Competency of Nursing Personnel

Competency of Nursing Personnel 

Policy 
All members of the nursing staff are assessed and confirmed as competent to fulfill their assigned responsibilities. Each member is assigned clinical and/or managerial responsibilities based on their educational preparation, applicable licensing laws and regulations, and an assessment of current competency. 

Procedure 

Interviewing/Hiring: 

• Competency assessment begins during the initial interview process and includes: 

• Initial screening and an interview with the Director of Nursing or Assistant Director of Nursing. 

• Reference check. 

• Background check. 

• License certification/verification. 

Orientation: 

• All nursing staff employees participate in an orientation program designed to: 

1. Provide the new employee with information necessary to ensure the provision of physical, emotional, and spiritual nursing care to residents. 

2. Assess the competency of the employee to provide safe and competent nursing care. 

3. Orient the employee to policies and procedures that comply with State, Federal, and OSHA standards. 

• The orientation program is coordinated by the Director of Staff Development in collaboration with Nursing Management. Orientation plans, defining the length of orientation, objectives, and broad content outline for orientation programs, are maintained in the Staff Development Office. 

• Orientees are evaluated throughout their orientation program by Nursing Management, Supervisors, and the Director of Staff Development. Decisions to extend an orientation period are made by Nursing Management in consultation with the Director of Staff Development. This decision is based on the assessment of competencies demonstrated, deficiencies, impact on resident care, and resource utilization. 

• Nursing staff assigned to multiple units will be oriented to each area where they must be prepared to function as staff. 

Probation Period: 

• The probationary period is six (6) months from the date of hire. Probationary periods can be extended, or the employee can be terminated at the discretion of the Director of Nursing Services. If an extension is granted, a written action plan to improve employee performance is established by the Director of Nursing and/or Assistant Director of Nursing and the employee. The employee is re-evaluated at the end of the extended probationary period. If consistently competent practice is not demonstrated at this time, the employee is terminated. 

Annual Evaluations: 

• Employees are evaluated annually in the month of their anniversary of the hire date. Re-evaluation may be done at any time interval determined by Nursing Administration for reasons of performance issues or attendance. 

Ongoing Competency Assessments: 

• The competency of nursing staff members is maintained through a combination of ongoing assessment and educational activities, including: 

• Direct observation of nursing practice. 

• Resident satisfaction surveys. 

• Quality improvement/risk management data. 

• Peer review. 

• Self-assessment. 

• Educational activities are designed to meet staff needs based on: 

• Learning needs surveys. 

• Quality Improvement data. 

• Risk Management data. 

• Resident surveys. 

• Direct requests from nursing staff, nursing management, and other departments. 

Documentation: 

• All competency assessments, orientation evaluations, and performance reviews are to be documented and maintained in the employee’s personnel file. 

• Any action plans, probation extensions, and re-evaluation results are also to be documented and included in the personnel file. 

References: 

• Centers for Medicare & Medicaid Services (CMS), State Operations Manual (SOM) 

• Requirements of Participation for Nursing Homes, CMS 

• OSHA Standards