Observations
Based on a review of personnel records, the facility failed to ensure that the project director completed at least 12 clock hours of training during the facility's July 1, 2022 through June 30, 2023 training year.
Employee #1 was hired as the Project Director on January 22, 2019. The personnel record documented 0 hours of training during the training year reviewed.
This finding was reviewed with facility staff during the licensing process.
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Plan of Correction
By 12/1/2023, the compliance officer will assign a minimum of 12 hours of training to the project director for the current training year. The compliance officer will continue to assign 12 hours of training per training year in the My E-Learning system, to the project director. The facility director will monitor completion of training hours quarterly.
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