Nursing Staffing Assignment And Sign In Sheet California
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State of California-Health and Human Service Agency California Department of Public Health NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET (DHPPD SALARIED/DUAL ROLE/NURSE ASSISTANT) 1. FACILITY NAME 2. DATE OF PATIENT DAY (MM/DD/YY) 3. DIRECTOR OF NURSING/DESIGNEE 4. SHIFT 1 2 3 5. SHIFT START TIME (HH:MM AM/PM) 6. STATION/WING/UNIT/FLOOR 7
ACTUAL ACTUAL NURSING SERVICES SHIFT MEAL BREAK ASSIGNMENT EMPLOYEE NAME DISCIPLINE START/ END START/END EMPLOYEE SIGNATURE x x x x x x x 8. I have reviewed and verified all staffing assignments are true and accurate. Employees not captured in payroll records, nurse assistants or employees who are primarily engaged in duties other than nursing services that provided nursing services during the patient day are recorded and their direct care service hours to be included in Direct Care Service Hours Per Patient Day are accounted for with an original signature
X DIRECTOR OF NURSING/DESIGNEE SIGNATURECDPH 530 (06/19) 1 State of California-Health and Human Service Agency California Department of Public Health DHPPD SALARIED/DUAL ROLE/NURSE ASSISTANT NURSING STAFFING ASSIGNMENT AND SIGN-IN SHEET INSTRUCTIONSDirect caregivers not captured in payroll records must capture their direct care servicehours on this form. This includes nursing management, supervisors, registry, contract,nurse assistants, and corporate staff
For example, this may apply but not be limited to, the direct care service hours providedby such employees as a Director of Nursing in a facility with 60 or more beds and aDirector of Staff Development when providing nursing services beyond the hoursrequired to carry out the duties of these positions
SNFs with a subacute unit, shall not count direct care service hours provided in thesubacute unit for purposes of determining compliance with the 3.5 and 2.4 minimumstandards. CCR, Title 22, section 51215.5(h) prohibits nursing staff assigned to thesubacute care unit from being assigned other duties outside of the subacute care unitduring any given shift. Direct care service hours of nursing services provided by cross-trained staff who are otherwise regularly assigned to departments such as medicalrecords, housekeeping, dietary or laundry, must be captured on this form. Documentationmust delineate the time spent on nursing services. Failure to provide this information willresult in the exclusion of all direct care service hours for such employees
The Nursing Staffing Assignment and Sign-In Sheet must be legible. All employeenames must be include both first and last name
Corrections and modifications must be completed on the Nursing Staffing Assignmentand Sign-In Sheet to document employee absences, substitutions, and/or schedulechanges. Legible pen/ink changes are acceptable
Each direct caregiver included on the Nursing Staffing Assignment and Sign-In Sheetmust provide an original, written signature next to their printed name. This signatureverifies the employee was present in the facility, provided nursing services, and actuallyworked the hours stated. Initials are not acceptable
Only the employee that worked the nursing assignment may sign for him/herself
The form must be signed by the Director of Nursing or his/her designee verifying theinformation on the Nursing Staffing Assignment and Sign-In Sheet is complete, true andaccurate
CDPH 530 (06/19) 2 State of California-Health and Human Service Agency California Department of Public Health 1. Enter the facility name
2. Enter the date of the patient day in MM/DD/YY format
3. Enter the name of the person who has Director of Nursing responsibility for the day
4. Circle the appropriate shift: one, two or three
5. Enter the shift start time in HH:MM AM/PM format
6. If applicable, enter the name of the specific location in the facility for the patient assignments
7. Record only direct caregivers not otherwise captured in payroll records. Enter the specific patient assignment and the employee’s name responsible for the patient assignment. Enter the employee’s discipline (RN, LVN, CNA, NA, Psych Tech). Enter the employee’s actual shift start and end time. Enter the start and end time of the employee’s meal breaks. The employee must sign the form
8. At the conclusion of each patient day, the Director of Nursing or his/her designee shall sign the form verifying the nursing assignments are true and accurate and that all assignments are accounted for with an employee signature, or state a reason why the assignment was vacant. The DON or designee should not sign the 530 form to verify his or her own time. The facility administrator or other designated staff should sign to verify the hours
CDPH 530 (06/19) 3
State of California-Health and Human Service Agency California Department of Public Health . 1. Enter the facility name. 2. Enter the date of the patient day in MM/DD/YY format.
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What are the requirements for the nursing staffing assignment and sign in sheet?
The Nursing Staffing Assignment and Sign-In Sheet must be legible. All employee names must be include both first and last name. Corrections and modifications must be completed on the Nursing Staffing Assignment and Sign-In Sheet to document employee absences, substitutions, and/or schedule changes. Legible pen/ink changes are acceptable.
How do i complete assignment sheet nursing?
The tips below can help you complete Assignment Sheet Nursing easily and quickly: Open the template in our feature-rich online editing tool by clicking on Get form. Fill in the necessary boxes which are marked in yellow. Click the green arrow with the inscription Next to move on from one field to another.
How do i assign nursing shifts to the designated unit layout?
Now you can easily assign nursing shifts to the designated unit layout of average patients using our Standard Nursing Student Assignment Sheet Template. The main layout of this template is a list of columns with the labels for your personal information and the patient details for the specified nurse.
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