Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in two of three personnel records.
The findings include:
Three personnel records were reviewed on June 27, 2012. Annual staff work performance evaluations were required in three personnel records. The facility did not document annual staff work performance evaluations in personnel records #1 and 2.
Employee # 1 was hired on April 21, 2008. The annual work performance evaluation for 2012 was due by April 2012. The facility failed to document an annual work performance evaluation. The last work evaluation for employee #1 was July 20, 2009.
Employee # 2 was hired on November 2, 1992.. The annual work performance evaluation for 2012 was due by November 2011. The facility failed to document an annual work performance evaluation. The last documented work performance evaluation was completed on April 17, 2006.
This facility has a policy in place to complete work evaluations on the anniversary of the
date of hire.
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Plan of Correction
Audit all Human Resources Record to identify missing performance evaluations.
Notify supervisors to complete past due performance evaluations.
Implement an electronic Human Resources Record
The Human Resources Director will print a monthly report of performance evaluations that are due the following month.
The Human Resources Director will notify the supervisor that the performance review is due.
The Human Resources Director will track performance review completion compliance and follow up with supervisors if a performance evaluation is past due.
The Human Resources Director will report performance evaluation completion compliance results to the Hospital Operations Committee.
The Human Resources Director will report individual supervisor compliance issues to the Project Director.
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