| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 2380.36(a) | Staff #2 started working at Royer Greaves on 4/10/17 through a temp agency. Staff #2 has worked over 40 hours in a month at Royer-Greaves and has not been provided with orientation training relevant to his/her responsibilities, the daily operations of the facility and on policies and procedures of the facility before working with individuals. | The facility shall provide orientation for staff persons relevant to their responsibilities, the daily operation of the facility and policies and procedures of the facility before working with individuals or in their appointed positions. | the complete orientation training will be provided to this temp staff by 12/29/17.
In the future, the HR Specialist will monitor the hours of all agency staff to assure that RG is compliant with this regulation. |
12/29/2017
| Implemented |
| 2380.36(d) | Staff #2 started working at Royer Greaves on 4/10/17 through a temp agency. Staff #2 has worked over 40 hours in a month at Royer-Greaves and has not been provided with training in the areas of services for people with disabilities, program planning and implementation.
. | Program specialists and direct service workers shall have training in the areas of services for people with disabilities and program planning and implementation, within 30 calendar days after the day of initial employment or within 12 months prior to initial employment. | This temp staff will be provided with the following training by 12/19/17: program planning and implementation.
In the future, this training will be added to the orientation training for any temp staff. |
12/29/2017
| Implemented |
| 2380.53(a) | Repeat 4/5/16: In each of the program areas including the Eagle room, Sharks room, Dolphins room, quiet room and Music room there were first aid kits present that were unlocked and contained poisonous materials. All of the individuals attending program are not safe with poisonous materials. There was a first aid kit present in the hall closet which contained poisonous materials and was accessible to individuals. | Poisonous materials shall be kept locked or made inaccessible to individuals, when not in use. | All First Aid kits were removed from the walls in the Classroom to a Central location and locked. This solution will prevent a re-occurrence of this Citation. |
10/17/2017
| Implemented |
| 2380.55(a) | Repeat 4/5/16: There were undergarments laying on the floor in the hall bathroom between the Eagles room and the Sharks room. Outside of the door of the bathroom there were brown spots on the wall beside the hamper where soiled clothing is disposed of measuring approximately 2 inches in length. There were individual toothbrushes being stored in the men's and women's bathroom in the music room in baskets attached to the wall by the sink, uncovered. There were pieces of masking tape on some of the baskets with individual first names. There was a basket with a toothbrush in the women's bathroom without a name on it. | Clean and sanitary conditions shall be maintained in the facility. | All toothbrushes have been disposed as this is not a personal goal for any person attending the program.
In the future, there will be no toothbrushes in the facility.
The bathrooms are cleaned daily by the maintenance staff. Staff have been instructed that they must clean any toileting accidents immediately after occurrence. |
12/04/2017
| Implemented |
| 2380.62 | The emergency contact phone numbers by the phones in the Dauphin room and the Shark room did not contain the number for the ambulance. | Telephone numbers of the nearest hospital, police department, fire department, ambulance and poison control center shall be posted on or by each telephone in the facility with an outside line. | The emergency contact number form was updated on October 17, 2017 during the survey.
See attached form.
In the future, this template will be used when updating the form. |
10/17/2017
| Implemented |
| 2380.82 | The women's bathroom in the hallway between the Eagles and Sharks room had a trashcan inside the bathroom blocking a door to exit. The bed in the quiet room area was blocking a door to exit. The women's bathroom door in the music room did not open the entire way due to the door being blocked by chairs outside of the bathroom. | Stairways, halls, doorways, aisles, passageways and exits from rooms and from the building shall be unobstructed. | The trashcan in the ladies room in the hallway between the Eagles and Sharks room is now located _________________. See picture documentation.The bed in the classroom has been moved. See picture documentation.
The seating in the music room has been rearranged so that the door will not be blocked by chairs. see attached photo documentation.
Staff have been instructed to assure that no egress is obstructed in the building. See attached memo |
12/04/2017
| Implemented |
| 2380.87(b) | Repeat 4/5/16: There was no strobe light present in the quite room. Individual #4 is deaf and requires strobe lights to notify him/her in the event of a fire. | If one or more individuals or staff persons are not able to hear the fire alarm system, the fire alarm system shall be equipped so that each person who is not able to hear the alarm shall be alerted in the event of a fire. | The strobe light was installed on the date of inspection, October 17, 2017.
All other rooms are equipped wit a strobe light.
As there are strobe lights in all the rooms, this citation will not be a repeat |
10/17/2017
| Implemented |
| 2380.89(g) | The fire drill log did not indicate if individuals met at the meeting place during the fire drills since last licensing in April 2016. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | The fire drill log has been revised to document the location of the designated meeting place.
This new form will be used for the December 2017 and future fire drills. |
12/29/2017
| Implemented |
| 2380.111(a) | Individual #1 had a physical exam completed on 1/9/17. A previous physical exam was never brought to licensers even though it was asked for on multiple occasions. A physical was brought to the licensers at exit however it was dated 1/6/15. | Each individual shall have a physical examination within 12 months prior to admission and annually thereafter. | Royer Greaves has requested a copy of the missing physical from the provider.
In the future, The Royer-Greaves nurse will assure that all physicals are received in the required time frame. |
12/29/2017
| Implemented |
| 2380.111(c)(3) | Individual #3's physical completed on 9/1/17 did not include his/her immunizations. | The physical examination shall include: Immunizations as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | A copy of the immunizations has been requested from the provider.
In the future, the agency nurse will assure that all regulatory requirements concerning physicals are in compliance. |
12/29/2017
| Implemented |
| 2380.111(c)(5) | Individual #1 had a tuberculin skin test completed with negative results on 12/24/14 and not again until 1/11/17. | The physical examination shall include: Tuberculin skin testing with negative results every 2 years; or, if the tuberculin skin test is positvie, an initial chest X-ray with results noted. | There is no way to correct this error.
In the future, the agency nurse will track the due dates of physicals and the regulatory health care needs.
A chart will be developed by the director of quality management to reflect these due dates.
The chart will be developed by the due date and implemented by the nurse. |
12/29/2017
| Implemented |
| 2380.111(c)(8) | Repeat 4/5/16: Individual #1's 1/9/17 physical indicated he/she did not have any physical limitations. However Individual #1 has depth perception and gait issues that require some assistance when performing different activities or walking throughout the community. Individual #3's physical dated 9/1/17 indicated he/she did not have any physical limitations. However Individual #3 is blind and requires a sighted guide at times. | The physical examination shall include: Physical limitations of the individual. | These two physicals will be returned to the PCP to request the missing information.
In the future, the agency nurse will review all physicals to assure that the information accurately reflects the needs of the person. |
12/29/2017
| Implemented |
| 2380.111(c)(10) | Individual #1's 1/9/17 physical did not include information pertinent to diagnosis in case of emergency. The field was left blank. Individual #1 is nonverbal and would require a familiar person to explain all medical information during an emergency. He/she also has a seizure disorder and history of self-injurious behaviors. Individual #3's physical dated 9/1/17 did not include information pertinent to diagnosis in case of emergency. This field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | These physicals have been updated and signed by the agency nurse.
If the future, the agency nurse will review all physicals prior to the document being filed in the person's chart |
12/04/2017
| Implemented |
| 2380.111(c)(10) | Individual #1's 1/9/17 physical did not include information pertinent to diagnosis in case of emergency. The field was left blank. Individual #1 is nonverbal and would require a familiar person to explain all medical information during an emergency. He/she also has a seizure disorder and history of self-injurious behaviors. Individual #3's physical dated 9/1/17 did not include information pertinent to diagnosis in case of emergency. This field was left blank. | The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. | The agency nurse has updated the physical with the needed information.
In the future, the agency nurse will review all physicals to assure compliance before the physical is filled int he person's chart. |
12/04/2017
| Implemented |
| 2380.113(b) | The Certified Nurse Practitioner signing off on Staff #1's physical dated 9/7/16 did not include the date. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or certified physician's assistant. | The physical for individual #1 will be returned to the provider to secure the signature. We will request the document to be returned by 12/29/17
In the future, the Royer Greaves nurse will review all the physicals before they are filed in the chart to assure accuracy |
12/29/2017
| Implemented |
| 2380.113(c)(3) | Staff #1's physical dated 9/7/16 did not indicate if he/she was free from communicable diseases. | The physical examination shall include: A signed statement that the person is free of serious communicable diseases as defined in 28 Pa. Code § 27.2 (relating to specific identified reportable diseases, infections and conditions) to the extent that confidentiality laws permit reporting, or that the person has a serious communicable disease as defined in § 27.2 to the extent that confidentiality laws permit reporting, but is able to work in the facility if specific precautions are taken that will prevent spread of disease to individuals. | This staff person physical will be returned to them to return to the PCP . The staff will request that the PCP document that the person did not have a communicable disease as of that date.
In the future the HR Specialist will review the physical to assure regulatory compliance |
12/29/2017
| Implemented |
| 2380.124(a) | Individual #2's October 2017 medication administration record (mar) did not match his/her medication label for his/her prescribed Clonidine. The medication label indicated to take 1 tablet, .1mg, at 7am, noon, 4pm, and 7pm. The October 2017 medication log indicated Clonidine.1mg, 1 tablet PO QID for ADHD.' The medication label for Risperidone indicated 3mg take 1 tablet at 7am and noon.' The October 2017 mar indicated 1 tablet O BID.' Risperidone .5mg on med label indicated take 1 tablet at 7am and 1 tablet at noon. The mar only indicated to take 1 tablet PO BID.' | A medication log listing the medications prescribed, dosage, time and date that prescription medications, including insulin, were administered, and the name of the person who administered the prescription medication or insulin shall be kept for each individual who does not self-administer medication. | Upon discovery, The nurse changed the MAR to match the medication label.
In the future, the nurse will make these changes immediately upon being notified of the change. |
10/11/2017
| Implemented |
| 2380.132(2) | Daily meals are prepared for individuals attending program each day. The meals are posted on the wall each day however they are not posted at least one program day prior to the menu date. | If the facility provides or arranges for meals for individuals, the following requirements apply: Menus shall be posted at least 1 program day prior to the menu date. | The menus will be developed and posted every Friday for the following week.
This procedure change will assure compliance with this regulation moving forward. |
12/08/2017
| Implemented |
| 2380.132(6) | There were several meals on the menu that did not include one item from dairy, protein, fruits, vegetables and grain food groups. On Monday of the week one menu there was nothing from the dairy group offered. On Friday of week one nothing from the fruit group was offered. | If the facility provides or arranges for meals for individuals, the following requirements apply: Each meal served shall contain at least one item from the dairy, protein, fruits and vegetables and grain food groups, unless medically contraindicated for an individual. | The formatting of the menu posting will change to reflect the regulatory guidelines.
This will assure ongoing compliance |
12/08/2017
| Implemented |
| 2380.171(b)(1) | Individual #1's record only indicated that his/her emergency contact person was his/her supports coordinator. However, his/her family (legal guardians) need to be contacted in an emergency as well. | Emergency information for each individual shall include: The name, address, telephone number and relationship of a designated person to be contacted in case of an emergency. | This information has been changed. The Program Specialist will assure that all required demographic information is included in each file. by 12/15/17.
The Director of quality management will conduct random chart audits throughout the year and this area will be reviewed |
12/04/2017
| Implemented |
| 2380.173(1)(ii) | Individual #1's record did not include his/her race, height, hair color, eye color and identifying marks. | Each individual's record must include the following information: Personal information including: The race, height, weight, color of hair, color of eyes and identifying marks. | The demographic form has been completed and filed in this individual's file.
when the Director of Quality Management performs random audits throughout the year,, this form will be included in the review. |
12/04/2017
| Implemented |
| 2380.173(1)(iv) | Individual #1's record did not include his/her religious affiliation | Each individual¿s record must include the following information: Personal information including: Religious affiliation. | This information has ben added to the chart.
All individuals charts will be reviewed to assure that the required demographic is included by 12/15/17 |
12/04/2017
| Implemented |
| 2380.173(9) | Individual #1's record contains many instances of content discrepancies across all documents in his/her record; his/her assessments, physicals, identification sheets, and Individual Support Plan (ISP) does not include cohesive information. His/Her ISP indicated he/she was allergic to Carbamazepine, Thioridazine, seasonal allergies, latex, and lactose. His/Her 1st identification sheet in his/her record indicated allergies to Penicillin, Cephalosporin, red dye, no corn fish, dairy products or eggs. His/Her 2nd identification sheet in his/her record indicated allergies to latex, lactose, thioridazine, carbamazepine. His/Her 1/9/17 physical examination form indicated allergies to mellaril, tegretol, lactulose intolerance. His/Her 2017 and 2016 assessments indicated lactose intolerance allergy/sensitivity. His/Her 1st identification sheet indicated diagnosis of profound ID, bilateral enuncleation, asthma, eosinophilic esophagitis, and history of seizures. His/Her 2nd identification sheet indicated diagnosis of severe ID, pervasive developmental disorder, seizures, GERD, impulse control disorder, hearing loss, poor sight. His/Her assessment and ISP also includes a diagnosis of Autism in addition to the diagnosis listed above. His/Her 1st identification sheet indicated he/she was to follow a pureed diet.' His/Her 2nd identification sheet indicated he/she was to follow a high fiber, mechanically chopped to dime sized pieces, no milk, needs supervision because he/she eats too fast' diet. His/Her 1/9/17 physical examination form indicated he/she was to follow a diet of low fat.' A residential medical history document attached to his/her 1/9/17 physical form indicated a diet of don't eat pretzels, they cause him/her to choke. Low fat, soft mechanical high fiber, cut into bite sized pieces, alternate food and liquid, history of uncontrollable eating, dysphasia level I and II pureed and ground, softened, moistened, small, bolus forming foods. Diet; thin liquids.' His/Her 2017 and 2016 assessments indicate that he/she is to follow a lactulose intolerant, mechanical chopped (dime size pieces) no foods past 8pm (GERD)' diet. His/Her ISP indicated to follow increased fiber, 2nds allowed of fruit and vegetables, low calorie diet with no food past 8pm due to GERD. Texture of diet mechanical chopped to dime sized pieces. Supervision at all times as he's/she's impulsive and will eat too fast. Staff encourage him/her to alternate food and liquid 1:1' diet. Individual #1's identification sheets had two different living addresses. | Each individual's record must include the following information: Content discrepancies in the ISP, the annual update or revision under § 2380.186. | The cause of discrepancy established after full examination was that the old face sheet that was left in the binder was mixed up with another individual's records while the revised face sheet was also in the records has well(The other individual's name was not in the record). The revised face sheet had the correct information based on the information from the ISP. As for the physicals, some of the diagnosis were listed but also said see attached Lifetime Medical for a full list. Brand names of Medications were used instead of Generic which created confusion. In the future, information on face sheet will be updated during the ISP plan update meeting and reviewed for accuracy. |
12/01/2017
| Implemented |
| 2380.176(a) | Individual daily goals and activity logs were left out on a table unattended in the Shark room. A cork board located in the Shark room had a document stating the individuals' names in the program, their date of birth, names of family members and contact information. This information was not locked and available for anyone in the program area to see. There was individual information left out in the Dolphins room unlocked and unattended. | Individual records shall be kept locked when they are unattended. | No personal information will be posted in the individual classrooms. This information was immediately removed form the bulletin board. the day of the inspection.
It has been reviewed with all staff that records can not be left unattended and must be locked in the assigned area. |
10/10/2017
| Implemented |
| 2380.181(a) | Individual #1's assessments completed on 7/4/16 and 7/4/17 were the exact same assessment, just had a date change. The individual never had an assessment of their needs for 2017. Individual #3's assessments completed on 1/6/16 and 1/10/17 were the same exact assessments with only the date and the Individual's age being change. | Each individual shall have an initial assessment within 1 year prior to or 60 calendar days after admission to the facility and an updated assessment annually thereafter. | The assessment for individual #1 that was due in July 2017, will be rewritten to reflect his current abilities and needs.
Individual #3's assessment is due again in January. The Program Specialist will assure that the assessment done in January 2018 will reflect current abilities and needs.
In the future, the Program Specialist will assure that the Assessments are completed correctly.
The director of quality Management will perform random chart audits throughout the year. the audit will include review that the assessments do not just have a date change but are current. |
01/15/2018
| Implemented |
| 2380.181(f) | Individual #1's assessment was not sent out to the Support Coordinator and team 30 days prior to the Individual Support Plan meeting. | The program specialist shall provide the assessment to the SC or plan lead, as applicable, and plan team members at least 30 calendar days prior to an ISP meeting for the development, annual update and revision of the ISP under § § 2380.182, 2390.152, 6400.182 and 6500.152 (relating to development, annual update and revision of the ISP). | Individual #1 assessment ill be redone and sent to all team members by January 15, 2018.
In the future the Program Specialist will assure that the assessment is done 30 days prior to the ISP and sent to all team members. There was an ISP conducted on 12/1/17/ The Assessment was sent to all Team members on 11/1/17. See supporting documentation. |
12/01/2017
| Implemented |
| 2380.183(4) | Individual #1's Individual Support Plan (ISP) did not include his/her supervision needs while at the day program. His/Her ISP indicated he/she has 2:1 -- 1:1 staffing at Royer Greaves in facility. He/She attends 8:30am-3:30pm.' According to his/her assessment, he/she receives a 1:1 staff while at the facility and 2:1 staff in the community. His/Her ISP does not indicate if supervision needs to be visual, hearing, arms-length etc. at all times. His/Her ISP also does not include a protocol to reduce the intensive staffing towards a higher level of achievement. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol and schedule outlining specified periods of time for the individual to be without direct supervision, if the individual¿s current assessment states the individual may be without direct supervision and if the individual¿s ISP includes an expected outcome which requires the achievement of a higher level of independence. The protocol must include the current level of independence and the method of evaluation used to determine progress toward the expected outcome to achieve the higher level of independence. | Individual #1's Supervision needs at the Day Program are 1:1 and within arm's length and 2:1 Supervision within arm's length while in the Community. This information was submitted to the Support's Coordinator In October for a change in the Isp with a justification for variance and plan to reduce the intensive staffing. Program Specialist will follow up with the Support's Coordinator to ensure that all these changes are added to the Isp. |
12/01/2017
| Implemented |
| 2380.183(5) | Individual #1's Individual Support Plan (ISP) did not include a protocol to address his/her social, emotional and environmental needs. His/Her ISP indicated he/she had a behavior support plan but only behavior support staff and residential staff were responsible for collecting data. The behavior support plan included in the ISP only provided support for Individual #1's behaviors of property destruction and clothes tearing. According to the behavior support plan, he/she also displays many self-injurious behaviors that need addressed. A SEEN plan was not created for Individual #1 until 9/10/17. Individual #3 is taking psychotropic medications and has a Social, Emotional, and Environmental Plan (SEEP) in place. Individual #3's ISP updated 8/9/17 did not contain the protocol to address his/her SEEP. | The ISP, including annual updates and revisions under § 2380.186 (relating to ISP review and revision), must include the following: A protocol to address the social, emotional and environmental needs of the individual, if medication has been prescribed to treat symptoms of a diagnosed psychiatric illness. | individual #1's SEEP Plan was being updated on an annual basis not during ISP plan update meetings. In the future, His SEEP Plan will be updated during ISP Plan update meeting. Behavior date Collection used in the Residential will be used at the Day Program. Individual #1's behaviorist will provide training to the Day Program Staff on data collection. An email will be sent to Individual#1's Supports Coordinator to add to the Isp additional behaviors addressed in the Behavior Support Plan. Individual#3'S SEEP will be emailed to Individual#3'S Support's Coordinator to include in her ISP Plan. |
12/29/2017
| Implemented |
| 2380.184(a)(1)(i) | -Individual #1 did not attend his/her annual Individual Support Plan (ISP) meeting on 8/8/17. There is no documentation in his/her record to support that he/she attended his/her annual ISP meeting. | The plan team shall participate in the development of the ISP, including the annual updates and revisions under § 2380.186 (relating to ISP review and revision). A plan team must include as its members the following: The individual. | Individual # 1 was invited and given the opportunity to attend his ISP Meeting held on the 8/8/17. It is documented in his plan under know and do that his Parents who are his legal guardians have requested that he do not attend his meeting while they attend as it makes him anxious as he relates the meetings with going home and may cause significant behaviors. The Plan has since been reviewed with him. In the future Team members will continue to give him the opportunity to attend his meetings and support him through the meeting. |
12/01/2017
| Implemented |
| 2380.185(b) | Individual #1's Individual Support Plan (ISP) indicated that staff encourage him/her to alternate food and liquid 1:1.' During onsite inspection on 10/17/17, Individual #1's 1:1 staff was sitting next to him/her during lunch time. However, during the time frame of the inspection, staff never verbally interacted with Individual #1 during his/her lunch to remind him/her to alternate food and liquid 1:1. During inspection, Individual #1 was only witnessed to eat food during lunch, and not drink; taking bite after bite of his/her food. | The ISP shall be implemented as written. | The ISP for Individual #1 has been reviewed with Individual #1'S 1:1 Staff. ATF Supervisor will randomly monitor meal times to ensure that meal protocols are implemented as written in the ISP. |
12/08/2017
| Implemented |
| 2380.186(a) | Repeat 4/5/16: The Individual Support Plan (ISP) reviews for Individuals #1 and #3 were not completed by the program specialist. The day program staff complete the ISP reviews and submit for the program specialist to review, sign and date. Individual #3's ISP reviews completed on 8/31/17, 5/31/17, 3/1/17 and 12/1/16 were not completed by the program specialist. The day program staff completed the ISP reviews and submitted them for the program specialist to review, sign and date. | The program specialist shall complete an ISP review of the services and expected outcomes in the ISP specific to the facility licensed under this chapter with the individual every 3 months or more frequently if the individual¿s needs change which impact the services as specified in the current ISP. | Program Specialist will effective immediately complete and sign all the ISP Plan reviews for all individuals served in the ATF Program every three months or if there are any changes in any of the individual's needs.Quality Assurance Director will conduct routine chart audits to ensure compliance with this regulation. |
11/30/2017
| Implemented |
| 2380.186(c)(1) | Individual #1's Individual Support Plan (ISP) reviews did not review their participation and progress in his/her outcomes of social interaction' and communication.' The reviews did not indicate the type of participation. | The ISP review must include the following: A review of the monthly documentation of an individual's participation and progress during the prior 3 months toward ISP outcomes supported by services provided by the facility licensed under this chapter. | Program Specialist will ensure that all ISP reviews completed every three months includes individual's participation and progress for the three months covered. Quality Assurance Director will perform random chart reviews and ensure Participation and Progress is covered in all ISP reviews.
The next quarterly report is due December 30th. The review will be completed by 1/5/18. |
01/05/2018
| Implemented |
| 2380.186(c)(2) | Individual Support Plan (ISP) reviews didn't review individual #1's Social, Emotional, Environmental Plan (SEEP), Behavior Support Plan (BSP), behaviors, communication needs, 1:1 at day, 2:1 in community, his diet. There is a lot of daily data indicating he/she has behaviors daily of biting himself/herself but not how many times per day, how long, etc. The documentation is not sufficient. Individual #3's ISP reviews dated 8/31/17, 5/31/17, 3/1/17 and 12/1/16 did not review the area of his/her SEEP. | The ISP review must include the following: A review of each section of the ISP specific to the facility licensed under this chapter. | Procedural plans will be made to update SEEP Plans when ISP's are renewed or updated instead of yearly expiration dates posted on the document. |
12/01/2017
| Implemented |
| 2380.186(d) | There was no documentation that individual #1's Individual Support Plan (ISP) reviews sent to any team members. | The program specialist shall provide the ISP review documentation, including recommendations, if applicable, to the SC or plan lead, as applicable, and plan team members within 30 calendar days after the ISP review meeting. | The Program Specialist will assure that documentation will be available in the chart to show that the quarterly report was sent to all Team members with 30 days after the quarterly review.
The Director of quality Assurance will perform random chart reviews throughout the year. This documentation will be included in the review. |
12/05/2017
| Implemented |
| 2380.186(e) | The option to decline was not offered to individual #1 and Individual #3's team members. | The program specialist shall notify the plan team members of the option to decline the ISP review documentation. | The option to decline form will be sent to the team members for individual #1 and individual #3.on 12/11/17.
The charts of the other individuals will be reviewed to assure that this regulation is in compliance by 12/18/17.
The Director of Quality Management will perform random chart audits throughout the year. This form will be included in the review. |
12/18/2017
| Implemented |