INITIAL COMMENTS
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This report is a result of an on-site licensure renewal and buprenorphine monitoring inspection conducted on February 7, 2024, by staff from the Department of Drug and Alcohol Programs, Bureau of Program Licensure. Based on the findings of the on-site inspection, White Deer Run of York was found not to be in compliance with the applicable chapters of 28 PA Code which pertain to the facility. The following deficiencies were identified during this inspection:
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Plan of Correction
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704.9(c) LICENSURE Supervised Period
704.9. Supervision of counselor assistant.
(c) Supervised period.
(1) A counselor assistant with a Master's Degree as set forth in 704.8 (a)(1) (relating to qualifications for the position of counselor assistant) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 3 months of employment.
(2) A counselor assistant with a Bachelor's Degree as set forth in 704.8 (a)(2) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(3) A registered nurse as set forth in 704.8 (a)(3) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 6 months of employment.
(4) A counselor assistant with an Associate Degree as set forth in 704.8 (a)(4) may counsel clients only under the close supervision of a trained counselor or clinical supervisor for at least the first 9 months of employment.
(5) A counselor assistant with a high school diploma or GED equivalent as set forth in 704.8 (a)(5) may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor.
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Observations
Based on a review of five personnel records, the facility failed to ensure that two counselor assistants were counseling clients under the supervision of a trained counselor or clinical supervisor based on their education.Employee #4 was hired on September 1, 2023 as a counselor assistant. Employee #4 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #4 did not receive direct observation from September 1, 2023 through December 1, 2023. Employee #4 did not receive close supervision from December 1, 2023 through the date of the inspection. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . During documented supervision only reported formal case reviews occurred and direct observation did not. Employee #5 was hired on October 10, 2023 as a counselor assistant. Employee #5 has a high school diploma and may counsel clients only under the direct observation of a trained counselor or clinical supervisor for the first 3 months of employment. For the next 9 months, the counselor assistant may counsel clients only under the close supervision of a lead counselor or a clinical supervisor. Employee #5 did not receive direct observation from October 10, 2023 through January 10, 2023. Employee #5 did not receive close supervision from January 10, 2023 through the date of the inspection. Close supervision is defined by regulation as follows: " Formal documented case review and an additional hour of direct observation by a supervising counselor or a clinical supervisor once a week " . During documented supervision only reported formal case reviews occurred and direct observation did not. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The facility will follow counselor requirementsfrom DDAP for hiring and supervision.
The facility will be sending a letter to request Act66 flexibility in the hiring requirement.
The Assistant Director will review employee resumes prior to hiring to determine if they meet the requirements for a Counselor and proceed with the correct form of supervision.
Ongoing: Human Resources and the Assistant Director will determine if a candidate is to be hired and the requirements they will need.
Director will review with clinical staff and will ensure proper training and supervision is being conducted and documented.
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704.11(b)(1) LICENSURE Individual training plan.
704.11. Staff development program.
(b) Individual training plan.
(1) A written individual training plan for each employee, appropriate to that employee's skill level, shall be developed annually with input from both the employee and the supervisor.
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Observations
Based on a review of the personnel records, the facility failed to provide a written individual training plan for each employee, appropriate to that employee's skill level in two out of five employee records reviewed.Employee #3 was hired on October 10, 2022 as a counselor and was still in the position as of the date of the inspection. The facility failed to submit documentation of an individual training plan.Employee #5 was hired on October 10, 2023 as a counselor assistant and was still in the position as of the date of the inspection. The facility failed to submit documentation of an individual training plan.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will ensure all annual training plans are completed and available for the pre submission process.
Annually HR will collect from all managers the training plans for the upcoming year.
Director will keep a copy of all training plans on site.
HR will review all training plans to ensure they are completed and will be responsible to submit these on pre submission.
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704.11(d)(2) LICENSURE Annual Training Requirements
704.11. Staff development program.
(d) Training requirements for project directors and facility directors.
(2) A project director and facility director shall complete at least 12 clock hours of training annually in areas such as:
(i) Fiscal policy.
(ii) Administration.
(iii) Program planning.
(iv) Quality assurance.
(v) Grantsmanship.
(vi) Program licensure.
(vii) Personnel management.
(viii) Confidentiality.
(ix) Ethics.
(x) Substance abuse trends.
(xi) Developmental psychology.
(xii) Interaction of addiction and mental illness.
(xiii) Cultural awareness.
(xiv) Sexual harassment.
(xv) Relapse prevention.
(xvi) Disease of addiction.
(xvii) Principles of Alcoholics Anonymous and Narcotics Anonymous.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and five personnel records, the facility failed to document the completion of 12 clock hours of annual training required for the facility director.Employee #2 was hired as a facility director on October 31, 2021 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. The facility failed to submit documentation of Employee #2 ' s training hours. This is a repeat citation from the March 9, 2023 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure all staff training hours are completed and available for the pre submission process.
Annually HR will collect Training certificates from all managers for their direct staff.
Director will keep a copy of all trainings on site.
HR will review trainings to ensure they are completing the hours needed and will be responsible to submit these on pre submission.
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704.11(f)(2) LICENSURE Trng Hours Req-Coun
704.11. Staff development program.
(f) Training requirements for counselors.
(2) Each counselor shall complete at least 25 clock hours of training annually in areas such as:
(i) Client recordkeeping.
(ii) Confidentiality.
(iii) Pharmacology.
(iv) Treatment planning.
(v) Counseling techniques.
(vi) Drug and alcohol assessment.
(vii) Codependency.
(viii) Adult Children of Alcoholics (ACOA) issues.
(ix) Disease of addiction.
(x) Aftercare planning.
(xi) Principles of Alcoholics Anonymous and Narcotics Anonymous.
(xii) Ethics.
(xiii) Substance abuse trends.
(xiv) Interaction of addiction and mental illness.
(xv) Cultural awareness.
(xvi) Sexual harassment.
(xvii) Developmental psychology.
(xviii) Relapse prevention.
(3) If a counselor has been designated as lead counselor supervising other counselors, the training shall include courses appropriate to the functions of this position and a Department approved core curriculum or comparable training in supervision.
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Observations
Based on a review of the Staffing Requirements Facility Summary Report and five personnel records, the facility failed to document the completion of 25 clock hours of annual training required for one counselor.Employee #3 was hired as a lead counselor on October 10, 2022 and was still in the position as of the date of the onsite inspection. The facility's training year that was reviewed was from January 1, 2023 through December 31, 2023. The facility failed to submit documentation of Employee #3 ' s training hours. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure all staff training hours are completed and available for the pre submission process.
Annually HR will collect, from all managers, training certificates from their staff.
Director will keep a copy of all trainings on site.
HR will review trainings to ensure they are completing the hours needed and will be responsible to submit these on pre submission.
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705.10 (d) (1) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(1) Conduct unannounced fire drills at least once a month.
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Observations
Based on a review of fire drill logs from April 2023 through January 2024, the facility failed to conduct unannounced fire drills at least once a month. There was no documentation of a fire drill occurring during the month of May 2023. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Fire drill occurred May 25, 20203, however it was not submitted in pre-submission packet.
Director will keep a copy of all Fire Drills on site.
Ongoing: Director will review fire drills with BHA Supervisor quarterly all fire drills are conducted and logged.
Risk will review fire drill logs prior to submitting to DDAP.
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705.10 (d) (5) LICENSURE Fire safety.
705.10. Fire safety.
(d) Fire drills. The residential facility shall:
(5) Conduct a fire drill during sleeping hours at least every 6 months.
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Observations
Based on a review of the facility ' s fire drills logs from April 2023 through January 2024, the facility failed to conduct a fire drill during sleeping hours at least every 6 months. The facility conducted a fire drill during sleeping hours in January 2023 and not again until December 6, 2023. This is a repeat citation from the March 9, 2023 licensing inspection. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
The facility will ensure fire drills will be completed during sleeping hours at least every 6 months.
Director will meet with Behavior Health Associates and go over procedure for having at least 1 overnight fire drill per six months.
Ongoing: Director will review fire drills with BHA Supervisor quarterly.
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709.26 (b) (3) LICENSURE Personnel management.
§ 709.26. Personnel management.
(b) The personnel records must include, but are not limited to:
(3) Annual written individual staff performance evaluations, copies of which shall be reviewed and signed by the employee.
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Observations
Based on a review of personal records, the facility failed to ensure that all employees have an annual written individual staff performance evaluation, copies which shall be reviewed and signed by the employee in one out of five personal records reviewed. Employee #3 was a hired as a lead counselor on October 10, 2022 and was still employed at the time of the inspection. The facility failed to submit documentation that Employee #3 had an annual staff performance evaluation. This finding was reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will ensure all employee files include the Annual staff performance evaluations and available for the pre submission process.
Annually HR will collect from all managers the Annual Staff Performance Evaluations.
Director will keep a copy of Staff Performance Evaluations on site.
HR will review files to ensure the Performance Evaluations are complete and in the file and will be responsible to submit these on pre submission.
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709.28 (c) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record.
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Observations
Based on a review of client records, the facility failed to obtain a consent to release information form prior to releasing information in one out of twelve records reviewed. Client #6 was admitted to the detox level of care on July 21, 2023 and discharged on July 24, 2023. There was no informed and voluntary consent to release information form for the funding source. The facility staff confirmed billing had occurred.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will obtain an informed consent from the client for the disclosure of information contained in the client record.
Quality and Risk manager will conduct a training on consents at the facility by March 26, 2924 where employees will be trained on the correct procedures for obtaining consent.
Director will pull five random charts weekly over the next eight weeks to review and document consents are being completed correctly.
Since client #6 is no longer at the facility, we will not be able to obtain a release of information.
Ongoing, consents will be reviewed by Director on monthly chart reviews and in supervisions
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709.28 (c) (3) LICENSURE Confidentiality
§ 709.28. Confidentiality.
(c) The project shall obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record. The consent must be in writing and include, but not be limited to:
(3) Purpose of disclosure.
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Observations
Based on a review of client records, the facility failed to obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that included the purpose of disclosure in four out of twelve records reviewed.Client #4 was admitted to the detox level of care on January 14, 2023 and discharged on January 20, 2024 and was stepped down to the residential level of care on January 20, 2024 and was still active at the time of the inspection. The record contained one informed and voluntary consent to release information to a drug and alcohol provider signed by the client on January 17, 2024, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.Client #7 was admitted to the detox level of care on November 22, 2023 and discharged on November 29, 2023. The record contained four informed and voluntary consents to release information to medical providers and one to a mental health provider signed by the client on November 28, 2023, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.Client #10 was admitted to the detox level of care on May 16, 2023 and discharged on May 22, 2023 and stepped down to the residential level of care on May 22, 2023 and discharged on August 9, 2023. The record contained one informed and voluntary consent to release information to a drug and alcohol provider signed by the client on May 19, 2023, three informed and voluntary consents to release information to family members signed by the client on May 25, 2023, one informed and voluntary consent to release information to a referral source signed by the client on June 14, 2023 and one informed and voluntary consent to release information to a medical provider signed by the client on August 4, 2023 that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.Client #11 was admitted to the residential level of care on December 13, 2023 and discharged on January 29, 2024. The record contained two informed and voluntary consent to release information to drug and alcohol providers signed by the client on January 25, 2024, that had identified the purpose for disclosure as other, however no information was listed for what the other purpose was.This is a repeat citation from March 25, 2022 and March 9, 2023 licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will obtain an informed consent from the client for the disclosure of information contained in the client record.
Quality and Risk manager will conduct a training on consents at the facility by March 26, 2924 where employees will be trained on the correct procedures for obtaining consent.
Director will pull five random charts weekly over the next eight weeks to review and document consents are being completed correctly.
Since client #4 is still active, a new consent was obtained.
Since client #7 is no longer at the facility, we will not be able to obtain a release of information.
Since client #10 is no longer at the facility, we will not be able to obtain a release of information.
Since client #11 is no longer at the facility, we will not be able to obtain a release of information.
Ongoing, consents will be reviewed by Director on monthly chart reviews and in supervisions.
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709.31 (a) LICENSURE Data collection system
§ 709.31. Data collection system.
(a) A data collection and recordkeeping system shall be developed that allows for the efficient retrieval of data needed to measure the project ' s performance in relationship to its stated goals and objectives.
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Observations
Based on a review of administrative information, client records, personnel records, and the facility policy manual, the facility failed to develop a data collection and recordkeeping system that allows for the efficient retrieval of data needed to measure the project's performance in relationship to its stated goals and objectives.The following materials were requested however the facility was unable to provide them during the licensing process:The Staffing Requirement Facility Summary Report (SRFSR), training documentation, individual work performances, and individual training plans.This finding was reviewed with the facility during the licensing process.
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Plan of Correction
The facility will complete pre-submission documentation including staffing summary report, training plans, work performances, and date collection form prior to the inspection.
Risk and Quality Manager will receive technical support training on 2/28/24 on the pre-submission process. Risk and Quality Manager along with HR will provide training to all leadership on the proper completion of staffing grids as well as submission of documentation by 03/29/24.
HR and Risk Management will review Staffing Requirement Summary Report prior to submitting to DDAP.
Monthly, HR and Risk will review personnel records and update for new hires.
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709.32 (c) (3) (i) - (v) LICENSURE Medication control
§ 709.32. Medication control.
(3) Inspection of storage areas that ensures compliance with State and Federal laws and program policy. The policy must include, but not be limited to:
(i) What is to be verified through the inspection, who inspects, how often, but not less than quarterly, and in what manner it is to be recorded.
(ii) Disinfectants and drugs for external use are stored separately from oral and injectable drugs.
(iii) Drugs requiring special conditions for storage to insure stability are properly stored.
(iv) Outdated drugs are removed.
(v) Copies of drug-related regulations are available in appropriate areas.
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Observations
Based on a physical plant inspection on February 7, 2024, the facility failed to ensure that drugs for external use were stored separately from oral drugs as there were tubes of cream stored with the oral medication in the medication cart. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Nurse Manager removed the external medications out of the drawer that included oral drugs.
Ongoing: Nurse Manager and Director will review the medication cart quarterly to ensure no topical creams are in the same location as oral medications.
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709.63(a)(8) LICENSURE Follow-up Information
709.63. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to the following:
(8) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include follow-up information in one out of one applicable discharged record reviewed. Client #7 was admitted on November 22, 2023 and discharged on November 29, 2023. A follow up was due per the facility ' s policy and procedure manual at thirty days after discharge; however, there is no documentation that one occurred. This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will complete follow up information on every client. Director will review with all staff the procedure for completing the follow up form in our medical record in the March All Staff meeting.
Director will review 5 random charts weekly over the next eight weeks to ensure follow ups are being completed and placed in chart. Facility will go back and try to complete follow ups on the clients identified.
Ongoing, follow ups will be reviewed in supervisions and monthly chart audits.
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709.52(a)(2) LICENSURE Tx type & frequency
709.52. Treatment and rehabilitation services.
(a) An individual treatment and rehabilitation plan shall be developed with a client. This plan shall include, but not be limited to, written documentation of:
(2) Type and frequency of treatment and rehabilitation services.
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Observations
Based on a review of client records, the facility failed to provide a treatment and rehabilitation plan that included the type and frequency of services in four out of seven records reviewed. Client #8 was admitted on January 3, 2024 and was still active at the time of the inspection. A comprehensive treatment plan was developed on January 5, 2024 that did not include the type and frequency of services. Client #10 was admitted on May 22, 2023 and discharged on August 9, 2023. A comprehensive treatment plan was developed on May 25, 2023, that did not include the type and frequency of services. Client #11 was admitted on December 13, 2023 and discharged on January 29, 2024. A comprehensive treatment plan was developed on December 15, 2023, that did not include type and frequency of services.Client #12 was admitted on August 10, 2023 and discharged on September 22, 2023. A comprehensive treatment plan was developed on August 13, 2023, that did not include type and frequency of services.These findings were reviewed with the facility staff during the licensing process.
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Plan of Correction
Facility will complete treatment plans that include type and frequency on all rehab clients. Director will review with all staff the procedure for adding type and frequency in our medical record treatment plans in the March All Staff meeting.
Director will review 5 random charts weekly over the next eight weeks to ensure treatment plans address type and frequency in treatment plans.
Ongoing, chart audits will be conducted for type and frequency in the treatment plans and will be reviewed in supervisions.
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709.52(b) LICENSURE TX Plan update
709.52. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 30 days. For those projects whose client treatment regime is less than 30 days, the treatment and rehabilitation plan, review and update shall occur at least every 15 days.
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Observations
Based on a review of client records, the facility failed to document treatment plan updates within the facility ' s policy of every 14 days in seven out of seven records reviewed.Client #4 was admitted on January 20, 2024 and still active at the time of the inspection. A treatment plan was completed on January 22, 2024 and the next update was due no later than February 5, 2024; however, there is no documentation that one was completed. Client # 5 was admitted on January 19, 2024 and was still active at the time of the inspection. A treatment plan was completed on January 21, 2024 and the next update was due no later than February 4, 2024; however, there is no documentation that one was completed. Client #8 was admitted on January 3, 2024 and was still active at the time of the inspection. A treatment plan was completed on January 5, 2024 and the next update was due on January 19, 2024; however, there was no documentation that one was completed. Client #9 was admitted on April 13, 2023 and discharged on May 11, 2023. A treatment plan was completed on April 14, 2023 and the next update was due no later than April 28, 2023; however, there was no documentation that one was completed. Client #10 was admitted on May 22, 2023 and discharged on August 9, 2023. A treatment plan was completed on May 25, 2023 and the next update was due no later than June 8, 2023; however, it was not completed until July 24, 2023. The next update was due no later than August 7, 2023: however, there was no documentation that one was completed. Client #11 was admitted on December 13, 2023 and discharged on January 29, 20024. A treatment plan was completed on December 15, 2023 and the next update was due no later than December 29, 2024; however, there was no documentation that one was completed. Client #12 was admitted on August 10, 2023 and discharged on September 27, 2023. A treatment plan was completed on August 13, 2023 and the next update was due no later than August 27, 2023; however, it was not completed until September 15, 2023. This is a repeat citation from the March 9, 2023 licensing inspection. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure treatment plan updates are completed every 14 days. Director will provide a training to the Clinical staff by 3/29/24 reviewing the policy on treatment plan updates.
For the next eight weeks, Director will pull 5 random charts and review for treatment plan updates. Due to the length of time, client charts identified cannot be corrected now.
Ongoing, Director will review treatment plan updates during supervisions and monthly chart audits.
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709.53(a)(8) LICENSURE Case Consultation Notes
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(8) Case consultation notes.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include case consultation in four out of four applicable records reviewed. Per the facility ' s policy and procedure manual, case consultation is completed every ninety days or at least once per level of care. Client #9 was admitted on April 13, 2023 and was discharged on May 11, 2023. There was no documentation that a case consultation occurred. Client #10 was admitted on May 22, 2023 and discharged on August 9, 2023. The was no documentation that a case consultation occurred. Client #11 was admitted on December 13, 2023 and discharged on January 29, 2024. There was no documentation that a case consultation occurred. Client #12 was admitted on August 10, 2023 and discharged on September 22, 2023. There was no documentation that a case consultation occurred. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will ensure all active rehab clients will have a case consult. Director will provide a training to the Clinical staff by 3/29/24 reviewing the policy on case consults.
For the next eight weeks, Director will pull 5 random charts and review for case consults. Due to the length of time, client charts identified cannot be corrected now.
Client # 9, 10, 11, & 12 are all discharged so no case consult can be completed.
Ongoing, Director will review case consults during supervisions and monthly chart audits.
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709.53(a)(11) LICENSURE Follow-up information
709.53. Client records.
(a) There shall be a complete client record on an individual which includes information relative to the client's involvement with the project. This shall include, but not be limited to, the following:
(11) Follow-up information.
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Observations
Based on a review of client records, the facility failed to provide a complete client record, which is to include a follow up contact in two out of four applicable records reviewed. Per the facility ' s policy and procedure manual, follow up contacts are within 7 days if an aftercare appointment was made or within 30 days if no appointment was scheduled. Client #9 was admitted on April 13, 2023 and discharged on May 11, 2023. There is no documentation that a follow up occurred. Client #12 was admitted on August 10, 2023 and discharged on September 27, 2023. There is no documentation that a follow up occurred.This is a repeat citation from the March 25, 2022 and the March 9, 2023 licensing inspections. These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
Facility will complete follow up information on every client. Director will review with all staff the procedure for completing the follow up and uploading the form in the medical record in our 3/19/24 All Staff Meeting. Director will review 5 random charts weekly over the next eight weeks to ensure follow ups are being completed and placed in chart. Facility will go back and try to complete follow ups on the clients identified.
Ongoing, follow ups will be reviewed on monthly chart reviews and supervisions.
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709.17(a)(3) LICENSURE Subchapter B.Licensing Procedures.Refusal/rev
709.17. Refusal or revocation of license.
(a) The Department may revoke or refuse to issue a license for any of the following reasons:
(3) Failure to comply with a plan of correction approved by the Department, unless the Department approves an extension or modification of the plan of correction.
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Observations
Based on a review of client records, the facility failed to comply with plans of correction that were approved by the Department. A plan of correction for ensuring that the project obtain an informed and voluntary consent from the client for the disclosure of information contained in the client record that includes the specific information to be disclosed was submitted and approved by the Department for the March 25, 2022 and March 9, 2023 annual licensing inspections. Completing and documenting an informed and voluntary consent to release information containing the specific information to be disclosed was again found to be a deficiency in the February 7, 2024 licensing inspection.A plan of correction for completing and documenting follow up contacts in the Inpatient Non Hospital Residential level of care was submitted and approved by the Department for the March 25, 2022 and March 9, 2023 annual licensing inspections. Completing and documenting a follow up contact was again found to be a deficiency in the February 7, 2024 licensing inspection.This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
The facility failed to comply with plans of correction that were approved by the Department.
Assistant Director will meet with Managers monthly to review POC and ensure compliance.
Ongoing: The Campus Director will conduct quarterly reviews of the Plan of Correction to ensure compliance. |