Observations
Based on a discussion with the Facility Director the facility failed to present to the Department licensing representative at the time of the project's site visit, the plan documenting the qualifications and training of staff.
The findings include:
A discussion with the Facility Director took place on January 11, 2010 regarding the completion of the plan documenting staff qualifications and training. The completed plan was required at the start of the site visit, January 11, 2010. The Facility Director did not complete the plan prior to the start of the site visit. In an interview with the facility director, the director indicated knowledge of the need to complete the documentation but did not complete the plan although it was known this information was required to complete the licensing process. The Facility Director did not give the completed plan to the licensing representative until the last day of the site visit, January 14, 2010, which made it difficult for the licensing representative to complete the verification of staffing qualifications and training information.
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Plan of Correction
Not having the Staffing Plan prepared by the day of the site visit was an oversight. While the Plan was completed before the end of the visit, it will be prepared in advance of the next on-site visit. In the future, POWER's Associate & Clinical Director will notify the appropriate staff and direct the Executive Assistant to begin preparing the Staffing Plan. The Plan will be prepared and ready for the Associate & Clinical Director's review and approved by the day preceding the scheduled on-site-visit. |