Observations
Based on a review of personnel records and an interview with the project/facility director, the facility failed to document the results of a reference investigation in two of eight personnel records, as required.
The findings include:
Six personnel records were reviewed on March 21-22, 2011. Eight personnel records required reference investigations. Per regulation, the personnel records shall include the results of reference investigations. Personnel records # 2 and 5 did not include the results of a reference investigation.
Employee # 2 was hired on October 20, 2008. There was no documentation of a reference investigation in personnel record # 2.
Employee # 5 was hired on January 25, 2011. There was no documentation of a reference investigation in personnel record # 5.
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Plan of Correction
The facility will ensure that the personnel records are maintained and shall include reference investigations and include the results of reference investigations. The Program Director and will monitor the reference investigations and documentation within the personnel records for compliance. |