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. NURSING SERVICES ASSIGNMENT EMPLOYEE NAME ACTUAL ACTUAL SHIFT MEAL BREAK 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 SIGNATURE CDPH 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 INSTRUCTIONS Direct caregivers not captured in payroll records must capture their direct care service hours 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 provided by such employees as a Director of Nursing in a facility with 60 or more beds and a Director of Staff Development when providing nursing services beyond the hours required to carry out the duties of these positions. SNFs with a subacute unit, shall not count direct care service hours provided in the subacute unit for purposes of determining compliance with the 3.5 and 2.4 minimum standards. CCR, Title 22, section 51215.5(h) prohibits nursing staff assigned to the subacute care unit from being assigned other duties outside of the subacute care unit during any given shift. Direct care service hours of nursing services provided by crosstrained staff who are otherwise regularly assigned to departments such as medical records, housekeeping, dietary or laundry, must be captured on this form. Documentation must delineate the time spent on nursing services. Failure to provide this information will result in the exclusion of all direct care service hours for such employees. 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. Each direct caregiver included on the Nursing Staffing Assignment and Sign-In Sheet must provide an original, written signature next to their printed name. This signature verifies the employee was present in the facility, provided nursing services, and actually worked 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 the information on the Nursing Staffing Assignment and Sign-In Sheet is complete, true and accurate. 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
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