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 two out of four personnel 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 1 each year.
Employee # 1 was hired as the Project Director on September 9, 2019 and is current in that position. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until February 28, 2024.
Employee # 2 has been in the position of Facility Director since February 6, 2020. The annual written staff performance evaluation was due to be reviewed and signed by the employee by February 1, 2024, however, it was not signed by the employee until March 5, 2024.
The findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Annual Performance Evaluations are completed, reviewed with the employee during a documented supervision session, and acknowledged via signature by both parties no later than February 1st of each year.
The Outpatient Directors will ensure that performance evaluations for upper management are completed such as the ones for Division and Project Directors.
The Division Director will complete needed Annual performance evaluations of all the Facility Directors they oversee and will ensure that the Facility Directors complete the annual performance evaluations of the staff they oversee.
The Quality Assurance department will review staff files during semi-annual program reviews to ensure compliance.
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