for suctioning Able to suction secretions (oral, nasal, in tracheal) using proper techniques 5. Tracheostomy Care Able to inflate and deflate cuff when indicated Able to maintain patent airway Provides tracheostomy care per procedure 6. Oxygen administration Properly regulates oxygen via mask, cannula, CPAP, BiPAP Understands Oxygen % and related treatment protocols 7. Ability to manage respiratory treatment modalities (inclusive but not limited to ): nebulizer treatment MDIs and other inhalers BiPAP CPAP 8. Identifies potential and actual problems and appropriate interventions ICE Page 4 of 18 APRIL 2016

5 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Respiratory Assessment 9. Documents assessment, interventions, and evaluation of effectiveness and updates plan of care 10. Peak Flow Meter Application and interpretation 11. Interpretation of Arterial blood gases(abgs) 12. X-ray Interpretation of Chest Review or Cardiac 1. Assesses adequate circulation including pulses, capillary refill, skin temperature, skin color and edema and accurately documents 2. Identifies signs and symptoms of fluid retention 3. Identifies postural hypotension 4. Identifies pacemaker/internal cardiac defibrillator 5. Knowledge on pacemakers and AICDS/distinguish types of pacemakers 6. Understands Pacemaker/Internal Cardiac Defibrillator deactivation 7. Understands related institutional policy. 8. Able to monitor Left Ventricular Assist Device * 9. Able to monitor Inotropic Drug Infusion * 10. Identifies potential and actual problems and appropriate interventions, evaluates effectiveness and updates plan of care 11. Assesses and Accurately calculates New York Heart Association Classification (NYHA) 12. Recognizes disease-specific features of the following diseases and how they contribute to prognosis and/or hospice eligibility: Congestive Heart Failure Various Arrhythmias: Atrial Fibrillation Ventricular Arrhythmias Paroxysmal and sustained SVT Heart blocks Others Cardiomyopathies Myocardial infarctions Others Pericarditis ICE Page 5 of 18 APRIL 2016

6 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Cardiac cont d Skin/Wound Gastrointestinal/Nutrition Coronary artery disease Angina Murmurs/ valvular heart disease 1. Performs skin assessment using Norton Pressure Score Risk Assessment in HETB 2. Demonstrates ability to properly stage pressure ulcers I-IV 3. Ability to differentiate between vascular stasis wounds, diabetic wounds, and pressure ulcerations 4. Ability to manage complex wounds such as weeping, non-healing advanced, deep and/or infected. 5. Identifies potential and actual problems and appropriate interventions by type of wound 6. Performs diabetic skin/foot/nail assessment and teaching 7. Documents wound assessment and wound(s) appearance, interventions at each visit and updates the plan of care 8. Implements Unna boot therapies appropriately 9. Application and/or orders wound dressings appropriate to wound type 10. Suture Removal 11. Suture Insertion 12. Steri-Strip Application 13. Punch biopsy 14. Debridement concepts of wounds 1. Assesses and documents swallowing status 2. Assesses and documents oral and dental status 3. Assesses and documents percentage of intake/changes in intake 4. Able to complete nutritional screening/ assessment 5. Identifies quantity & quality of bowel sounds 6. Identifies potential and actual problems and appropriate interventions including consulting dietitian 7. Initiates bowel program in response to opioid therapy 8. Manages fecal impactions appropriately Review or ICE Page 6 of 18 APRIL 2016

7 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Gastrointestinal/Nutrition Diabetic Management 9. Nasogastric tube Able to change Nasogastric tube Assesses tube for placement and patency Properly performs irrigation Insertion if appropriate 10. Gastrostomy Tube Able to change Gastrostomy tube Assesses tube for placement and patency Properly performs irrigation Maintains site 11. Jejunostomy tube Assesses tube for placement and patency Maintains site 12. Ability to identify dumping syndrome with tube feedings and adjust plan of care appropriately 13. Ostomy management Able to change appliance Maintains skin integrity 14. Documents patient appearance as related to intake i.e. sunken cheeks, cachectic 15. Identifies potential and actual problems and appropriate interventions, evaluates effectiveness and updates plan of care 16. Asses for bowel incontinence 17. Recognizes disease-specific features of the following diseases and how they contribute to prognosis and/or hospice eligibility: Hepatitis Liver cancer Bowel cancers and tumors Malabsorption Malnutrition 1. Reviews trends of blood glucose and interprets findings and its application as a primary or comorbid condition through face to face and/or episodic visits. 2. Identifies patients at risk for hypo and hyperglycemic reactions 3. Knows signs and symptoms of hypo and hyperglycemia 4. Identifies knowledge patient and caregiver knowledge deficits, provides education and documents patient/caregiver understanding Review or KAH HOSPICE Page 7 of 18 APRIL 2016

8 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Diabetic Management Genitourinary 5. Reviews trends of blood glucose and interprets findings and its application as a primary or comorbid condition through face to face and/or episodic visits. 6. Identifies patients at risk for hypo and hyperglycemic reactions 7. Knows signs and symptoms of hypo and hyperglycemia 8. Identifies knowledge patient and caregiver knowledge deficits, provides education and documents patient/caregiver understanding 9. Communicates changes to the physician appropriately and updates plan of care 10. Able to assess and interpret complications common to diabetes, identify if they are present. 11. Able to assess neuropathy using microfilament testing. 12. Able to identify when there is a need for deescalation of diabetic medications and addresses appropriately with HMD. 1. Assesses urine output for quality and quantity 2. Assesses for urinary continence 3. Foley Catheter Able to insert using proper procedure Routinely assess tube for placement and patency Properly performs irrigation Maintains catheter and insertion site 4. Supra pubic catheter care Assess tube for placement and patency Properly performs irrigation Maintains catheter and insertion site Ability to perform a catheter exchange 5. Nephrostomy tube management and irrigation 6. Assesses for signs and symptoms of UTI and adjust plan of care with the collaboration of the HMD and IDG team members. 7. Understands and evaluates related clinical changes with UTI (i.e. VS, behavior, intake, etc) 8. Identifies potential and actual problems and appropriate interventions and updates plan of care 9. Recognizes disease-specific features of the following diseases and how they contribute to prognosis and/or hospice eligibility: Review or KAH HOSPICE Page 8 of 18 APRIL 2016

9 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration GU cont d Differentiates between cystitis and pyelonephritis Benign prostatic hypertrophy Prostatitis Prostate Cancer Bladder and kidney cancers Review or Other body systems Other body systems cont d Ears, eyes, nose throat: 1. Cancers and tumors of head and neck 2. Infectious processes of head and neck including but not limited to: Ear infections Allergic rhinitis Pharyngitis and oral candidiasis Conjunctivitis 3. Cerumen Impaction Removal* Skin: 1. Malignant and benign melanomas 2. Herpes Zoster 3. Scabies 4. Contact dermatitis 5. Tinea Corporis and Tinea pedis Endocirne: 1. Thyroid dysfunction included but not limited to: Graves disease Myexedema General thyroid dysfunction 2. Adrenal insufficiencies and associated disorders Hematological: 1. Various anemias and their impact on hospice eligibility and life expectancy: Iron deficiency Folic acid deficiency Sickle cell Pernicious anemia Musculoskeletal: 1. Recognizes disease-specific features of the following diseases and how they contribute to prognosis and/or hospice eligibility: Osteoporosis Osteomyelitis Rheumatoid arthritis Osteoarthritis Muscular dystrophy KAH HOSPICE Page 9 of 18 APRIL 2016

10 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Functional Status Psycho-social Spiritual 1. Able to complete functional status assessment 2. Identifies potential and actual problems and appropriate interventions including need for hospice aide services 3. Able to differentiate between deficits that are caused by cognitive disease vs physical disease. 4. Identifies potential and actual problems and appropriate interventions including consulting PT and OT as appropriate 5. Positioning a. Able to properly align body b. Supports joints and limbs c. Floats pressure points 6. Identifies actual and potential problems and appropriate interventions 7. Documents assessment, interventions, and evaluation of effectiveness and updates plan of care Identifies and addresses with HMD appropriate need for DME assisted devices or equipment. 1. Able to accurately assess the patients and caregivers coping mechanism, adjustment and risk factors 2. Identifies potential and actual problems and appropriate interventions including use of volunteer services in collaboration with the Medical Social Worker 3. Meets psycho-social needs in collaboration with CMRN and the MSW 4. Understands institutional policy and procedure on client suicide risk Able to differentiate between depression, grief and suicide risk 1. Able to accurately assess patient spiritual/ religious preferences and needs 2. Identifies potential and actual problems and appropriate interventions in collaboration with the Spiritual Care Coordinator 3. Meets spiritual needs in collaboration with the CMRN and Spiritual Care Coordinator (SCC) Review or KAH HOSPICE Page 10 of 18 APRIL 2016

11 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Patient Safety Symptom Management 1. Able to accurately calculate a Fall Risk Assessment Score using the HETB appropriately 2. Able to accurately complete an environmental risk assessment including oxygen safety. 3. Identifies potential and actual problems, and appropriate interventions and updates the plan of care Utilizes principles of proper body mechanics 1. Assess the patient considering individual differences, cultural background, terminal diagnosis, co morbid conditions 2. Consistently evaluates and documents patient outcome measures 3. Identifies the patient s level of pain, dyspnea, anxiety and shortness of breath at each face to face and/or episodic visits using the appropriate scale and documents accurately 4. Plans care based on the patient s assessed needs, symptom management protocols and physician collaboration 5. Evaluates and implements non pharmacological measures 6. Evaluates and documents effectiveness of symptom management and updates plan of care 7. Educates the patient and caregiver on symptom management and documents education and understanding in the medical record 8. Recognizes and addresses (from a hospice philosophy goal of care) the following common GI symptoms associated with end-of-life: Constipation Diarrhea Irritable bowel syndrome Acute gastroenteritis Nausea/vomiting Hemorrhoids Duodenal ulcer Cholecystitis Pyloric stenosis and other upper GI stenosis etiologies dehydration Review or KAH HOSPICE Page 11 of 18 APRIL 2016

12 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Symptom management cont d Infection Control: * Bag Technique * Hand Hygiene * Aseptic Technique * Sterile 9. Recognizes and addresses (from a hospice philosophy goal of care) the following common Neuro symptoms associated with end- of life: Dementia related behavioral disturbances Hallucinations Aggression Psychosis Headaches 10. Recognizes and addresses (from a hospice philosophy goal of care) the following common pulmonary symptoms associated with end- of life: Respiratory failure, respiratory distress and associated dyspnea Upper respiratory infections Cyanosis/mottling 11. Recognizes and addresses ( from a hospice philosophy goal of care) the following common cardiovascular symptoms associated with end-oflife: Bradycardias and tachycardias Low perfusion states ( mentation, mottling etc) 1. Institutes Standard Precautions at all times 2. Performs proper bag technique 3. Performs hand washing per CDC guidelines 4. Uses Personal Protective Equipment (PPE) appropriately 5. Properly handles biohazardous materials 6. Demonstrates proper sharps disposal 7. Understands Exposure Control Plan and related responsibilities 8. Understands responsibility to report patient infections and communicable diseases a. Uses correct form 9. Demonstrates location of Infection Control Policies 10. Demonstrates aseptic and sterile technique appropriately Review or KAH HOSPICE Page 12 of 18 APRIL 2016

13 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Comprehensive Plan of Care Reassessment Discharge Planning 1. Identifies potential and actual diagnosis related to history, physicals and follow-up face to face visits or episodic visits. 2. Develops and implements adjustments to established care plans with the patient / caregivers participation and documents involvement in the medical record. 3. Evaluates needs/progress at each face to face visit and/or episodic visit and addresses findings with the IDG and HMD. 4. Updates plan of care based on on-going assessment, changes in patient condition and goals 5. Actively participates in IDG using the IDG Care Process (when NP attends). 6. Able to communicate measurable data and all clinical findings indicating a limited life expectancy of 6 months or less. 1. Performs ongoing comparison from last face to face visit and/or episodic visit highlighting changes in condition and/or changes in underlying disease process and associated symptomology 2. Documents changes and/or trends in note effectively. 3. Collects and assesses objective and subjective data in a systematic manner, focusing on physical, bio-psychosocial and spiritual status of patient and their response to care 4. Utilizes and understands the tools associated with pain assessment including the pain ad scale and other pain assessment scales 5. Documents pain descriptors appropriately in the medical record 1. Identifies difference between discharge and revocation 2. Assists in coordinating care across the continuum 3. Assists in planning care to include any necessary family counseling, patient education, or other services before the patient is discharged 4. Identifies three (3) reasons CMS allow s a hospice to discharge a patient Review or KAH HOSPICE Page 13 of 18 APRIL 2016

14 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Medication Management Infusion Therapy 1. Identifies drug allergies 2. Observes and reports adverse drug reaction a. Assesses patient for adverse reaction b. Notifies physician and intervenes appropriately c. Reports using incident report 3. Knowledgeable of drug formulary 4. Uses approval process for off formulary medications 5. Patient/Caregiver teaching related to medications a. Explains reason for drug, action and side effects b. Explains precautions related to food-drug interactions c. Explains how to assess for effectiveness and when and how to communicate needs to the RNCM/on-call staff 6. Prescribe appropriate medications, inclusive of selecting correct drug, dose, route for client needs within the scope of hospice goals of care. 7. Prescribe and identify specific nonpharmacological therapeutic interventions for symptom management 8. Reviews medication treatment profile evaluating medication effectiveness, pharmacological and non pharmacological therapy, duplicative therapy, potential and actual drug interactions, and side effects at face to face visits and/or episodic visits with the client/family. 9. Engages HMD and IDG team IDG team and HMD when problems identified. 10. Identifies and discusses with CMRN, HMD and IDG team medications for de-escalation, nonbeneficial and cost effective solutions. 1. Peripheral Catheters a. Prepares patient and IV site b. Inserts and secures using proper technique* c. Flushes lock before and after medication administration using proper technique d. Provides for site care/cap change e. Teaches patient/caregiver f. Discontinues using proper technique g. Documents therapy and site care in the medical record with each intervention Review or KAH HOSPICE Page 14 of 18 APRIL 2016

15 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Infusion Therapy cont d 2. Central Venous Catheters a. Uses sterile technique for dressing changes b. Assesses dressing for drainage; observes for and reports complications c. Flushes before and after medication administration using proper technique d. Follows declotting protocol* e. Provides for site care/cap change f. Discontinues using proper technique g. Draws labs using proper technique* h. Documents therapy and site care in the medical record with each intervention 3. Midline Catheters a. Prepares patient and site b. Inserts and secures using proper technique* c. Provides for site care/cap change d. Flushes before and after medication administration using proper technique e. Documents therapy and site care in the medical record with each intervention 4. PICC Catheters a. Prepares patient and site* b. Inserts and secures using proper technique (requires certification)* c. Provides for site care/cap change d. Flushes before and after medication administration using proper technique e. Documents therapy and site care in the medical record with each intervention 5. Implanted Ports a. Access and deaccess using proper technique* b. Uses sterile technique for dressing changes c. Flushes before and after medication administration using proper technique d. Documents therapy and site care in the medical record with each intervention 6. IV Drip Medications a. Selects appropriate tubing b. Demonstrates expertise in calculation and monitoring IV flow rates c. Checks patency of site; observes for and reports complications d. Changes and labels tubing appropriately e. Documents administration and patient outcome in the medical record Review or KAH HOSPICE Page 15 of 18 APRIL 2016

16 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Infusion Therapy Quality Assessment Performance Improvement (QAPI) Communication Skills 7. IV Push Medications* a. Understands indications and contraindications, solution capabilities and limitations for administration b. Documents administration and patient outcome in the medical record 8. IV Piggyback Medication a. Connects tubing properly b. Discontinues using proper technique c. Documents administration and outcome in the medical record c. Manages TPN Administration appropriately 1. Understands the QAPI function and methodology of improvement (Plan, Do, Check, Act) 2. Actively participates in data collection, audit activities, risk management, when applicable a. Reports and documents all unusual occurrences per Incident Reporting Policy 3. Meets patient safety goals in all practice 4. Actively participates in Performance Improvement Projects (PIP) as appropriate 5. Reports and resolves Patient Grievances using the Grievance Process 6. Identifies and shares improvement opportunities with the leadership team 7. Knowledgeable of Family Evaluation of Hospice Care (FEHC) and key indicators 8. Supports a culture of improvement at all times 9. Promote evidence based practice 1. Demonstrates effective written and oral skills with internal and external customers 2. Communicates relevant patient information verbally and in writing 3. Demonstrates understanding of HIPAA laws regarding communicating/protecting patient information with internal and external customers 4. Demonstrates ability to create and maintain professional relationships with internal and external customers and peers 5. Demonstrates knowledge and limits of nursing practice by working as a team member under the guidance and direction of the Hospice Medical Director and/or the patient identified attending physician Review or KAH HOSPICE Page 16 of 18 APRIL 2016

17 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Communication Skills cont d Changes in Condition/Crisis Management Communication with client/family: 1. Identifies best method of communication to meet the client/caregiver needs (i.e. verbal, written, demonstration) 2. Assesses client/ caregiver knowledge deficit, ability to learn and how each learns best. 3. Shares best methods of connection with IDG and documents in the medical record 4. Listens and speaks clearly and directly to the client/caregiver 5. Identifies special needs i.e. language, vision, hearing and shares needs with IDG 6. Accesses language interpretation line when appropriate 7. Identifies environment that promotes effective communication 8. Requests permission to speak about client and care when others are present i.e. friends, roommates 9. Confirms each visit that the client knows how and when to contact the hospice 10. nurse 11. Confirms the next scheduled visit at the end of each visit 12. Provides education and documents patient caregiver understanding 1. Ensures CMRN, PCM and attending physician is notified of changes in condition found at face to face visits and/or episodic visits. 2. Understands continuous care processes and documents and continuous care (CC) criteria 3. Understands the ordering, handling and disposing of narcotics policy. 4. Ability to recognize and intervene appropriate for the following common changes in condition seen in hospice patients and implement appropriate plan: seizure activity Anaphylaxis Anxiety and/or terminal restlessness GI distress/bleeding Pain crisis (bone pain, acute on chronic) Epistaxis Overdose of sedatives, hypnotics, ingestions and/or poisonings Shock Review or KAH HOSPICE Page 17 of 18 APRIL 2016

18 Previous Experience Guidelines to Evaluate Competency, Review or Skill Demonstration Changes in Condition/Crisis Management cont d Miscellaneous skills (not required) State Specifics Other 5. Communicates effectively with family letting them know what to expect next, answer questions 6. Supports the grieving process 7. Coordinates care with the IDG timely 1. PPD technique, and reading 2. IM steroid injections 3. Trigger point injections 4. Pain management nerve blocks 5. Education of other health providers via in-services or formal CME lecturing 6. Education of the community via speaking engagements. 1. Pain management via controlled substances. a. Involvement of the HMD b. Follows state specific guidelines and company policy and procedure 2. Collaborative agreement active and on file if applicable Review or Initials Print Name Signature/Title Date / / / / / / / / / / / / / / KAH HOSPICE Page 18 of 18 APRIL 2016