1. Human Resources Chapter Mock Survey Findings Corrective Action Survey Prep Activities May 2016

2. Findings Received During Mock Survey Human Resources Chapter Unit Specific (HR 01.04.01) The hospital provides orientation to staff. Float staff do not receive unit specific orientation Competencies (HR 01.06.01) Staff are competent to perform their responsibilities. No competencies for CNA doing translation No specific sedation competencies in Cath Lab Registry CSD and CSD had no competencies Peds infusion nurse did not have chemo competencies up to date 2

3. HR Chapter Overview of Corrective Action Plans Float Staff – Unit Orientation to every area Contract Staff – UCLA Involvement/Contacts; Orientation; Competencies; Training; JD & PE Competencies – Back-up docs/Tests; Score Legends; Observation/Evidence; Assessment of Unit-Specific Topics; Fire Safety/Emergency Prep topics Evaluations – Organizational Compliance Job Descriptions – Complete Qualifications Section; Consistency in Education, Experience, and Credentials Licenses – Timely Verification; Evercheck System Interpreting/Translating – How to educate the staff; Certification Sedation Competency – National standard vs. UCLA process Chemo Competency – Comps. not up to date 3

4. HR File Review Sessions Mock Survey Findings – how they relate to each dept. Job Description 3 years of performance evals 3 years of annual competencies Initial Competencies Department-specific Orientation License/Credentials CPR HR Tracking dates – consistent with forms HR Files converting to electronic personnel records soon 4

5. HR Requirements Competencies: Unit Specific and basic tasks Include fire safety and emergency preparedness Back up docs/evidence of steps observed Tests with scoring/score legends/pass or fail Include all contract staff and registry in process Contract language for Registry staff- abide by all policies and procedures 5

6. Specific Competency Findings Chemo – Plan set for competency completion for all RNs; recent approval through ONS and APHON Sedation – Plan set for recertifying staff; 6 hr. didactic and demonstrative class; accredited; new online presentation and quiz in addition to class. Interpreter/Translating – Info. added to Service Recovery Training 7x/month; Inservices and dept. mtgs. by Hala Fam, but staff turnover is high 6

7. HR Requirements Job Descriptions On the JD page with the requirements/qualifications, please be clear on what is checked off and identified. Make sure this section is completed If specialty certifications are required, be sure to include them on JD in the requirements section. If section is blank, can raise questions when it is a clinical position. Be clear on whether requirement is preferred or required. Be consistent across JDs. Be consistent on baseline education / knowledge required for anyone entering that job Be consistent on experience required If a manager, be consistent with managerial experience requirements 7

8. HR Requirements Evaluations: Qualifications section completed and consistent for all job titles 12 month timeframe max Timeframe should be the same each year no matter the signature date on eval Complete field that says “Period Covered by this Evaluation”. Need to identify the timeframe here. Looking for 3 years of evals; no missing blocks of work time 8

9. HR Requirements Department-Specific Orientation: Floaters orientated to all areas worked for safety and emergency items; document where oriented Include all contract staff and registry in process Articulate what environment of care/safety topics are covered throughout the year Training: Document promotion/management training Bring all course details to interview Show proof of UCLA certified interpreter training if translating or interpreting for patients 9

10. HR Requirements License/Credentials Evercheck TIMELY Primary Source Verification remains priority Qualifications listed on JD – preferred or required CPR Current copy of cards in file Cannot use automated system (Evercheck) to verify CPR New card names from AHA and ARC AHA – Basic Life Support ARC – Basic Life Support for Healthcare Providers 10

11. Ongoing Preparation Activities File review sessions continue HR Tracking Report – Monthly/Bi-Monthly distribution Automated emails – 15 th of the month reminders of what is due/overdue in HR Tracking Timely delivery of docs to HR for filing; scanning started Primary Source Verification remains priority – through Evercheck or manually through each applicable Board During survey, HR will contact the dept. manager and dept. rep. of the personnel file chosen as soon as we get the employee name. 11

12. Human Resources Document Guidelines for HR Tracking. 12 Human Resources Document Guidelines for HR Tracking Documents Date Expiring Comments Abuse Reporting – Child, Adult, Domestic (3 forms)12/31/9999One time only Age Specific Training (if app.)/Module & Post Test12/31/9999One time only – Growth and Development Module. Specific titles only. Annual Competency AssessmentOne year after hire dateAnnual/Due at the end of the month the next year. Specific titles only Annual Education Post test –online (Cert.) One year after hire dateAnnual / Auto Download CICARE Module and Post Test – online (Cert.) 30 days after hire date, then annualAnnual/ Auto Download Compliance Module and Post Test –online (Cert.)30 days after hire date, then 12/31/9999One time only / Auto Download Confidentiality Agreement 12/31/999One time only Cultural Competency Post Test –online (Cert.)30 days after hire date, then 12/31/9999One time only/ Auto Download Cybersecurity Training –online 30 days after hire date, then annualLMS System/ Annual / Auto download CPR Card (BLS, ACLS, PALS, NALS, etc. (check JD)See card for expiration dateUsually every 2 years, due at end of month, 2 yrs after class date Department /Job Specific Orientation30 days after hire date, then 12/31/9999One time only. Must complete again if transfer Flu Vaccine SurveyDue immediately after hire date between 10/1- 3/31. Use 10/1 of survey year as exp. date. Annual / Auto Download. Based on online flu survey date, not when you receive flu shot. Valid between 10/1 and 3/31 each year only. If hired between 4/1 and 9/30, wait until new survey available to complete HIPAA Privacy & Info Security Trng & P&P (Cert.)12/31/9999One time only. Completed prior to start date before access can be given Hospital Orientation & Post Test-online (Cert.)30 days after hire date, then 12/31/9999One time only. Online module. NOT date of attending Day One class. Auto download FYI: The following are Placeholder fields - No Updates needed in HR Tracking for: * HIPAA Confidentiality * HIPAA Security * HIPAA Edu and Training program

13. Documents Date Expiring Comments Initial Competency Assessment6 months after hire date, then 12/31/9999 One time only. If transfer or reclass to new job, then must do again after first 6 months. Job Description12/31/9999One time only. Complete, sign and date ASAP after hire date. Complete again if transfer or reclass. Licenses/Certifications/Source Verification printout (when verified / when expiring)? See expiration date on credential.Source verification printout from Board website must be printed prior to expiration date. Evercheck must renew on system prior to expiration date. Mobile Device Attestation – online (Cert.)30 days after hire date, then 12/31/9999. One time only/ Auto Download Performance Evaluation3 and 6 months for specific titles. Policy says annual. One year after hire date. Annual / Cannot have more than 12 months of working time included in eval. Next eval exp. date is based on 12 month eval period, NOT signature date. Radiation Safety Training – online (Cert.) 30 days after hire date, then annual Annual/ Auto Download Safe Patient Handling Training – online (Cert.) 30 days after hire date, then annual Annual/ Auto Download Sexual Harassment Training – online 30 days after hire date, then annual LMS System/ Annual / Auto download Physical Examination12/31/9999One time only. If transfer and never had one, complete upon transfer TBOne year after TB completed upon hire Annual/Due at the end of the month the next year. Any manually added entriesDepends on dept requirementManager can manually add unique dept. fields if needed Human Resources Document Guidelines for HR Tracking. Date Codes: 1/1/1900 – No info inputted / default date 12/31/9999 – Req. has been satisfied/ One time only

14. Thank You!