Observations
Based on a review of personnel records and administrative documentation, the facility failed to provide documentation of individual training plans for all staff listed on the Department's Staffing Requirements Facility Summary Report (SRFSR), except for the newly hired staff who had initial training plans.
The findings include:
Four personnel/training records were reviewed June 11, 2014. The SRFSR was reviewed June 11-13, 2014. It was discussed with the facility staff person who oversees the training program for all facility staff.
It was discovered that there are no specific annual individualized training plans for staff documented for review. The current training system is electronic and contains hundreds of titles for staff to choose from depending on their respective discipline. In reviewing a few staff, it was noted that if a training had been assigned, the training was highlighted and would generate reminder emails if not completed within the assigned time frame. However, there was no documentation showing the employee had consulted with the supervisor and both had input as required by regulation. There was no documentation that demonstrated the training's assigned were appropriate for the employee's skill level.
A specific training plan for any staff person was requested but not presented for review. In discussion with the staff overseeing the training department, it was confirmed the current system does not provide for an individualized training plan nor identify who assigned the training's.
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Plan of Correction
A. A formal written individual training plan will be accomplished by adding specific questions to both the 90 day Performance Evaluation and the Annual Performance Evaluation. A section will be devoted to capture the individual employee's self- identified training needs for the upcoming year; a second section will incorporate the supervisor's approval of the topics and/or recommendations for additional training subjects. Together, these additions will constitute the required documentation for the state mandated "Individual Training Plan". Performance Evaluations will be amended to incorporate the changes to the training plan and implementation will begin immediately following the update. Responsible Persons: Human Resources Director and Staff Development Manager. Completion date
7-18-14
B. Both the employee and supervisor recommendations for annual training will be entered into the Hospital's E-learning system. Supervisors will be trained in how to utilize the e-learning system to enroll their staff in trainings and to track participation in educational offerings. Training of all supervisors will be completed. Responsible Person(s): Human Resources Director and Staff Development Manager. Completion date: 8-1-14
C. Completion of annual training plans and trainings will be monitored by Human Resources on a quarterly basis. Responsible Person(s): Human Resources Director and Staff Development Manager.
Completion date: 4th quarter audit |