Observations
Based on review of personnel records, the facility failed to document annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee in two of three applicable records reviewed.Employee # 1 was hired as a Facility Director on February 27, 2023 and was current in that position at time of licensing inspection. The annual staff performance evaluation documented in the record did not contain the employee signature.Employee # 3 was hired as a counselor on October 23, 2023 and was current in that position at time of licensing inspection. The annual staff performance evaluation documented in the record did not contain the employee signature.These findings were reviewed with project staff during the licensing process.
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Plan of Correction
The Facility/Project Director will ensure that all annual staff performance evaluations are signed by both the reviewer/supervisor and the staff member. To address this, the following steps will be implemented:The supervisor will print the performance evaluation and provide it to the staff member for their signature prior to the supervisor's sign-off. The signed evaluation forms will be kept as an open agenda item during staff meetings, ensuring that they are returned with both signatures. Follow-up will be conducted to ensure timely completion and return of signed evaluations. By implementing these procedures, we will ensure compliance with documentation requirements moving forward. |