DSHS Form 10-369 Attachment K "Assisted Living Facility Staff Sample/Record Review" - Washington

What Is DSHS Form 10-369 Attachment K?

This is a legal form that was released by the Washington State Department of Social and Health Services - a government authority operating within Washington. As of today, no separate filing guidelines for the form are provided by the issuing department.

Form Details:

  • Released on October 1, 2021;
  • The latest edition provided by the Washington State Department of Social and Health Services;
  • Easy to use and ready to print;
  • Quick to customize;
  • Compatible with most PDF-viewing applications;
  • Fill out the form in our online filing application.

Download a printable version of DSHS Form 10-369 Attachment K by clicking the link below or browse more documents and templates provided by the Washington State Department of Social and Health Services.

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Download DSHS Form 10-369 Attachment K "Assisted Living Facility Staff Sample/Record Review" - Washington

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Attachment K
AGING AND LONG-TERM SUPPORT ADMINISTRATION (ALTSA)
Assisted Living Facility
Staff Sample / Record Review
ASSISTED LIVING FACILITY NAME
LICENSE NUMBER
INSPECTION DATE
LICENSOR NAME
Inspection Type:
Initial
Full
Follow up
Monitoring
Complaint: Number
STAFF
ADMINISTRATOR
STAFF A
STAFF B
STAFF C
STAFF D
STAFF E
NAME
POSITION
DATE OF HIRE
DATE OF BIRTH
BGI EXPIRE DATE
FINGERPRINT CHECK
(IF NOT REQUIRED,
PUT N/A) DATE
CHARACTER,
COMPETENCE AND
SUITABILITY
TB TEST RESULTS
STEP 1
STEP 2
TB BLOOD TEST, X-
RAY OR SYMPTOMS
WORKSHEET
ORIENTATION TO THE
FACILITY
ORIENTATION AND
SAFETY (5 HOURS)
70 HOUR BASIC /
POPULAION SPECIFIC
*HCA EXEMPT STAFF
ONLY
NURSE DELEGATION
INSULIN
DOH TYPE
EXPIRATION DATE
SPECIALTY TRAINING
Training not available at this time.
ALF ADMINISTRATOR
DEMENTIA*
MENTAL HEALTH*
DDA
FOOD SAFETY /
HANDLER
12 HOURS
CONTINUING
EDUCATION
1
ST
AID / CPR
* Could include documentation employee worked in 2011 and met training requirements at that time or documentation
employee has worked in current home since 2011. Has Fundamentals or Basics of Caregiving Certificate.
Note: If additional staff entries are needed use another copy of this form.
Page 1 of 2
ALF STAFF SAMPLE / RECORD REVIEW
DSHS 10-369 (REV. 10/2021)
Attachment K
AGING AND LONG-TERM SUPPORT ADMINISTRATION (ALTSA)
Assisted Living Facility
Staff Sample / Record Review
ASSISTED LIVING FACILITY NAME
LICENSE NUMBER
INSPECTION DATE
LICENSOR NAME
Inspection Type:
Initial
Full
Follow up
Monitoring
Complaint: Number
STAFF
ADMINISTRATOR
STAFF A
STAFF B
STAFF C
STAFF D
STAFF E
NAME
POSITION
DATE OF HIRE
DATE OF BIRTH
BGI EXPIRE DATE
FINGERPRINT CHECK
(IF NOT REQUIRED,
PUT N/A) DATE
CHARACTER,
COMPETENCE AND
SUITABILITY
TB TEST RESULTS
STEP 1
STEP 2
TB BLOOD TEST, X-
RAY OR SYMPTOMS
WORKSHEET
ORIENTATION TO THE
FACILITY
ORIENTATION AND
SAFETY (5 HOURS)
70 HOUR BASIC /
POPULAION SPECIFIC
*HCA EXEMPT STAFF
ONLY
NURSE DELEGATION
INSULIN
DOH TYPE
EXPIRATION DATE
SPECIALTY TRAINING
Training not available at this time.
ALF ADMINISTRATOR
DEMENTIA*
MENTAL HEALTH*
DDA
FOOD SAFETY /
HANDLER
12 HOURS
CONTINUING
EDUCATION
1
ST
AID / CPR
* Could include documentation employee worked in 2011 and met training requirements at that time or documentation
employee has worked in current home since 2011. Has Fundamentals or Basics of Caregiving Certificate.
Note: If additional staff entries are needed use another copy of this form.
Page 1 of 2
ALF STAFF SAMPLE / RECORD REVIEW
DSHS 10-369 (REV. 10/2021)
Notes
Attachment K
Page 2 of 2
ALF STAFF SAMPLE / RECORD REVIEW
DSHS 10-369 (REV. 10/2021)
Page of 2