Observations
Based on an administrative review of the facility's policy and procedure manual, the facility failed to document the project director had annually prepared, updated, and signed the written manual delineating the project policies and procedures for the current year reviewed.These findings were reviewed with facility staff during the licensing process.
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Plan of Correction
The Policies and Procedures manual has been reviewed by the Project Director as of August 14, 2023.
An official document has been placed in the Policies and Procedures Manual so that every January starting in year 2024, the Project Director will review the manual and then attest that this has been completed by signing and dating the form. |