Observations
Based on a review of the project ' s policy and procedure manual, the facility failed to document an annual evaluation of the overall training plan.
The findings include:
The facility was asked to provide documentation of an annual evaluation of the overall training plan.
The facility was unable to provide documentation of an annual evaluation of the overall training plan. The findings were confirmed with the Executive Director prior to the exit interview.
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Plan of Correction
Corrective Action: The Director of Operations has provided a written evaluation and summary of the 2012 overall training plan.
Preventative Action: In order to prevent this from recurring, the Executive Director has provided written direction (in memorandum form) instructing the Liaison to the State to provide to the Executive Director an evaluation, including a written summary, of the annual overall training plan of the previous calendar year. The Executive Director will review and sign the evaluation and return it to the Liaison to the State within 60 days following the end of the calendar year.
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