Missing Competency Assessment Documentation

Honestly you don’t want to draw attention to anything missing when it comes to inspections, but just show that going forward you have tightened up ship and made changes. Knowing that there is a chance you will be cited for missing comps.

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You should list this internally as a risk for being cited for missing competencies maybe when you do tracers prior to inspections. Inform everyone that should be informed about this. Since there is no documentation, you will be cited for it. The fact that you are aware of it and have a plan now prior to being cited is the correct approach. If cited, you can use what you already have in place as part of your response to the findings.

Agree with Juan, that internally you should write up some kind of risk assessment and corrective action.  When an inspector sees that you knew about it and had addressed it, he/she will less likely to cite you.

Just some thoughts...are you sure they are 'missing' or did the previous person start storing them in a different place.? I find it hard to believe that they weren't done. or an entire year was misplaced.  

What was the process? Do you keep them in POC, in staff personnel files with their manager or in HR?

The process I inherited in 2005 was that all competency forms were sent to their nurse mgr to reside in files. Once a nurse left the hospital they went to HR. I had a huge problem with 'missing' competencies that the managers would want me to recreate every inspection year.  In 2010 I started scanning all competencies into my computer before I sent them to mgrs. It was a little more work but it has paid off in spades. Last September our TJC inspector was impressed with how quickly I could pull up the competencies of whomever she desired. I haven't had to have a mgr pull papers since I started scanning. Most inspectors are OK seeing the scanned copies because it saves them time.  

Back to your immediate problem...I wouldn't be above calling or emailing your predecessor to see if they remember where they were put. Worst thing that can happen is they don't respond and you know you tried. Everyone has given you good advice for if they are definitely non-existent.

Just a thought....

Lois.snider@stclair.org

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Thank you for your responses! It is an odd situation because my predecessor had the perfusion tech (who I think may have been a med tech) perform all the competency assessments and that person has also left the organization. The competency paperwork that was stored in a binder in that department only contained items from 2014 - 2017, then nothing. I did address the issue in my IQCP assessment and listed my corrective action of keeping a folder for each operator in my office. 

I like the scanning idea a lot going forward. Thanks again. Y'all are the best! 

That is odd and of course both have left. lol.  Guess there's nothing much you can do but what you have at this point.

I do have nursing educators that do CNA/PCA comps and a Family Birth educator that does comps after I do theirs. They all return the completed forms to me, I check to make sure the forms are filled out properly and then scan them and return. Scanning would save you valuable file space.

Good luck. Don't volunteer anything during inspections but if they ask for 2018 and you don't have it, be honest. Always worked for me. At least you won't be surprised. You seem to be on top of things for being new. You will be fine!

Lois

I would make some kind of internal statement that you can sign off on (or maybe your Laboratory/Medical Director) stating that records have been misplaced due to a coordinator change, then show what you are currently doing to the inspector.

If you are using CAP, the waived testing competency does not need to include all six markers, so you may be able to actually have something on those.  For non-waived testing, all six apply so that may be the group that causes you trouble.