INITIAL COMMENTS
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This report is a result of an onsite follow-up inspection regarding the plans of correction for the 1-27-2011 licensure inspection. The follow-up inspection was conducted on June 14, 2011 by staff from the Division of Drug and Alcohol Program Licensure. The following is a report of these findings.
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Plan of Correction
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709.22(e) LICENSURE Governing Body
709.22. Governing body.
(e) If a facility is publicly funded, the governing body shall make available to the public an annual report which includes, but is not limited to:
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Observations
Citation Text for Tag 0135, Regulation EWQV
Snyder, Virginia A.
Based on a review of the 2009-2010 annual report and an interview with the project director, the governing body failed to make available to the public the 2009-2010 annual report.
The findings include:
The 2009-2010 annual report was due for review on January 27, 2011. The facility is publicly funded and is required to make available to the public an annual report. In an interview, the project director reported the 2009-2010 annual report was not completed. The governing body failed to make the 2009-2010 annual report available to the public, as required.
This cannot be re-evaluated until next licensing inspection. Please resubmit the original plan of corrections.
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Plan of Correction
The facility director will be responsible for making available a public report detailing the activities and accomplishments of the last year, a financial statement of income and expense, and a statement disclosing the names of officer, directors and shareholders. This will be completed by 12/31/11. |
709.23(b)(2) LICENSURE Project Director
709.23. Project director.
(b) The project director shall assist the governing body in formulating policy and shall present the following to the governing body at least annually:
(2) Written reports of project operations.
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Observations
Based on a review of the policy and procedure manual, the facility failed to document current board meeting minutes.
The finding include:
A review of the facility's policy and procedure manual and an interview conducted on January 27, 2011 with the Project Director confirmed that the facility could not produce current board of director meeting minutes for the last 12 months.
This cannot be re-evaluated until next licensing inspection. Please resubmit the original plan of correction.
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Plan of Correction
The project director will be responsible for gathering meeting minutes from the governing body that include board members, board meeting minutes, achievements, goals, and public monies received for the project. This will then be forwarded on to the facility director and included in the public report. |
704.11(a)(1) LICENSURE Training Needs assessments
704.11. Staff development program.
(a) Components. The project director shall develop a comprehensive staff development program for agency personnel including policies and procedures for the program indicating who is responsible and the time frames for completion of the following components:
(1) An assessment of staff training needs.
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Observations
Based on a review of agency training files, the facility did not comply with this regulation. No documentation was available of the assessment of staff training needs for the current training year 2011.
The findings include:
A conversation with the Project Director on January 27, 2011 and a review of project personnel records confirmed the facility failed to have an assessment of staff training needs available for review.
Personnel files #1, 2, 3 and 4 did not contain staff training assessmenst included in the personnel files.
This cannot be re-evaluated until next licensing inspection. Please resubmit the original plan of corrections.
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Plan of Correction
The facility director will meet with the lead counselor to discuss observed training needs identified and seek feedback from the employee on their training goals. The facility director will be responsible for having each staff member complete and submit a training needs assessment. The results of the assessment will be reflected in the employee's Individual Training Plan and Overall Training Plan. This will be completed by 12/31/11. |