Observations
Based on a review of the 2012 annual report, the governing body failed to make available to the public an annual report which included a statement disclosing the names of officers, directors and principal shareholders.
The findings include:
The 2012 annual report was reviewed on December 2, 2013. The facility made the 2012 annual report available to the public; however, the 2012 annual report did not include a statement disclosing the names of officers, directors and principal shareholders.
The Clinical Supervisor did not dispute the findings.
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Plan of Correction
The Project Director will make certain that the Annual Report will include a statement disclosing the names of officers and directors (there are no principle share holders). This will replace the Annual Report and will be completed by 1/15/14. The Project Director will review the Annual Report 3 months before it is available to the public to guarantee that the names of officers and directors are included, while reviewing the report the Project Director will ensure all of the components are included to be sure this deficiency does not recur.. |