Observations
Based on a review of personnel records, the facility failed to document annual staff work performance evaluations in three of five personnel records.
The findings include:
Five personnel records were reviewed on January 21, 2014. Annual staff work performance evaluations were required in four personnel records. The facility did not document annual staff work performance evaluations in personnel records # 1, 3, and 4.
Employee # 1 was hired on April 4, 2011. The documented work performance evaluation was signed and dated by the employee on March 1, 2013; however it lacked the signature and date of a supervisor/evaluator verifying that this was presented to the employee by the supervisor/evaluator.
Employee # 3 was hired on June 16, 2010. The documented work performance evaluation was signed and dated by the employee on June 10, 2013; however it lacked the signature and date of a supervisor/evaluator verifying that this was presented to the employee by the supervisor/evaluator.
Employee # 4 was hired on November 1, 2012. An annual work performance evaluation was due by November 1 2013, but was signed and dated by the employee on December 12, 2013. Additionally, it lacked the signature and date of a supervisor/evaluator verifying that this was presented to the employee by the supervisor/evaluator.
The Project Director did not dispute the findings.
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Plan of Correction
The Director of Outpatient Services will review the review policy in the year 2014 and have a new employee review template for the year 2015. Currently both employees are required to fill out the document twice and sign twice which can allow for error.
The Director of Outpatient Services will meet with the employee during the time of the review and check for signatures on the employee portion prior to starting the review. The Director will then forward the reviews to the President of the Board to ensure all signatures are on the document
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