Observations
Based on review of the facility policy and procedure manual, the facility failed to provide documentation of the project director preparing, annually updating, and signing a written manual delineating project policies and procedures. The policy and procedure manual was not annually updated by signature for the year 2022.
These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Project directors shall prepare, annually update and add a signature line to the written manual delineating project policies and procedures. The Project Director shall review the annual update is in the manual. The annual update shall be completed and reviewed by 1/1/2023. |