Observations
Based on a review of personnel records, the facility failed to ensure that annual written individual staff performance evaluations, were reviewed and signed by the employee per the facility's policy and procedure manual in three of four applicable records reviewed.
The facility's policy and procedure manual states that the annual job performance evaluations are due at the beginning of each calendar year. Project staff indicated evaluations specifically are to be completed and signed by February 28 each year.
Employee #2 was promoted to facility director on July 22, 2020 and is still in that position at the time of the inspection The annual work performance evaluation was not completed until March 4, 2024.
Employee #3 was hired on March 26, 2018 as clinical supervisor and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until July 3, 2024.
Employee #4 was promoted to clinical supervisor on August 24, 2020 and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until June 21, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All supervisory staff will be trained retrained in the annual evaluation process, and have the policy reviewed. The program director will track all reviews, with due dates and completion dates through an excel spreadsheet. |