“If you don’t have proof, it didn’t happen”, this is something many administrators have heard from surveyors over the years due to their inability to track employee records properly. If training employees is the number 1 key to success, then 1b would be ensuring you keep an accurate and up-to-date employee file, complete with all the necessary information. Check out this regulation provided by DOSS for what is required to be kept in every employee file:
22VAC40-73-250. Staff records and health requirements.
- A record shall be established for each staff person. It shall not be destroyed until at least two years after employment is terminated. Staff records and health requirements.
- All staff records shall be retained at the facility, treated confidentially, and kept in a locked area.
EXCEPTION: Emergency contact information required by subdivision C 9 of this section shall also be kept in an easily accessible place.
- Personal and social data to be maintained on staff and included in the staff record are as follows:
- Name;
- Birth date;
- Current address and telephone number;
- Position title and date employed;
- Verification that the staff person has received a copy of his current job description;
- An original criminal record report and a sworn disclosure statement;
- Documentation of qualifications for employment related to the staff person’s position, including any specified relevant information;
- Verification of current professional license, certification, registration, medication aide provisional authorization, or completion of a required approved training course;
- Name and telephone number of person to contact in an emergency;
- Documentation of orientation, training, and education required by this chapter, including any specified relevant information, with annual training requirements determined by starting date of employment; and
- Date of termination of employment.
- Health information required by these standards shall be maintained at the facility and be included in the staff record for each staff person, and also shall be maintained at the facility for each household member who comes in contact with residents.
- Initial tuberculosis examination and report.
- Each staff person on or within seven days prior to the first day of work at the facility and each household member prior to coming in contact with residents shall submit the results of a risk assessment, documenting the absence of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.
- The risk assessment shall be no older than 30 days.
- Subsequent tuberculosis evaluations and reports.
- Any staff person or household member required to be evaluated who comes in contact with a known case of infectious tuberculosis shall be screened as determined appropriate based on consultation with the local health department.
- Any staff person or household member required to be evaluated who develops chronic respiratory symptoms of three weeks duration shall be evaluated immediately for the presence of infectious tuberculosis.
- Each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.
- Any individual suspected to have infectious tuberculosis shall not be allowed to return to work or have any contact with the residents and personnel of the facility until a physician has determined that the individual is free of infectious tuberculosis.
- The facility shall report any active case of tuberculosis developed by a staff person or household member required to be evaluated to the local health department.
- Record of any vaccinations and immunizations received as noted in 22VAC40-73-100 D.
Top Takeaways:
- Personal and social data to be maintained on staff and included in the staff record are as follows: 1-11
One of the top areas of focus for the DOSS survey team is the employee file. They will pick through staff files with a fine-tooth comb. Ensure you audit the files on a regular basis to avoid any potential issues.
- Initial tuberculosis examination and report.
- Each staff person or household member required to be evaluated shall annually submit the results of a risk assessment, documenting that the individual is free of tuberculosis in a communicable form as evidenced by the completion of the current screening form published by the Virginia Department of Health or a form consistent with it.
One of the top deficiencies we see year in, and year out is failure to have employees screened for tuberculosis and other infectious diseases. Maybe you did screen them, but did you keep an accurate record of that screening? If not, you will be tagged during an inspection. Ensure you or your designee have a system put in place for tracking these screenings.