INITIAL COMMENTS
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This report is a result of an on-site licensure renewal inspection conducted on June 2 and June 3, 2010 by staff from the Division of Drug and Alcohol Program Licensure. Based on the findings of the on-site inspection, NTP Consultants, LLC 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 and a plan of correction is due on July 30, 2010.
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Plan of Correction
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704.2(b) LICENSURE Staffing Plan
704.2. Compliance plan.
(b) The plan documenting the qualifications and training of staff shall be presented to Department licensing representatives at the time of the project's site visit.
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Observations
Based on an on-site-inspection on June 2 through June 3, 2010, the facility failed to present a complete and accurate staffing form as required.
The findings include:
The project failed to present to the Department licensing representative a staffing form that was complete and accurate. Staff were not appropriately designated on the staffing form nor were dates of hire, working hours and position assignments included. Employee # 4 was documented on the staffing form as a counselor, however other facility documentation and staff interviews revealed that the employee was a counselor assistant. Personnel # 5 was documented on the staffing form as a counselor, however other facility documentation and staff interviews revealed that the employee was an assessment coordinator.
In an interview with staff, it was confirmed the facility had submitted an incorrect and incomplete staffing form.
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Plan of Correction
On June 3, 2010, the staffing form was corrected by the Director. To prepare for the next audit, Director will ensure that the form is ready the day the auditors arrive so they can receive the form as soon as they begin the audit. |
704.9(a) LICENSURE Counselor Asst Supervision
704.9. Supervision of counselor assistant.
(a) Supervision. A counselor assistant shall be supervised by a full-time clinical supervisor or counselor who meets the qualifications in 704.6 or 704.7 (relating to qualifications for the position of clinical supervisor; and qualifications for the position of counselor).
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Observations
Based on the review of staff schedule on June 3, 2010 and an interview with the Facility Director on June 3, 2010, the facility failed to provide adequate supervision to the counselor assistant.
The findings include:
Based on the review of employee schedules, supervision records, and client records, the facility failed to document adequate supervision notes and co-signed group notes and case consultations.
Supervision sessions of counselor assistant #3 documented on May 18, 20,24, 2010 and June 10, 2010 failed to describe the content of the supervisory sessions. The facility was also required to provide documentation of direct supervision to include co-signed progress notes, client records of services and staffing records.
Additionally, the documented supervision notes did not coincide with the staffing schedule presented to the licensing staff. In an interview on June 3, 2010, the supervisor stated that employee # 3 only conducted groups with the supervisor's direct supervision. This statement was inconsistent with the findings during the inspection explained below.
Employee #3 documented a treatment plan update on client #7 on May 15, 2010. Facility records indicated the previous supervisor/facility director had terminated employment with the facility prior to the new supervisor/facility director's employment with the facility. As the new supervisor was not hired until May 17, 2010, there was no documentation of supervision provided to the employee on this date.
Facility documentation revealed that Employee #3 conducted a Kid's Group on May 10, 2010 from 4:00 P.M. - 5:00 P.M. while the supervisor provided a private counseling session from 4:00 P.M.- 5:00 P.M. There was no documentation of direct observation provided by the supervisor to employee # 3 during the May 10, 2010 Kid's Group.
Facility documentation revealed that employee #3 conducted a Teen Group on May 17, 2010 from 4:00 P.M. to 5:00 P.M. while the supervisor had a scheduled session from 3:00 P.M. to 4:30 P.M. Further, employee #3 had a group from 5:00 P.M. to 6:00 P.M. while records documented that the supervisor left for the day at 5:00 P.M. There was no documentation of direct observation provided by the supervisor to employee # 3 during these specified time periods.
On May 20, 2010, the supervisor signed a supervisory note with employee # 3; however, employee # 3 was in Harrisburg at another meeting on this date and not at the facility as documented in the supervisory notes.
On May 24, 2010, the supervisor had a 3:00 P.M. to 4:30 P.M. appointment with a client and the schedule stated the employee #3 was running a group from 4:00 P.M. to 5:00 P.M. on May 24, 2010. There were no co-signed group notes or documentation of direct observation of these sessions.
On May 25, 2010, employee #3 conducted an anger group from 9:00 A.M. to 10:00 P.M. The supervisor had a client session from 9:00 A.M. to 10:00 A.M. and was unable to provide direct supervision and document supervisory supports to employee # 3 during this time period.
On May 27, 2010, the supervisor left for the day at 5:00 P.M. Employee # 3 ran a group from 5:00 P.M. to 6:00 P.M.; according to the schedule, there was no direct supervision from the supervisor.
On June 1, 2010, the supervisor had a meeting from 8:30 A.M. to 11:30 A.M. and employee #3 had an anger session with clients from 9:00 A.M. to 10:00 A.M. No direct supervision from employee # 1 was provided, according to the schedule.
During a staff interview, the facility was unable to provide clarification for the discrepancies
that were revealed during the licensing inspection.
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Plan of Correction
There were errors on the office calendar that had not been updated to reflect Supervisor and Counselor Assistant's activities correctly. There were times when Supervisor and Counselor Asst. were in groups together but it did not show that on the calendar.
Since June 3, 2010, the calendars are checked on a daily basis to make sure accurate information is noted. Furthermore, staff have been trained on scheduling to avoid such errors in the future.
As of June 4, 2010, we have implemented a policy that if the direct supervisor is away from the office during an activity where the assistant needs supervision, the Lead Counselor will complete all supervision as needed in place of the Director.
Supervision took place on this day after the staff returned from training in Harrisburg. In addition, we sometimes hold supervision by phone and by email when needed.
To avoid any confusion in the future, a supervision form has been created by the Director which documents supervision meeting times as well as case consultation information. This document was created on July 14, 2010 and was implemented the following day. The supervisor has also begun, on July 15, 2010, a full audit of the counselor asst. charts. On July 13, supervisor began co-signing group notes and progress notes.
we have held a staff training so that everyone knows not to schedule appointment times for the Supervisor while the counselor Assistant is running a group so that Supervisor can be there with the Counselor Assistant. In addition, we have created supervision forms that allow Director to document the details of supervision with the Counselor Assistant. This form was created July 14, 2010.
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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.
The findings include:
Six employee records were reviewed on June 2 and June 3, 2010. According to facility policy and procedure manual that was reviewed on June 2, 2010, an assessment of staff training needs is completed in May of each year. The facility failed to document an assessment of training staff needs for employees # 2 , 4, 5 and 6 for the 2009/2010 training year.
An interview with the owner, employee # 6, confirmed that this had not been completed.
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Plan of Correction
Beginning June 10th, Director began developing the staff training needs for the 2010-2011. The plan is expected to be completed by August 15, 2010.
To make sure this does not occur in the future, the Director will meet monthly with each individual staff to discuss training needs of the staff; and if changes are needed or if training needs to be added to their plans, the Director will do so at that time. If no changes are needed, the training plan will remain the same.
This review will take place monthly. |
704.11(a)(4) LICENSURE Evaluation of Overall Plan
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:
(4) An annual evaluation of the overall training plan.
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Observations
Based on a review of the policy and procedure manual and an interview with the facility owner and facility director, the facility failed to document an annual evaluation of the overall training plan, as required by regulation.
The findings include:
On June 2 and 3, 2010, the policy and procedure manual was reviewed. Per the agency policy and procedure manual, an annual review of the training plan will be completed in June each year. The regulation requires an annual evaluation of the overall training plan to be completed as a component of a staff development program. The facility failed to document the completion of an annual evaluation of the overall training plan for the 2009/2010 training year.
Staff interviews were conducted during the June 2 and 3, 2010 inspection and it was confirmed that the overall training plan for the 2009/2010 had not been completed.
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Plan of Correction
Beginning June 10th, Director began developing the individual training plans with each employee for 2010-2011. In addition, evaluation of the overall training plan is being created. The plans are expected to be completed by August 15, 2010.
To avoid this error in the future, the Director will be meeting monthly with each individual staff member to make sure the staff development/training plans are correct and if they need to be changed, to make sure they are changed at that time. If no changes need to be made, the plan will remain the same. A final overall annual review will be completed in June 2011 with all staff before each new fiscal year begins. |
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 personnel records, the facility failed to provide documentation of individual training plans in four of six personnel records reviewed.
The findings include:
Six personnel records were reviewed on June 3, 2010. Individual training plans were required in six personnel records. The facility failed to document individual training plans in personnel records # 2, 4, 5 and 6.
An interview with the project owned confirmed that training plans for employees # 4 and 6 had not been completed. Additionally, the plans for employee # 2 and 5 were not dated nor signed by the employee and the supervisor, therefore, there was no way to determine if the training plans had been developed between the supervisor and the employee. Further, the training plans did not document potential resources for attaining the training indicated.
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Plan of Correction
Beginning June 10th, Director began developing the individual training plans with each employee for 2010-2011. The plans are expected to be completed by August 15, 2010.
To avoid this error in the future, the Director is creating individual training plans for each staff member that will be reviewed with them on a monthly basis. At this monthly meeting staff will be given training resources to help them meet the needs of their training plans. If changes are to be made, documents will be updated. If no changes are needed, the plans will remain the same. For new employees, training plans will be created for them during their probationary period. |
704.12(a)(6) LICENSURE OutPatient Caseload
704.12. Full-time equivalent (FTE) maximum client/staff and client/counselor ratios.
(a) General requirements. Projects shall be required to comply with the client/staff and client/counselor ratios in paragraphs (1)-(6) during primary care hours. These ratios refer to the total number of clients being treated including clients with diagnoses other than drug and alcohol addiction served in other facets of the project. Family units may be counted as one client.
(6) Outpatients. FTE counselor caseload for counseling in outpatient programs may not exceed 35 active clients.
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Observations
Based on a review of the staffing requirements and the facility summary report form completed by the facility on June 3, 2010 and an interview with the facility director/clinical supervisor on June 3, 2010, the facility failed to ensure that staff to client ratios remained at or under 35:1.
The findings included:
Based on the number of hours the employee worked at this facility, and the number of clients on the counselors' caseload, all employees who provided counseling exceeded the maximum ratio of 35:1. The facility director represented as employee # 1 had a caseload of 40:1. The counselor represented as employee # 2 had a caseload of 40:1 and the counselor assistant represented as employee # 3 had a caseload of 56:1. Additionally, the counselor assistant was not eligible for a caseload.
On June 2 and 3, 2010, the Staffing Requirements Facility Summary Report form completed by the facility was reviewed. The form listed the facility director, a counselor and a counselor assistant as having clients on a caseload. The facility's standard work week, as reported by the facility on the Staffing Requirements Facility Summary Report form, was 40 hours per week.
Based on the total number of hours per week that the facility reported the employees devoted to their clients, the total number of hours in the facility's standard work week (40), and the total number of clients assigned to the following employees on June 2 and 3, 2010, employees 4, #1, 2 and 3 exceeded the allowable maximum 35:1 caseload.
The actual client caseload is determined by dividing the Full Time Equivalent (FTE) into the actual number of clients. The FTE is determined by dividing the number of hours devoted to the clients' treatment by the facility's standard workweek.
The number of hours per week devoted by Employee # 1 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 1 had 40 active clients on June 2 and 3, 2010.
Employee # 1 (40/40 = 1 FTE 40 clients/1 FTE = 40:1 caseload)
The number of hours per week devoted by Employee # 2 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 2 had active clients on May 12, 2010.
Employee # 2 (40/40 = 1 FTE 40 clients/1 FTE = 40:1 caseload)
The number of hours per week devoted by Employee # 7 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 2 had 40 active clients on June 2 and 3, 2010.
Employee # 3 (40/40 = 1 FTE 56 clients/1 FTE = 56:1 caseload)
The number of hours per week devoted by Employee # 3 to client treatment, as reported by the facility on the Staffing Requirements Facility Summary Report, was 40 hours per week. The facility reported on the Staffing Requirements Facility Summary Report form that Employee # 3 had 53 active clients on June 2 and 3, 2010.
During an interview, the facility director confirmed that they had exceeded the allowable maximum caseload of 35:1 for employees # 1, 2 and 3.
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Plan of Correction
Director corrected form on June 2, 2010.
To avoid this error in the future the Director will have form completed and ready for the auditors when they arrive. Director will also train all other staff on how to complete the form and appropriately define staff to client ratios to all staff.
The Director and Lead Counselor will regularly check ratios to make sure we are maintaining our staff to client ratios. |
705.28 (c) (4) LICENSURE Fire safety.
705.28. Fire safety.
(c) Fire extinguishers. The nonresidential facility shall:
(4) Instruct staff in the use of the fire extinguisher upon staff employment. This instruction shall be documented by the facility.
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Observations
Based on a review of six employee personnel and training records, the facility failed to document fire extinguisher training upon staff employment in three of six personnel records.
The findings include:
Six personnel records were reviewed on June 3, 2010. Three personnel records of new employees since the last inspection were reviewed to verify that staff had been instructed in the use of a fire extinguisher upon employment. The facility failed to document the completion of fire extinguisher training upon staff employment in personnel records #1, 3, and 4.
Employee #1 was hired on May 17, 2010. The training was due upon employment; documentation that training had been completed was not provided at the time of the review on 6/3/10.
Employee # 3 was hired on May 10, 2010. The training was due upon employment; documentation that training had been completed was not provided at the time of the review on 6/3/10.
Employee #4 was hired April 12, 2010. The training was due upon employment; documentation that training had been completed was not provided at the time of the review on 6/3/10.
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Plan of Correction
On June 4, 2010, training on how to use the Fire Extinguisher was completed with all staff.
To make sure this error does not happen in the future, Director will train and document the training of new employees on use of the fire extinguisher. |
709.23(b)(1) 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:
(1) Project goals and objectives which include time frames and available resources.
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Observations
Based on a review of administrative documentation and staff interviews, it was determined that the project failed to develop goals and objectives for the fiscal year 2009/2010.
The findings were:
A review of administrative documents on June 3, 2010 indicated that the annual goals and objectives for the fiscal year of July 1, 2009 to June 30, 2010 were missing.
An interview with the facility owner on September June 3, 2010 confirmed that the annual goals and objectives for the fiscal year of 2009/2010 had not been developed. Further, there was no documentation of board meeting minutes or any presentation to the board that addressed the goals and objectives for the fiscal year 2009/2010.
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Plan of Correction
On June 15, 2010 the Director began developing the Annual Goals and Objectives for the next fiscal year to avoid this error in the future. The Goals and Objectives are expected to be completed by August 15, 2010. The Director also began working with Owner to establish Board and establish a system of getting meeting minutes and notes from each scheduled meeting. This will begin in August 2010. |
709.23(b)(3) 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:
(3) A performance report summarizing the progress towards meeting goals and objectives.
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Observations
Based on the review of the Policy and Procedure manual, the Project Director failed to complete a performance report summarizing the progress towards meeting goals and objectives.
The findings include:
On June 2, 2010, the policy and procedure manual was reviewed. The facility failed to present documentation of an annual performance report summarizing the progress towards meeting goals and objectives for the fiscal year of 2008/2009.
An interview with the facility director confirmed there was no documentation to summarize the progress toward goal attainment.
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Plan of Correction
Director will complete the Annual Performance Report summarizing the progress towards meeting goals and objectives for 08-09 by August 15, 2010.
To make sure this error is avoided in the future, Director will complete the annual performance reports summarizing the progress towards meeting goals and objectives for each previous fiscal year by June 1 of that fiscal year. |
709.25(a) LICENSURE Fiscal Management
709.25. Fiscal management.
(a) The project shall obtain the services of an independent public accountant for an annual audit of financial activities associated with the project's drug/alcohol abuse services.
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Observations
Based on a review of administrative materials and an interview with the owner during the onsite inspection on June 2, 2010, the annual audit for the fiscal year reviewed was not completed.
The findings include:
During the onsite licensing inspection conducted from June 2 to June 3, 2010, the fiscal documents were reviewed. The certified public accountant's dated and signed comments at the beginning of the fiscal document indicated that the document was not an audit. The letter from the accountant stated "... we have not audited or reviewed the accompanying financial statements and accordingly do not express an opinion or any other form of assurance.."
The documentation presented failed to meet the requirement for the annual financial audit.
The owner was interviewed on June 3, 2010 regarding the documentation and content of the annual audit and confirmed that this was the only fiscal document available for review.
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Plan of Correction
NTP Consultants is requesting an exception to these requirements as noted by the Division of Drug and Alcohol Program Licensing Alert 4-97 (Requests for Exceptions to Regulations, Part V., Drug and Alcohol Activities, Chapter 701). Application is in process.
If the exception request is rejected, Owner will work with accountant to develop an audit plan for the company. Owner will begin working with accountant on September 1, 2010 to determine exact fiscal documents that are acceptable for audits. The audits will then take place by June of that fiscal year- auditing the previous fiscal year's financial records. The Owner will be responsible for all actions related to the financial records and auditing.
To make sure this error does not happen in the future, the Owner will make sure all financial documents are received from the accountant by June 30 of each fiscal year- for the previous fiscal year's financials. |
709.28(d) LICENSURE Confidentiality
709.28. Confidentiality.
(d) A copy of a client consent shall be offered to the client and a copy maintained in the client records.
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Observations
Based on the review of client records, the facility failed to document the client was offered a copy of the consent to release information form.
The findings included:
Seven client records were reviewed on June 3, 2010. The facility failed to provide the client with a copy of the consent in three of seven records reviewed. Records #2, 3, and 4 contained consents to release information that did not indicate whether the client refused or accepted a copy.
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Plan of Correction
On June 4, 2010 Director and Counselors implemented a Chart auditing form that allows us to use this checklist to avoid overlooking errors such as this. Director will conduct monthly audits of charts to ensure all consent forms are completed and up to date. |
709.33(a) LICENSURE Notification of Termination
709.33. Notification of termination.
(a) Project staff shall notify the client, in writing, of a decision to involuntarily terminate the client's treatment at the project. The notice shall include the reason for termination.
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Observations
Based on a review of client records, the facility failed to inform the client, in writing, of a decision to involuntarily terminate the client's treatment.
The findings included:
Based on a review of seven client records on June 3, 2010, the facility failed to provide one of three clients discharged with notification of termination. The facility failed to provide client # 2 a notification indicating the reason for termination. Client # 2 was involuntarily discharged on January 17, 2010.
A staff interview concurred that the facility failed to document that written notification had been provided to client # 2.
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Plan of Correction
On June 10, 2010 Director and Counselors implemented a plan to provide written notification to clients if we decide to involuntarily terminate them from treatment. Counselors will notify a designated staff member, who will then write and mail a letter to the client stating the reason for the termination and also give them the opportunity to remain active rather than be terminated. |
709.33(b) LICENSURE Notification of Termination
709.33. Notification of termination.
(b) The client shall have an opportunity to request reconsideration of a decision terminating treatment.
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Observations
Based on the review of client records, the facility failed to give the client an opportunity to request reconsideration of a decision terminating treatment.
The findings include:
Seven client records were reviewed June 3, 2010. The facility failed to provide one of three clients discharged with notification of termination. The project was required to give the client an opportunity to request reconsideration of a decision terminating treatment in one client record. The project did not document that the client was given an opportunity to request reconsideration in client record # 2. The client was discharged on January 17, 2010.
A staff interview confirmed that the facility did not provide client # 2 with the opportunity to request reconsideration of the involuntary termination.
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Plan of Correction
On June 10, 2010 Director and Counselors implemented a plan to provide written notification to clients if we decide to involuntarily terminate them from treatment. Counselors will notify a designated staff member, who will then write and mail a letter to the client stating the reason for the termination and also give them the opportunity to remain active rather than be terminated. |
709.91(b)(6) LICENSURE Intake and admission
709.91. Intake and admission.
(b) Intake procedures shall include documentation of:
(6) Psychosocial evaluation.
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Observations
Based on a review of client records, the administrative policy and procedures manual and an interview with the project/facility director, the facility failed to document psychosocial evaluations that included a clinical assessment of the client in three of seven client records, as required by regulation.
The findings included:
Seven client records were reviewed on June 3, 2010; all seven client records required the completion of psychosocial evaluations, per regulation. Three client records did not include a clinical assessment of the client; and only included client historical information. The facility failed to document a psychosocial evaluation that included a clinical assessment in client records # 1, 2 and 3.
Client record # 1 failed to provide documentation of the client's support systems.
Client record # 2 failed to include documentation of the client's assets/strengths, support systems, negative factors, and attitude towards treatment. Additionally, the therapist did not evaluate the client's coping mechanisms.
Client record #3 failed to include documentation of the client's problems/needs, assets/strengths, support systems, coping mechanisms, negative factors, attitude toward treatment and the counselor's conclusions/impressions.
In an interview, the facility director agreed that the psychosocial evaluation documented by facility staff did not include clinical assessments.
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Plan of Correction
On June 4, 2010 Director and Counselors implemented a Chart auditing form that allows us to use this checklist to avoid overlooking errors such as this. Director will conduct monthly audits of charts to ensure all assessments and psychosocial forms are completed, in detail, and up to date. |
709.92(b) LICENSURE Treatment and rehabilitation services
709.92. Treatment and rehabilitation services.
(b) Treatment and rehabilitation plans shall be reviewed and updated at least every 60 days.
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Observations
Based on a review of client records, it was determined that the facility failed to document client treatment plan updates every sixty days.
The findings were:
Seven client records were reviewed on June 3, 2010. Five records required treatment plan updates. The facility failed to provide a treatment plan update for clients #2 and 7.
Client #2 was admitted on 7/17/2009. According to the facility policy and procedure manual, treatment plan updates are due every sixty days. The facility failed to document treatment plan updates that were due by 9/19/2009 and 11/19/2009. Client # 2 was discharged from the program on January 17, 2010.
Client record # 7 was admitted on 3/2/2010. The facility failed to document a treatment plan update for 5/2/2010. As of the date of inspection, there were no treatment plan updates documented for this record.
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Plan of Correction
On June 4, 2010 Director and Counselors implemented a Chart auditing form that allows us to use this checklist to avoid overlooking errors such as this. Director will conduct monthly audits of charts to ensure all treatment plans are completed, in detail, and up to date. |
709.93(a)(11) LICENSURE Client records
709.93. 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 and facility policy and procedure as well as staff interviews, the facility failed to document follow-up attempts in accordance with their policy and procedure.
The findings include:
Seven client records were reviewed on June 3, 2010. When additional client discharge records were requested, the facility failed to provide the requested information in the client records. An interview with the counselor and facility director on June 3, 2010, confirmed that follow-ups were not being documented prior to January 2, 2010 and the staff were unable to provide any records prior to January 2010. According to the interview with the facility director and counselor, the practice has been to conduct follow-up three months after discharge.
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Plan of Correction
On June 10, 2010 a follow-up plan was implemented by Director and Lead Counselor. A designated staff member will begin making follow-up contact with clients within 3 months of the client's discharge date. NTP had been doing follow-ups since January, 2010 but there was not a specific format in place. As of June 10, 2010, there is a specific format to follow. Director will be auditing charts monthly to make sure correct follow-up procedures are being followed. |
709.94(b) LICENSURE Project management services
709.94. Project management services.
(b) The hours of project operation shall be displayed conspicuously to the general public.
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Observations
Based on observation, the facility failed to have the hours of the operation displayed conspicuously to the general public.
The findings include:
Based on a physical plant tour on June 2, 2010, the hours of operation were not displayed for view by the general public.
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Plan of Correction
Beginning July, 2009, the hours have been posted on the front desk right as you walk in the building, so that anyone entering our office can see our hours of operation. On June 15, 2010, Director posted the office hours and contact information on the front door of the building.
To make sure this error does not happen in the future, Director and all staff will view the sign posted on the door each day as we enter the building. If the hours change, Director will post a new sign on the door immediately. If the sign becomes damaged, Director will replace the sign immediately. |