2. HR Tracking and HR Competency Review March 2015 2

3. What can HR Tracking Do For You? Reminder Tool Helps You Prioritize Completing Documents System Which Captures All Online Completion dates Can Add Own Fields To Track by Account Print Own Reports Easy Entry 3

5. Active Inactive On-Site Off-Site *If change status to Inactive or Off-Site, then this profile will not count against department compliance percentages until return to Active or On-site status. Status Change

6. Department Profile

7. 7 HR Tracking Report DirectorManager Abuse Reporting Annual Competency Annual Education CICARE Annual Training Cultural Competency Dept Orientation Hospital Orientation Initial CompetencyJob Description Perf Eval Physical Exam TB ScreeningOCR ARVIN,MARTHAARVIN,MARTHA n=21100% 89%100% 83%100% AZAR,RICHARD FAZAR,RICHARD F n=55100% 98% 100% AZAR,RICHARD FGIDEON,MELANIE ANN n=4100% BACA,MICHAEL THOMASBACA,MICHAEL THOMAS n=75100% 97%100% 99%100%79%100% BATISTE,QUANNA NOROTHIABATISTE,QUANNA NOROTHIA n=3100% BETWARDA,MICHELLEBETWARDA,MICHELLE n=122100% 99%100% 80%98%100% BETWARDA,MICHELLERIOS JR,JESSE n=15100%87%100% 87%100%93%100%73%100% BETWARDA,MICHELLEVERKEST,JAMES R n=13100% 92%100% BETWARDA,MICHELLEWEAVER,ANDREW n=22100% 95% 100% 95%100% BOUBELIK,JANE ESTHERBOUBELIK,JANE ESTHER n=5100% BRAUN,THEODOREBRAUN,THEODORE n=5100% 80%100% BROWN-SALTZMAN,KATHERINE ABROWN-SALTZMAN,KATHERINE A n=5100% 80%100% 50%100%80%100% BRUNER, JOHANNAASCENCIO,ERICK n=34100%94%97% 94%100% 97%100%68%100% BRUNER, JOHANNASULLIVAN,ANN MARIE n=33100% 97%100% 97%100%73%100% BRUNER, JOHANNAYANG,ROBERT MENHSIU n=27100% 96%100%96%100%

8. 8 HR Tracking Priorities HR WEB APPLICATIONS All requirements must be at 95% and above at all times to be in compliance OCR must be 100% at all times Reports distributed every other month as reminders Departments/Units have access to own profile 24/7 30, 60, 90 day expiration reports available. PEs most challenging requirement to complete – annual for all Annual Competencies – annual for clinical staff Education Requirements – some one-time, some annual Licenses - 100% compliance at all times Licenses must be current and active or employee cannot work

9. The Hospital Verifies Staff Qualifications It is the responsibility of the department mgr/designee (or Nursing Admin for RN and LVNs) to ensure that all individuals employed in a position requiring a license, CPR certificate, certification and/or degree, assure that primary source verification requirements are met and are current. It is the responsibility of the employees in such positions to maintain appropriate licensure, CPR card, certification, and to renew their license and/or certification prior to the expiration date. Staff cannot work with an expired license, not even with a cancelled check and copy of renewal paperwork. Current Primary Source Verification Printouts must be in all applicable personnel files if not using Evercheck. Evercheck is the automated source verification system utilized to renew licenses. 9

10. License Verification Evercheck, our contracted licensing company monitors license renewals First Phase: All inpatient nursing licenses Second Phase: Ambulatory care areas, SMH, RNPH Third Phase: SOM and identify missing depts. License title and license # entered into database and uploaded to Evercheck system Assigned Evercheck Users to monitor reports for cost centers Evercheck is constantly emailing findings/notifications – approaching expiration dates, and change in license status; license lapse 10 DEBORAH BROWN, UCLA HEALTH SYSTEM There are 2 employee(s) with the license expiration date of 03/21/2015. Please login to your Employer account to access the License Expiration Date report for details. Thank you, EverCheck www.EverCheck.com www.EverCheck.com 2015 Evercheck, All Right Reserved. Privacy Policy & Conditions of Use Privacy PolicyConditions of Use

11. License Verification Receive weekly Exception reports from Evercheck Examples: Name Inquiry, Maryann Smith vs. Mary Ann Smith or license number transposed, i.e. #12345 vs 12435 or Disciplinary action Capture license upon hire and enter into database. Cannot monitor BLS through this system and some licenses are exceptions and still remain a manual review. Will use for upcoming surveys as applicable Now have real time information on daily basis as every license is checked every day rather than waiting for expiration date and renewal process to discover a problem or miss out on something that happened within that last license period. 11

12. License Verification Evercheck Exception Report 12

13. The Hospital Evaluates Staff Performance Performance Evaluations shall be completed for all employees, at every level in the organization, at least every twelve (12) months by the employee's immediate supervisor or designee. A grace period of 60 days is in place to allow for completion, meeting with the employee and signature gathering. Employees are evaluated on all duties described on their Job Description. The job description and the performance evaluation are a combined tool to insure all elements of the job description are reviewed and evaluated annually. 13

14. Must check one or both boxes Must fill in eval period dates Must check applicable age groups 1/1/1412/31/14

15. Check all applicable boxes.

16. New PE Content Latest org-wide PE content

17. SKA section must be completed if form being used as a JD Must check required boxes! Specify Required or Preferred. *HR relies on this section for survey prep. HR refers to this page first when reviewing files so we know what to look for in the file.

18. Date signed MUST be within 60 days of period of evaluation identified on first page of form Evaluator needs to complete this section so employee knows what goals are for next year Evaluator needs to complete this section for final comments Employee needs to identify any education changes here HR Tracking Entry: **date signed on evaluation is entered as “date completed” in PE field ** “date expiring” is based on end date of period of evaluation identified on first page (month and day) and one year later 2/13/15

19. 19 Docs Reviewed During HR/Competency Interview License Verification Printouts (Evercheck or Board) Other Certifications, such as BCLS,ACLS & PALS Job Description Performance Evaluations for the last three years Initial and Annual Competencies Annual Education See File Review form for additional forms *Health System HR should be the first area contacted when a file is requested during a survey, BUT if any Department is called directly for a file, follow-up with HSHR ASAP.

20. Human Resources File Review Employee Name: When a file is requested for survey, prior to sending it to HR, complete this form with all dates and make note of anything missing and what your dept. is doing about it. Title:File Review Date: Hire Date:Dept. Documents Appropriate Documentation Yes / No Comments Follow Up: JOINT COMMISSION & DPH REQUIRED ELEMENTS Age Specific Trng (if app.)/Module & Post TestPut completion datesAdd any noteworthyAnything missing? Annual/Age Spec. Comp. Assessment: Year 1In these columns forexplanations in thisLet HR know what Annual/Age Spec. Comp. Assessment: Year 2all requirementscolumnyour dept. is doing Annual/Age Spec. Comp. Assessment: Year 3 (survey year)to revise/complete Performance Evaluation: Year 1 a req. document Performance Evaluation: Year 2 Performance Evaluation: Year 3 (survey year) Department /Job Specific Orientation CPRWrite in exp. date Licenses/Certifications/Source VerificationWrite in exp. date DPH and UCLA REQUIRED ELEMENTS Abuse, Child Abuse, Adult Abuse, Domestic Confidentiality Agreement Annual Education Post Test (Cert.)HR will reprint CICARE Module and Post Test (Cert.)all online certs. Corporate Compliance Post Test (Cert.) Cultural Competency Post Test (Cert.) HIPAA Privacy & Info Security Training Post Test (Cert.) Hospital Orientation & Post Test (Test or Cert.) Initial Competency Assessment Job Description Employee PhysicalHR will contact OHF Office of Records TB TestOHF for health forms OHF Office of Records Form can be found on HR website under HR Requirements & Forms HR File Review Form

21. HR Survey Related Questions What is your process for competence assessment, maintenance and improvement? Initial Competency Assessment: Performed for all staff at the point of hire or transfer to a new position. Addresses the ages of the patients being served and ALL skills/functions required for the job. Completed and signed by all appropriate parties within six months from the date of hire/transfer. An annual competency assessment: Addresses high-risk and low frequency skills/functions. Skills not required to do every day. Completed and signed by all appropriate parties every twelve- (12) month. Employees in non-clinical and/or non-technical positions that do not have any high risk and low frequency skills/functions associated with their positions are not required to complete the Annual Competency Validation Summary. For any new skills/functions introduced to their positions, training should be provided and a one time competency needs to be validated at that time. The newly identified competency should be added to the new Initial Competency Assessment form for future new employees. Department managers will address their specific competency process in the HR interview as it relates to their area. 21

22. 22 Competency Form – Do You Notice Anything That We Should Avoid Doing On This Form?

23. Performance Evaluation Process Questions Examples: 1. Employee starts work 2/15/14. One year later would be 2/14/15. She goes on maternity leave and is out 9/1/14-12/1/14. When is eval due? Answer: 5/14/15 (2/15/14-2/14/15, plus 3 month leave added to eval period = 2/15/14-5/14/15) This would be 12 months of working time and 3 months on leave. 2a. Eval period is 2/15/14-2/14/15. When is latest date to sign eval to stay within policy? Answer: 4/14/15 (2 month grace period) 2b. If the employee signs this evaluation late on 5/1/15, what is the next 12 month eval period and when is the next evaluation due? Answer: The next evaluation period is 2/15/15 – 2/14/16. The next due date will be 4/14/16, based on the evaluation period, not previous signature date. 23

24. Performance Evaluation Process Questions Examples: 1. What happens when an employee transfers to another department? Answer: A new 12 month eval period starts again on first day in new dept. It works the same as new employees. If employee transfers at 11 th month, it would be nice to give the employee an evaluation, although not required. 2.If a supervisor is behind on evals and wants to catch up because a survey is coming, can they use this eval period? 2/15/13-8/31/14 (this is 18 months of time) Answer: No. Dates cannot be more than 12 months of working time on any evaluation form. Can create 2 evals to capture all the time. One can be for 12 months and another for 6 months of time. (Can complete eval sooner than 12 months, but never longer than 12 months) (HR will look at the current PE policy, process and form because it is a requirement difficult for many areas). 24

25. 25 Going Forward... Upcoming Surveys:  MERP Survey (Medication Error Reduction Plan)- open  PSLS (Patient Safety Licensing Survey) - open  VAD Survey (Ventricular Assist Device)– July-Sept 2015 Same preparation process for all licensing visits:  Use HR Staff as a resource for forms, entry, and compliance  Keep HR Tracking up to date  Be aware of due dates and expiration dates  Complete forms timely  Review documents for completeness before entry and filing  Follow-up with Evercheck Notifications and Exception Reports  Must have current online verification printed prior to expiration date and placed in file OR verified in Evercheck prior to expiration date. --Staff cannot work with an expired license, not even with a cancelled check and copy of renewal paperwork

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