Chapter 1 – Health Care Governance and Administration

1.4.4.1 Dietary Services Staff Onboarding and Competency Assessment

• Policy

  • California Correctional Health Care Services (CCHCS) shall provide all Dietary Services staff including, but not limited to, Food Administrator II, Food Administrator I, Registered Dietitian, Correctional Facility, Supervising Correctional Cook, and Correctional Supervising Cook who provide clinical or support type of services in licensed health care facilities within California Department of Corrections and Rehabilitation (CDCR) institutions with relevant and job-specific orientation and training (onboarding). Clinical competency assessments shall also be provided for applicable clinical job classifications.  This policy shall not be construed as altering existing laws and regulations governing civil service probationary periods or any applicable bargaining unit contract provisions.

• Purpose

  • To establish a comprehensive and standardized onboarding and competency assessment process for Dietary Services staff that:

  • Promotes consistency and standardization among all institutions statewide regarding minimum onboarding expectations for new Dietary Services staff.

  • Supports newly appointed Dietary Services staff with relevant orientation and training by experienced subject matter experts (SMEs) during the probationary period.

  • Facilitates adherence to applicable scope and standards of practice, clinical guidelines, and CCHCS, CDCR standards.

  • Promotes job satisfaction while enhancing Dietary Services staff effectiveness, efficiency, competence, and knowledge.

• Responsibility

  • Statewide

    • The Statewide Chief of Dietary Services is responsible for planning, implementing, and evaluating this policy and procedure on an as-needed basis.

  • Regional

    • The Regional Health Care Executives are responsible for the application of this policy at the subset of institutions within their assigned region.

  • Institution

    • The Chief Executive Officer, or designee, is responsible for the implementation, monitoring, and evaluation of this policy.

    • The Chief Support Executive or the Correctional Health Services Administrator and the institution Food Administrator are responsible for the local application of this policy and procedure, and the supervision of orientation, training, probationary and professional evaluations, and competency assessments for Dietary Services staff.

      • The Chief Support Executive or the Correctional Health Services Administrator and the institution Food Administrator shall coordinate with headquarters and the regional health care office on these tasks.

      • The Chief Support Executive or the Correctional Health Services Administrator and the institution Food Administrator shall defer to an appropriate clinical SME for the validation component and subject matter expertise of these tasks if they do not have the required clinical expertise and experience to perform them.

• Procedure

  • Orientation and On-the-Job Support during the Probationary Period

    • The direct supervisor and applicable SMEs shall use the appropriate Dietary Services Onboarding and Competency Assessment Checklist to ensure each newly hired staff completes the appropriate checklist during the first 90 calendar days of hire. (The checklists are located within the Dietary Services Portal under the Professional Workforce heading.

      • During the staff’s first two weeks of hire, it is expected the staff’s supervisor or SME shall complete items under the “Orientation to the Institution and Dietary Department” section of the checklist, which includes, but is not limited to:

        • Facility tour and introduction to Executive staff.

        • Completion of Human Resources and Information Technology departments mandated forms.

        • Overview of the institution’s or work location’s missions and physical layout.

        • Overview of the new staff’s workspace.

        • Issuance of the new staff’s identification card and other essential work items.

      • Onboarding of the new staff that is institution or work location-based shall address the designated topics specified in the Dietary Services Onboarding and Competency Assessment Checklist.

      • CDCR Non-Custody New Employee Orientation, as applicable to the staff’s assigned work location, is to be completed by all staff within the six-month or twelve-month probationary period. This training is composed of classroom and computer-based modules. The classroom portion is provided by the institution’s In-Service Training Office.

      • Dietary Services staff shall complete Electronic Health Record System (EHRS) training and competency assessment. Training shall include completion of CCHCS Learning Management System EHRS Modules consistent with the staff’s duty statement.
        

      • Dietary Services staff shall complete orientation and mentoring as identified in the Dietary Services Staff Onboarding and Competency Assessment Checklist.

    • Staff beginning independent work shall have access to Dietary Services staff with similar job duties for questions and assistance.

    • Within 90 calendar days after the new staff hire date, the direct supervisor shall ensure completion of the Dietary Services Onboarding and Competency Assessment Checklist and shall review, sign, and maintain the completed forms in the supervisory file of the staff being assessed. If the new dietary staff member is delayed in completing the Dietary Services Onboarding and Competency Assessment Checklist, the direct supervisor may provide additional time on a case-by-case basis to complete the onboarding process and the checklists as soon as possible after the 90 calendar days.

  • Probationary and Professional Performance Evaluations

    • For staff who have a one-year probationary period:

      • The 12-month STD 636 may be completed as soon as 11 months but no later than 12 months after the hire date.

      • Interim STD 636s may be completed as needed between probationary periods, to assess professional performance and clinical competency.

    • For staff who have a six-month probationary period:

      • The six-month STD 636 may be completed as soon as five months but no later than six months after the hire date.

      • Interim STD 636s may be completed as needed between probationary periods, to assess professional performance and clinical competency.

    • Prior to the end of the probationary period, the direct supervisor shall review the probationary evaluations and other clinical and performance observations such as competency assessments in order to make a recommendation regarding permanent civil service employment.

  • Determination of Permanent Civil Service Status

    • After completion of the second STD 636, but no later than one month prior to the end of probation, the direct supervisor shall review the findings and recommendations contained in the probationary evaluations and other documented professional observations in order to make a recommendation about whether to grant permanent civil service status.

    • If there are concerns regarding the performance of the probationary staff, the direct supervisor shall immediately notify their supervisor and the Health Care Employee Relations Officer.

    • A recommendation to reject the staff during the probationary period may occur any time during the probationary period if the previous STD 636, professional practice evaluations, competency assessments, or other documented performance observations show significant concerns regarding the staff’s performance or conduct.

  • Re-orientation of Dietary Services staff (Re-entry Training)

    • For Dietary Services staff who are out of the office for an extended period but did not separate from service with CDCR (e.g., long term sick):

      • If staff has been out for six months or less, the following is required:

        • There must be documentation of prior completion of the Dietary Services Staff Onboarding and Competency Assessment Checklist.

        • Staff shall review all classes, updates, and mandatory training missed.

        • A competency assessment shall be completed for the areas in which staff will be working.

      • If staff has been out for six months to one year, the following is required:

        • There must be documentation of prior completion of the Dietary Services Staff Onboarding and Competency Checklist.

        • Staff shall review all classes, updates, and mandatory training missed, including CDCR Non-Custody Annual Block Training and In-Service Training.

        • A competency assessment shall be completed for the areas in which staff will be working.

      • Staff who are out more than one year shall complete the onboarding process in its entirety upon return.

    • Staff who separate from the Department and then return to state service, regardless of the length of time, shall be required to complete the onboarding process in its entirety.

  • Transferring Between Institutions without a Break in Service or Performing Duties at More Than One Institution

    • The direct supervisor is responsible for ensuring that all Dietary Services staff working at that institution are competent to perform all the duties of the position for which the Dietary Services staff has been hired.

    • The direct supervisor may develop an abbreviated Dietary Services Staff Onboarding and Competency Assessment Checklist for the staff sharing assignments between multiple institutions.

    • Proof of completion of the onboarding process, clinical competencies, and professional performance shall be maintained at each CDCR location. This does not absolve the direct supervisor at each CDCR location from ensuring that annual performance evaluations are conducted or that dietary staff is competent to perform the duties required in their position.

  • Clinical Competency Assessment

    • Program Development

      • Clinical competencies shall be developed by CCHCS headquarters Dietary Services based upon internal and external requirements. Dietary Services leadership shall review and update all clinical competencies developed by Dietary Services, as needed.

    • Competency Components

      • Registered Dietitians (RDs)

      • The California Commission on Dietetic Registration sets forth duties all RDs, regardless of role, population, or specialty, are expected to perform competently. The components of competency include, but are not limited to:

        • Nutrition Screening: The RD performs or obtains and reviews nutrition screening data.

        • Nutrition Assessment: The RD performs via in-person or telemedicine a nutritional assessment and documents the results of the assessment in EHRS.

        • Nutrition Diagnosis: The RD determines current nutrition diagnosis(es).

        • Nutrition Intervention or Plan of Care: The RD determines or recommends a nutrition prescription and initiates interventions. When applicable, the RD adheres to established and approved disease or condition-specific protocol orders from the referring health care practitioner.

        • Nutrition Monitoring and Evaluation: The RD determines and documents the outcome of interventions reflecting input from all sources to recognize primary care team member contributions, the patient experience, and quality outcomes.

        • Discharge Planning and Transitions of Care: The RD coordinates and communicates the nutrition plan of care for patient discharge or transitions of care, or both.

    • Competency Assessment Frequency

      • A competency assessment shall be conducted every six months within the first year of hire. After the first year, a competency assessment shall be completed, at a minimum, on an annual basis for the evaluation of the staff member’s professional performance and clinical competency.

        • The staff member’s direct supervisor shall review the dietary staff member’s duty statement with the staff. This review shall be acknowledged by the staff’s signature on the duty statement. The signed duty statement shall be retained in the supervisor’s staff member file.

      • A competency assessment may also be conducted on an as needed basis for the following reasons:

        • Change in staff member job duties;

        • Quality improvement initiatives;

        • Performance evaluation;

        • Performance Improvement Plan; or

        • New policies and procedures

      • Competency assessment results shall be part of a staff member’s probationary and professional practice evaluation and performance appraisals.

      • Informal, or practice competency assessments may be administered under the direction of Dietary Services leadership as an internal audit to ensure staff members can achieve sufficient competency levels to meet Department and clinical standards. The methodology, scoring, and remediation efforts of these informal assessments shall be established by the Statewide Chief of Dietary Services.

    • Competency Assessment Methodology

      • Competency assessment methods used to measure the individual abilities for specific competency standards include, but are not limited to:

        • Tests

        • Observation

        • Case studies

        • Mock events

        • Quality improvement monitors

      • Some competencies may require a combination of assessment methods. The Statewide Chief of Dietary Services shall determine the particular methodology, scoring, and remediation efforts for the Department’s Dietary Services clinical competencies.

      • Competency assessment forms, checklists, and background materials can be found on Lifeline Dietary Services Resources.

    • Documentation and Tracking

      • A record of Dietary Services staff member’s competency assessments shall be maintained in the following files: their supervisory, the designated regional health care office, and headquarters Dietary Services.

        • Identifying Patient Health Information shall be removed or blacked out to safeguard patient privacy when applicable.

• References

  • California Code of Regulation, Title 15, Division 3, Chapter 1, Subchapter 5, Article 4, Section 3435, In-Service Training

  • California Code of Regulation, Title 22, Division 5, Chapter 3, Article 3, Section 72351 Dietetic Services-Staff

  • California Code of Regulation, Title 22, Division 5, Chapter 12, Article 3, Section 79701, Dietary Services Staff

  • California Department of Corrections and Rehabilitation, Department Operations Manual, Chapter 3, Article 18, General Training

  • Academy of Nutrition and Dietetics: Revised 2017 Scope of Practice for Nutrition and Dietetics Technician, Registered as cited in Journal of the Academy of Nutrition and Dietetics, February 2018, Vol. 118, No. 2.

• Revision History

  • Effective: 05/2022

  • Revised: 09/01/2023