Observations
Based on a review of personnel files and administrative policies and procedures the facility failed to meet the requirements of this regulation as evidenced by the absence of annual performance reviews in the record sample. In file #2, an annual review was not documented.
The findings include:
Three staff records were reviewed on January 28, 2013. Staff # 2 failed to have an annual work performance evaluation. Staff # 2 was hired in January 2009. The last documented annual evaluation was completed on June 21, 2011. There was no performance evaluation completed in 2012.
This was confirmed by the Facility/Project Director on January 28, 2013.
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Plan of Correction
Facility Director will schedule all employee reviews on the employee date of hire. The Facility Director will use the outlook express meeting schedule to request the employee's attendance.
The Facility Director will schedule all subseqent reviews at beginning of the fiscal year.
The Facility Director will use a excel spreadsheet to keep track of the employee review time period and review the excel spread sheet quarterly as she reviews the employee training completion. The Facility Director will send reminder e-mails to the staff about their review and check for completion. |