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 six out of six 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 on September 9, 2019 as the project director and is still in that position at the time of the inspection The annual work performance evaluation was not completed until February 28, 2024.
Employee #2 was hired on January 10, 2021 s a facility director and is still in that position at the time of the inspection. The annual work performance evaluation was not completed until February 21, 2024.
Employee #3 was hired on January 10, 2021 as a clinical supervisor and was still in that position at the time of the inspection. The annual work performance was not competed until April 10, 2024.
Employee #4 was hired on February 28, 2022 as a counselor and was still in that position at the time of the inspection. The annual work performance was not competed until March 12, 2024.
Employee #5 was hired on January 24, 2022 as a counselor and was still in that position at the time of the inspection. The annual work performance was not competed until March 12, 2024.
Employee #6 was hired on February 14, 2022 as a counselor and was still in that position at the time of the inspection. The annual work performance was not competed until March 13, 2024.
These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
All Gaudenzia Managers will ensure that 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 Chief Executive Officer will ensure that this process is completed for the Project Director.
The Deputy Directors will ensure that this process is completed for all Division Directors.
The Division Directors will complete Annual Performance Evaluations for each of the Program Directors that they oversee and will also ensure that these Program Directors complete Annual Performance Evaluations for the staff that they oversee.
The Quality Assurance department will review staff files during semi-annual program reviews to ensure compliance. |