Initial Comments:
Based on the findings of an unannounced onsite state re-licensure survey conducted August 17, 2021 and August 18, 2021, Pampering Plus Inc., was found not to be in compliance with the requirements of 28 Pa. Code, Part IV, Health facilities, Subpart G. Chapter 601.
Plan of Correction:
601.21(f) REQUIREMENT
PERSONNEL POLICIES
Name - Component - 00
601.21(f) Personnel Policies.
Personnel practices and patient care
are supported by appropriate, written
personnel policies. Personnel records
include qualifications, licensure,
performance evaluations, health
examinations, documentation of
orientation provided, and job
descriptions, and are kept current.
Observations:
Based on a review of agency policy, personnel file reviews (PF), and interview with the Agency's Administrator/Director of Nursing, it was determined the agency failed to follow agency policy to ensure that personnel files contain yearly performance evaluations for one (1) of four (4) PF reviewed (PF # 1).
Findings include:
A review of agency policy "Performance Evaluations" was conducted on 8/18/21 at approximately 10:30 A.M. which stated, "A competency-based performance evaluation will be conducted for all employed after one (1) year of employment and at least annually thereafter..."
A review of personnel files was conducted on 8/18/21 from approximately 9:30 A.M. to 10:30 A.M.
PF #1 , Date of Hire: 7/22/11. The PF did not contain documentation of any yearly performance evaluations completed since hire.
Interview with the Agency's Administrator/Director of Nursing on 8/18/21 at approximately 12:00 P.M. confirmed the above findings.
Plan of Correction:Prior to any employee providing care to a skilled care patient, a performance evaluation will be completed and placed in the employee file.
Going forward annual performance evaluations will be completed on all employees who provide care to skilled care patients.
Employee file audits will be performed quarterly by our Operations Manager to ensure compliance.
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on August 17, 2021 and August 18, 2021, Pampering Plus, Inc., was found to be in compliance with the requirements of 28 Pa. Code, Health Facilities, Part IV, Chapter 51, Subpart A.
Plan of Correction:
Initial Comments:
Based on the findings of an onsite unannounced state re-licensure survey conducted on August 17, 2021 and August 18, 2021, Pampering Plus, Inc., was found to be in compliance with the requirements of 35 P.S. 448.809 (b).
Plan of Correction:
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