| Inspection ID | Reason for Inspection | Inspection Date | Inspection Status | |
|
SIN-00261705
|
Renewal
|
03/05/2025
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.15(c) | The self-assessment completed on 8/5/2024 does not include a plan for the items cited as non-compliant. | A copy of the agency's self-assessment results and a written summary of corrections made shall be kept by the agency for at least 1 year.
| a. WHO will be responsible for correcting the problem in the future: CEO will make the corrections for this violation.
b.WHAT will be corrected: Written corrections for violations identified on the 8/5/24 provider self-assessment. The issues were corrected before inspection but were not documented on the form. These will be written on the form as required. The corrections state the smoke detectors were replaced with new ones and the items were restocked in the first aid kit.
c. WHEN and HOW: On 3/11/24 completed written corrections for the violations identified on the 8/5/24 provider self-assessment as an example of how they would need to be completed in the future.
Attachment 1: Written corrections for violations identified on the 8/5/24 self-assessment. |
03/16/2025
| Implemented |
| 6400.166(a)(2) | 166a2 - At the time of the inspection, the name of the prescriber of the medication Lizness Cap 145mg for Individual #1 did not match the MAR. The MAR lists have two different doctors. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | a. WHO will be responsible for correcting the problem in the future: KLHS LPN Wellness Coordinator.
b.WHAT will be corrected: The name of the prescriber has been changed on the MAR to match the prescriber listed on the medication label.
c. WHEN and HOW: The Wellness Coordinator completed the change by 11/16/25.
Attachment 5: MAR showing change to prescriber. |
03/16/2025
| Implemented |
|
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|
SIN-00240035
|
Renewal
|
03/05/2024
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.22(d)(1) | Individual # 2 does not have an up to date personal property inventory. The agency reported that they do not have a personal property inventory for Individual # 2. | The home shall keep an up-to-date financial and property record for each individual that includes the following: Personal possessions and funds received by or deposited with the home. | a. WHO will be responsible for correcting the problem in the future: DSPs will complete an up-to-date property inventory for individuals #1 and #2. KLHS CEO will send a memo to employees notifying them of the procedural update and track employee acknowledgement of the memo to ensure each person has received the information.
b.¿WHAT will be corrected: KLHS will immediately generate a personal property inventory for individuals #1 and #2. KLHS will maintain an up-to-date personal property inventory by updating it within 3 days of obtaining/discarding an item over $50 or of sentimental value.
c. WHEN and HOW: Personal property inventories of both individuals #1 and #2 were completed on 3/16/24. DSPs used the ISP Data form on Therap to enter a complete property inventory list. Memo from CEO to employees informing them of the procedural changes was sent on 3/13/24. An additional staff training on the procedures is planned for 3/21/24 and employees were notified of the training date in the original memo sent by KLHS CEO. The new procedures include DSPs entering a personal property update on the ISP Data form in Therap within 3 days of obtaining or discarding an item of $50 in value or of sentimental value. This will keep a running up-to-date personal property inventory.
Attachment 1: Individual #1¿s personal property inventory.
Attachment 2: Individual #2¿s personal property inventory.
Attachment 3: KLHS CEO Memo to staff about the personal property inventory procedure changes. |
03/18/2024
| Implemented |
| 6400.144 | Individual # 1 is prescribed a PRN medication of Gavilax Powder once daily as needed for constipation. The agency did not track BM frequency on 01/05, 08, 11, 12, 13, 15, 20, 25, 29/24. Nor did it track BM frequency on 02/01, 03, 04, 05, 15, 16, 27, 28/24. The agency reported that if there is no BM that they do not document this information and simply leave the tracking form blank. The physical examination dated 01/25/24 reads "If individual fails to have a bowel movement within 3 days, then use the PRN medication, Gavilax POW, to help promote a BM". Gavilax POW was not given 02/06/24 after the 3 days from 02/03-05/24 with no BM.
The Gastroenterologist recommended that Individual # 1 receive 90 ounces of fluid/day on 08/02/23. The agency reported that they did not track fluid intake from 08/02/23-January 2024.
Individual # 2 was recommended to receive 70 oz of fluids per day by physicians on 01/31/24 and 04/25/24. The agency did not track daily fluid intake on 02/14/24. The space is left blank. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| a. WHO will be responsible for correcting the problem in the future: KLHS LPN Wellness Coordinator reached out to individual #1 and individual #2¿s PCPs for clarification on fluid intake recommendations and sent an ISP Change form on 3/18/24 with the changes in recommendations. The Wellness Coordinator sent a scomm message on 3/14/24 to all DSPs informing them that bowel movements and fluid intake for individual #1 and #2 must be tracked on every shift and a ¿0¿ must be entered if the individual did not have a bowel movement of consume fluid on that shift. DSPs will be responsible for tracking bowel movements and fluid intake for individual #1 and #2. KLHS Wellness Coordinator will be responsible for monitoring the completion of health tracking by DSPs daily.
Attachment 22: ISP Change form for individual #1.
Attachment 23: ISP Change form for individual #2.
Attachment 5: Wellness Coordinator scomm to DSPs informing them of the need to track bowel movements and fluid intake for individual #1.
Attachment 6: Wellness Coordinator scomm to DSPs informing them of the need to track bowel movements and fluid intake for individual #2.
b.¿WHAT will be corrected: KLHS DSPs will document bowel movements and fluid intake for individuals #1 and #2 on every shift. A ¿0¿ will be entered at the end of their shift if there have been no bowel movements or fluids consumed.
c. WHEN and HOW: DSP¿s will use KLHS¿s electronic documentation system called Therap to enter bowel movements and fluid intake under the ¿intake and elimination¿ section in health tracking. They will enter a ¿0¿ at the end of their shift if there were no bowel movements of fluid consumed.
Attachment 7: Completed intake and elimination form example for individual #1.
Attachment 8: Completed intake and elimination form example for individual #2. |
03/18/2024
| Implemented |
| 6400.52(c)(1) | Staff # 2 was not trained in Person Centered Planning during the 2022-2023 training year. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships. | a. WHO will be responsible for correcting the problem in the future: KLHS CEO assigned staff #2 Person Centered Planning and Safe and Appropriate use of Behavior Supports training on 3/17/24. KLHS Residential Manager revised the Annual Training curriculum in Direct Course, and the Annual Training course record in Therap for clarity and to ensure each staff person completes all required training.
b.¿WHAT will be corrected: Staff #2 was assigned Person Centered Planning training on 3/17/24 and it was completed on 3/18/24.While performing a record review KLHS found that staff #2 also did not receive Safe and Appropriate use of Behavior Supports Training so it was assigned on 3/17/24 and completed on 3/18/24.
Attachment 10: Person Centered Planning and Safe Behavior Supports for staff #2.
c. WHEN and HOW: Staff #2 was assigned Person Centered Planning and Safe and Appropriate use of Behavior Supports training on 3/17/24 on Direct Course which is a platform that provides training from the College of Direct Support. The courses were completed on 3/18/24. |
03/18/2024
| Implemented |
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SIN-00221044
|
Renewal
|
03/20/2023
|
Compliant - Finalized
|
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Inside of oven was not clean at the time of the walkthrough. | Clean and sanitary conditions shall be maintained in the home. | 1. A plan to fix the immediate problem:
a. WHO: KLHS Program Manager and DSPs
b. WHAT: The inside of the oven was cleaned.
c. WHEN and HOW: On 3/24/23 third shift DSP ran the self-clean feature on the oven then wiped it clean. She took a photograph of the cleaned oven to submit as a supporting document for KLHSs POC (attachment #1). |
03/31/2023
| Implemented |
| 6400.144 | - Individual #2's current assessment states that they are incontinent and needs to be woken up every 2 hours for support staff to assist in using the restroom. Staff are logging this information in shift notes, but there are times where the Individual has exceeded 2 hours and was not woken up or woke up on their own. For example: On 2/20/23 Individual #2 used the restroom at 1:40am, then was not woken up or used on their own again until 4:35am (almost 3 hours), on 2/21/23 Individual #2 used the restroom at 1:25am, then was not woken up or used on their own again until 4:30am (3 hours), on 3/5/23 Individual used the restroom at 2:57am, then was not woken up or used on the own again until 6:30am. (3 ½ hours)
- Individual #2's Nutritionist has advised that staff are to keep track of how much water the Individual drinks per day. On 3/8/23 and 3/10/23 staff did not track any fluid intake. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| 1. A plan to fix the immediate problem:
a. WHO: Program Specialist, CEO, and Wellness Coordinator
b. WHAT:
i. Individual #2s ISP team has agreed to amend her ISP and Assessment to state that support staff will assist her to use the bathroom throughout the night when she signals for them using the motion sensor next to her bed. The previous procedure was in the ISP/assessment from when she lived with her aunt. The team felt this change was a more functional procedure and individual #2 expressed it is her preference to notify staff when she needs to use the restroom so she can sleep with less interruptions while still receiving assistance every time she uses the restroom.
ii. KLHS Wellness Coordinator instructed Individual # 2s support staff to record water intake everyday in accordance with her nutritionist¿s recommendations.
c. WHEN and HOW:
i. The ISP team, including individual #2s Supports Coordinator met on 3/30/23 to discuss the change and KLHS CEO recorded meeting minutes and obtained a meeting signature page to document the teams agreement in making the change (attachment #4).
ii. The Wellness Coordinator sent an Scomm (secure communication message on Therap, KLHS¿s electronic database system) to support staff on 3/30/23 (attachment #5). |
03/31/2023
| Implemented |
| 6400.182(c) | Individual #2 moved in with Key Life Human Services, LLC on 9/22/22. The Individual's current ISP states that they reside with their aunt. Information has not been updated in the ISP to reflect the change. | The individual plan shall be initially developed, revised annually and revised when an individual's needs change based upon a current assessment. | 1. A plan to fix the immediate problem:
a. WHO: KLHS Program Specialist, CEO
b. WHAT: KLHS Program Specialist made corrections to Individual #2s ISP so that it is current and accurate in all areas, including her current residence (attachment #9).
c. WHEN and HOW: KLHS CEO submitted the corrected ISP via email on 3/31/23 to the individual¿s Supports Coordinator and requested that she make the changes in the ISP (attachment #10). |
03/31/2023
| Implemented |
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|
|
SIN-00201234
|
Renewal
|
03/09/2022
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.66 | There is no light outside of the Garage Egress. | Rooms, hallways, interior stairways, outside steps, outside doorways, porches, ramps and fire escapes shall be lighted to assure safety and to avoid accidents.
| 1. Why is the regulation important? To protect the safety of individuals entering and exiting the egress.
2. What happened? The home did not have a light outside the garage egress.
3. Why did it happen? The home has never had a light in that location.
4. What do we do right now? Install a light outside the egress.
5. A plan to fix the immediate problem
a. WHO: The KLHS Facility Manager will install a light in the desired location.
b. WHAT: The homes garage egress will now have a light outside the egress.
c. WHEN and HOW A light was installed by 3/23/22. All other egresses were inspected and are compliant. |
03/23/2022
| Implemented |
| 6400.67(a) | A 5-inch diameter drywall patch behind Individual # 1's bedroom door was unpainted. | Floors, walls, ceilings and other surfaces shall be in good repair. | 1. Why is the regulation important? To ensure a level of quality is maintained at residential homes so individuals receiving services are safe and comfortable in their homes.
2. What happened? A hole behind individual #1s bedroom door was patched and sanded but not painted to match the color of her bedroom walls.
3. Why did it happen? The spackle needed time to dry so it could not be painted at the same time it was patched. The facility manager had not returned to paint the patched section yet.
4. What do we do right now? Paint the patched section.
5. A plan to fix the immediate problem
a. WHO: The Facility Manager will paint the patched section of the wall.
b. WHAT: The patched section will be painted.
c. WHEN and HOW: The patched section of the wall was painted on 3/17/22. A painter was hired to paint a fresh coat of paint over the entire first floor of the home (except for the individuals bedroom which was recently painted) to cover any other patched sections that are unpainted. The painter is confirmed to paint as of 3/23/22. |
03/23/2022
| Implemented |
| 6400.103 | Individual # 1's Emergency Evacuation Procedure does not include individual responsibilities. | There shall be written emergency evacuation procedures that include individual and staff responsibilities, means of transportation and an emergency shelter location.
| a. WHO The CEO will correct the policy and ensure staff and individuals receiving services are trained.
b. WHAT: The Emergency Evacuation policy will be updated to include responsibilities and procedures for individuals receiving services in the event of an emergency evacuation.
c. WHEN and HOW: The policy was updated on 3/9/22 and was disseminated agency wide on 3/21/22. Individual #1 is the only person receiving services so there is no need for a review of records, and we are compliant. |
03/23/2022
| Implemented |
| 6400.166(a)(2) | At the time of the inspection, individual #1's MAR contained several medications that did not contain the prescribing Dr.'s information. Medications such as, but not limited to: Ibuprofen, Mirtazapine, and Olanzapine | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber. | 1. Why is the regulation important? To ensure the safety of individuals while administering medications. The prescribing doctor might need to be contacted in the instance of a medication error or medical emergency related to the medication. Having the information on the MAR will assist in keeping individuals safe and healthy.
2. What happened? There was no doctor/prescriber listed on the MAR for every medication.
3. Why did it happen? KLHS Medical Manager is no longer employed with the agency and the Program Manager is assuming those responsibilities including the development and maintenance of MARs.
4. What do we do right now? Add the prescriber to medications listed on the MAR.
5. A plan to fix the immediate problem
a. WHO: The Program Manager updated the MAR to include the doctor/prescriber of each medication.
b. WHAT: The Mar was updated to include the doctor/prescriber of each medication.
c. WHEN and HOW: The MAR was corrected by 3/21/22. Individual #1 is the only individual receiving services and therefore no review of records in needed and we are compliant. |
03/23/2022
| Implemented |
| 6400.166(a)(11) | At the time of the inspection, several of the medications on individual #1's Mar were missing the diagnosis or purpose of the medication that was prescribed. There was a location on the MAR for this information, however, the spot was filled with the medication instructions/directions, twice.
Some of the medications were, but not limited to;
Clonazepam, Risperidone, desmopressin acetate, potassium CL ER, Divalproex, Hydrochlorothiazide, Lamotrigine, Ibuprofen, mirtazapine, and olanzapine. | A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata. | 1. Why is the regulation important? To ensure the safe administration of medications to individuals receiving services.
2. What happened? There was no diagnosis or purpose for medications listed on the MAR
3. Why did it happen? KLHSs Medical Manager is no longer employed with the agency and the Program Manager is assuming those responsibilities including the development and maintenance of MARs.
4. What do we do right now? Update the MAR to include the diagnosis or purpose of each medication listed on the MAR.
5. A plan to fix the immediate problem
a. WHO: The Program Manager updated the MAR to include a diagnosis or purpose for each medication.
b. WHAT: The Program Manager updated the MAR to include a diagnosis or purpose for each medication.
c. WHEN and HOW: The MAR was corrected by 3/21/22. Individual #1 is the only individual receiving services and therefore no review of records in needed and we are compliant. |
03/23/2022
| Implemented |
|
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SIN-00187114
|
Unannounced Monitoring
|
05/04/2021
|
Compliant - Finalized
|
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.52(c)(3) | Staff #1 has not completed the annual 'Individual Rights' training since employee orientation on 5/11/2018. | The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights. | Why is this Regulation Important?
To ensure DSPs remain up to date and knowledgeable about the rights of the individuals they support as to not infringe on their rights. This protects the individuals health, safety, and wellbeing. It establishes the very basic foundation for a standard of care.
What Happened?
Staff person number 1 was not trained annually on the rights of the individuals receiving services as established by Department regulation.
Why Did it Happen?
KLHSs annual training did not contain the specific rights of individuals receiving services in a 6400 setting.
Immediate Correction
1. Completion Date: 5/12/21 Person Responsible: CEO Action Taken: Staff person number 1 was trained on individual rights Attachment: 1
Review of Records
2. Date Completed: 5/12/21 Responsible Person: CEO Actions Taken: On 5/6/21 all employees of KLHS were assigned a review of individual rights on Therap Services an electronic documentation system used by KLHS Attachment: 1 |
05/12/2021
| Implemented |
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|
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SIN-00184858
|
Renewal
|
03/08/2021
|
Compliant - Finalized
|
|
|
| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.16 | Failure to implement a fall protocol. Individual #1's 5/24/19 "Fall Protocol" requires staff to be within arm's length of Individual #1 at all times unless she is in her bedroom or bathroom due to being a fall risk. The protocol also requires staff to encourage Individual #1 to utilize her wheeled walker within her home. Individual #1 experienced a fall in the kitchen on 7/9/20 that resulted in a broken arm. Staff were not within arm's length distance of Individual #1, and Individual #1's walker was not present at the time of the fall.
Failure to administer medications On October 9, 2020, Dr. Patel ordered an increase in Individual #1's 8pm dose of Quetiapine from 600mg to 800mg. This dosage was confirmed by Key Life Human Services staff on 10/12/20. Staff only administered 400mg of Quetiapine at 8pm beginning 10/14/20 until 11/10/20. Staff failed to administer a proper dose of medication and failed to report this incorrect dose to Dr. Patel until 11/6/20. Quetiapine is prescribed for Individual #1's Mood Disorder. An incorrect dose of this medication could lead to outbursts of emotion or aggression per Dr. Patel's Medical Progress notes.
Failure to provide needed supervision Individual #1's 5/24/19 plan update indicates that staff are to be within arm's length supervision unless individual #1 is in her bedroom or bathroom, where staff is required to be within audible distance of Individual #1. Between the dates of 2/1/20 and 2/28/21, Individual #1's fall log reports a total of 95 falls; there is no evidence that staff were within arm's length of Individual #1 during these incidents. Key Life Human Services has not updated Individual #1's assessment nor have they notified the plan team that a change is required regarding Individual #1's supervision level in the bathroom or her bedroom. 58 of Individual #1's 95 falls during the above time period occurred while the individual was in her bedroom or bathroom, where she receives only audible distance supervision. Key Life Human Services requires that staff complete a fall log in Therap (Key Life Human Services' Health Tracking system) after every fall, however, they have no written protocol explaining what is to be done whenever a fall occurs. | Abuse of an individual is prohibited. Abuse is an act or omission of an act that willfully deprives an individual of rights or human dignity or which may cause or causes actual physical injury or emotional harm to an individual, such as striking or kicking an individual; neglect; rape; sexual molestation, sexual exploitation or sexual harassment of an individual; sexual contact between a staff person and an individual; restraining an individual without following the requirements in this chapter; financial exploitation of an individual; humiliating an individual; or withholding regularly scheduled meals. | Why is this Regulation Important?
To protect individuals from abuse or maltreatment in the residential setting.
What Happened?
There was no fall protocol in accordance with Dr. Cherpes Health Alert pertaining to calling emergency 911.
The quetiapine was given according to the written prescription sent to the pharmacy.
The individuals supervision needs were not updated in accordance with her declining mobility.
Why Did it Happen?
Fall procedures were in place for DSP¿s who are all certified in Red Cross First Aid to assess the individual and obtain medical care for the individual based on the criteria listed in the Emergency Medical policy.
Individual 1s prescribing doctor said to staff at an appointment that he wanted the individuals medication to be increased from 600mg to 800mg (2 tablets of 400mg). The script sent to the pharmacy said 400mg (1 400mg tablet instead of 2). Staff member 6 called multiple times to confirm the prescription and was told each time that 400mg was correct and no changes were made to the written prescription. The medication was administered exactly prescribed in writing.
The plan team met monthly to discuss the individuals falling and implemented many changes including obtaining adaptive equipment and increasing staffing and supervision. The team also consulted with her PCP and Neurologist who encouraged the modifications that were being implemented and did not suggest additional changes.
Immediate Correction
1. Date Completed: 4/2/21 Responsible Person: Staff Member 1 Actions Taken: Abuse reported on EIM and a certified investigation started. Attachment: 1
2. Date Completed: 3/23/21 Responsible Person: Staff Member 6 Actions Taken: Fall protocol developed based on the 1/4/15 Health Alert from Dr. Cherpes and received approval from Individual 1s PCP. Attachment: 2
3. Date Completed: 3/31/21 Responsible Person: Staff Member 2 Actions Taken: Fall Protocol approved by Individual 1¿s team and implemented into the ISP, documented on an ISP change form and reviewed by staff. Attachment: 3
4. Completion Date: 3/21/21 Person Responsible: Staff Member 1 Action Taken: KLHS employees assigned Direct Course trainings on fall prevention, maltreatment, individual rights, and medications. Attachment: 6
5. Completion Date: 4/7/21 Person Responsible: Staff Member 2 Action Taken: Supervision has been updated on an ISP change form and DSP¿s have acknowledged it. Attachment: 4
6. Completion Date: 4/12/21 Person Responsible: Staff Member 2 Actions Taken: Assessment has been updated to include changes in mobility, fall protocol, and supervision needs, and staff will be trained on it. Attachment: 5
7. Completion Date: 4/20/21 Person Responsible: Staff Member 2 Actions Taken: HCQU technical assistance review of individuals health maintenance needs related to mobility and falls. Attachment: 8
8. Completion Date: 4/7/21 Person Responsible: Staff Member 2 Actions Taken: Request sent for individual 1 to complete HCQU training on Falling Safely.
Attachment: 9
Review of Records
Compliant |
04/08/2021
| Implemented |
| 6400.43(b)(1) | Key Life Human Service's medication policy updated on 6/1/20 notes that if a documentation error (such as not initialing a Medication Administration Record) occurs that the error should be reported via GER on Therap, the medical manager will compare the number of medications in the blister pack to how many should be in the blister pack and then inspect the initials and date that are written on the blister pack next to the empty blister to confirm if the medication was given or missed. If the Medical Manger determines the medication was given, then she will correct the MAR. Correcting the MAR could mean that the Medical Manager would input staff's initial into the MAR as if the staff signed that the medication was administered. This process does not align with the Medication Administration Course. The CEO, staff person #1, has not ensured that Key Life Human Service's medication administration policy aligns with the Commonwealth's approved Medication Administration Training Course. | The chief executive officer shall be responsible for the administration and general management of the home, including the following: Implementation of policies and procedures. | Why is this Regulation Important?
To ensure policy and procedures are followed to protect the individual¿s health, rights, and safety and to ensure compliance with Department standards of care.
What Happened?
Staff member 6 corrected a documentation error on the MAR.
Why Did it Happen?
KLHSs documentation error procedures on the medication Administration policy were not in accordance with the Department approved medication administration course instructions for correcting documentation errors.
Immediate Correction
1. Completion Date: 4/1/21 Person Responsible: Staff Member 1 Action Taken: Updated Medication Safety policy to include procedures for correcting documentation errors which states Documentation errors include but are not limited to initialing under the wrong date, time, and medication, or failing to initial the MAR. Upon discovery the error shall be reported via GER on Therap which will notify the Medical Manager. The Medical Manager will consult with the person who made the documentation error to identify corrective actions to be taken on the MAR. The original person who made the documentation error will correct the MAR. All KLHS employees reviewed and acknowledged the Medication Safety policy. Attachment: 10
Review of Records:
Compliant |
04/08/2021
| Implemented |
| 6400.104 | The fire department notification letter dated 7/23/20 does not include the exact location of Individual #1's bedroom. | The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current.
| Why is this Regulation Important?
To ensure individuals who live in the residential home and may need assistance exiting their home in the event of a fire are able to be found and assisted to safety quickly.
What Happened?
The Fire Department Notification letter did not include a description of the exact location of individual 1s bedroom.
Why Did it Happen?
There were not specific instructions for what a Fire Department Notification letter should include in the agencys Fire Safety policy.
Immediate Correction
1. Completion Date: 3/15/21 Person Responsible: Staff Member 1 Action Taken: An updated fire safety letter was sent to the Reade Township Volunteer Fire Department which stated in bold the location of Individual #1s bedroom and referenced the location on the enclosed map of the home. A certificate of mail receipt was obtained. Attachment: 14
Review of Records
2. Completion Date: 3/31/21 Person Responsible: Staff Member 3 Action Taken: Preformed a review of fire safety letters for all KLHS residential locations and an updated letter, which included the location of the individuals bedroom and a map, was sent for the only other residential home operated by KLHS. Attachment: 15 |
04/08/2021
| Implemented |
| 6400.112(h) | Repeat Violation 2/11/2020: The 4/2020 fire drill log does not indicate if all individuals made it to the designated meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Why is this Regulation Important?
To ensure individuals have safely exited the home during drills as a way to be prepared for an actual fire situation.
What Happened?
The question on the fire drill form asked, ¿Did the individual and all staff make it to the meeting location in 2.5 minutes or less¿ and staff marked Yes without further explanation.
Why Did it Happen?
It appeared to sufficiently answer if everyone made it to the meeting location because the form said to in the comments if not everyone made it to the meeting location and describe (who, why, etc.)
Immediate Correction
1. Completion Date: 3/30/21 Person Responsible: Staff Member 1 Action Taken: The fire drill form has been edited to specifically ask if all individuals made it to the designated meeting place. Staff have been trained on the form. Attachment: 18
2. Completion Date: 4/1/21 Person Responsible: Staff Member 3 Actions Taken: A fire drill was preformed using the updated form. Attachment: 20
Review of Records
3. Completion Date: 3/30/21 Person Responsible: Staff Member 1 Action Taken: The updated fire drill form has been implemented in the only other residential home operated by KLHS and staff have been trained on it. Attachment: 19
4. Completion Date: 4/1/21Person Responsible: Staff Member 3 Actions Taken: A fire drill was preformed using the updated form. Attachment: 21 |
04/08/2021
| Implemented |
| 6400.113(a) | Individual #1 moved into the 340 Market St CLA on 7/23/20. She was not instructed in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safety area in the event of an actual fire until 8/7/20. | An individual, including an individual 17 years of age or younger, shall be instructed in the individual's primary language or mode of communication, upon initial admission and reinstructed annually in general fire safety, evacuation procedures, responsibilities during fire drills, the designated meeting place outside the building or within the fire safe area in the event of an actual fire and smoking safety procedures if individuals smoke at the home. | Why is this Regulation Important?
So individuals learn fire safety information related to their new home as soon as moving in.
What Happened?
The individual completed a fire drill but not fire safety training.
Why Did it Happen?
Fire safety was not listed on the checklist that is used when an individual moves to a new program site.
Immediate Correction
1. Completion Date: 4/7/21 Person Responsible: Staff Member 1 Action Taken: The Fire Safety policy has been edited to explain in detail what fire safety procedures need to be preformed on an individuals first day at a new site location and fire safety training is listed and staff have been trained on the policy. Attachment: 16
Review of Records
Compliant |
04/08/2021
| Implemented |
| 6400.143(a) | Individual #1 was prescribed TED stockings for leg swelling on 6/8/20 to be worn during the day and to be removed at night. Individual's MAR's from June 2020 to present indicate that most of the time, Individual #1 refused to wear the TED stockings. There is no record of the continued attempts to train individual on the importance of following this medical directive. | If an individual refuses routine medical or dental examination or treatment, the refusal and continued attempts to train the individual about the need for health care shall be documented in the individual's record. | Why is this Regulation Important?
To ensure the individuals health is maintained according to a physicians recommendations and oversite.
What Happened?
There was no written record of individual 1s refusal of TED stockings being communicated to the prescriber.
Why Did it Happen?
Individual 1 discussed it with her prescribing physician at an appointment and it was not recorded on an appointment summary.
Immediate Correction
1. Completion Date: 4/7/21 Person Responsible: Staff Member 6 Action Taken: Staff Member 6 trained Individual 1 about the need for health care maintenance including the importance of taking medications. Attachment: 23
Review of Records
2. Completion Date: 4/1/21 Person Responsible: Staff Member 6 Action Taken: Medical Manager trained only other individual receiving residential services from KLHS about the need for health care maintenance including the importance of taking medications for refused medications. Attachment: 24 |
04/08/2021
| Implemented |
| 6400.144 | Repeat Violation 2/11/2020: Individual #1 is diagnosed with cerebral palsy and is considered a fall risk. Key Life Human Services began tracking Individual #1's falls in 3/2019. Between the dates of 2/1/2020 and 2/28/2021, Individual #1 fell a total of 95 times. It was logged that in at least 21 of these incidents, Individual #1 had a suspected injury where no medical attention was sought. Per Health Alert issued by ODP's Medical Director, Dr. Cherpes, on 1/14/15, Key Life Human Services should have contacted 911 due to a fall with a suspected injury.
Key Life Human Services has failed to report changes in health and medication to Individual #1's medical providers. Individual #1 had an increased amount of falls between 8/1/20 and 1/31/21. This increase was not reported to her physicians until a 1/27/21 neurology appointment in order to determine a potential change in course of care. Key Life Human Services also failed to provide the correct dose of Quetiapine to Individual #1 beginning 10/14/20. This was not reported to the provider, nor was it corrected, until 11/11/20. Individual #1 continually refused to wear the TED stockings that were prescribed to her on 6/8/20 for lower extremity swelling. This refusal was not reported to Individual #1's medical provider until 3/10/21 to determine a potential change in course of care. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Why is this Regulation Important?
To ensure the health of individual¿s receiving residential services by providing for the recommendations of physicians.
What Happened?
KLHS did not implement a fall protocol in accordance with Dr. Cherpes Health Alert regarding when to call emergency 911.
There was no written record of KLHS reporting changes in individual 1s health to medical providers.
Why Did it Happen?
KLHS was unaware of the ODP Health Alert guidance for emergency 911 and instead obtain medical care in accordance with Red Cross standards.
KLHS verbally informed individual 1s PCP of falls and declining mobility, as it was a requirement to apply for insurance funded adaptive equipment which was obtained during the time between her neurology appointments.
Individual 1s prescribing doctor said to staff at an appointment that he wanted the individuals medication to be increased from 600mg to 800mg (2 tablets of 400mg). The script sent to the pharmacy said 400mg (1 400mg tablet instead of 2). Staff member 6 called multiple times to confirm the prescription and was told each time that 400mg was correct and no changes were made to the written prescription. The medication was administered exactly prescribed in writing.
Individual 1 discussed it with her prescribing physician at an appointment and it was not recorded on an appointment summary.
Immediate Correction
1. Completion Date: 3/23/21 Person Responsible: Staff Member 6 Action Taken: Developed a fall protocol in accordance with DR. Cherpes 1/4/12 Health Alert which includes providing record of falls to physicians and trained employees on it. Attachment: 2
Review of Records
2. Completion Date: 4/1/21 Person Responsible: Staff Member 6 Action Taken: Notified the physicians of the only other individual receiving residential services from KLHS of refusals of medication. Attachment: 26
3. Compliant with notification of health maintenance needs. |
04/08/2021
| Implemented |
| 6400.151(b) | Staff person #3's most recent physical dated 10/5/19 and Staff person #5's most recent physical dated 4/17/19 are signed by the Physician's Assistant, but are not dated by the PA as per regulation. | The physical examination shall be completed, signed and dated by a licensed physician, certified nurse practitioner or licensed physician's assistant. | Why is this Regulation Important?
So it is clear when the employees physical was conducted.
What Happened?
There was no date next to the person completing the physicals name.
Why Did it Happen?
Healthforces form did not provide a line for the date as the date is written at the top of the page.
Immediate Correction
1. Completion Date: 3/16/21 Person Responsible: Staff Member 3 Action Taken: Emailed Healthforce and received staff person 3 and 5s physicals dated.
Attachment: 27
Review of Records
2. Completion Date: 3/16/21 Person Responsible: Staff Member 3Action Taken: Healthforce dated all other employee physicals missing the date. Attachment: 27 |
04/08/2021
| Implemented |
| 6400.181(e)(4) | Individual #1's current assessment, dated 12/4/2020, and her current ISP, dated 7/1/20 updated 10/27/20, are not consistent in documenting Individual #1's current level of supervision. Individual #1's assessment section for "the individual's need for supervision" states that she needs 2:1 staffing from 8am to 4pm with one staff within visual distance when individual is awake and not in the bedroom or bathroom and one staff within audible distance when Individual is relaxing, sleeping, or napping in her bedroom or in the bathroom. Staffing is 1:1 from 4pm to 8am. In the section titled "individual's progress over the last 365 days and current level in the following area: motor and communication" states: "In her residence staff are within arms length at all times except in the bedroom and bathroom due to [Individual #1] being a fall risk." In the section of the assessment titled "Knowledge of water safety and ability to swim" it states, "[Individual #1] does not need assistance getting in and out of the shower/bath." Individual #1's ISP includes the following statements: [Individual #1] has one staff in the room that [individual #1] is in except for when [individual #1] is laying in her bedroom or when in the bathroom requiring privacy.", "[Individual #1] does not self medicate and needs within arms length supervision.", "[Individual #1] at times requires physical assistance getting in and out of the shower/bath and if she does staff would physically assist her with hands on supports.", "[Individual #1]" needs within arms length supervision unless she is sitting down in the kitchen near heat sources." | The assessment must include the following information: The individual's need for supervision.
| Why is this Regulation Important?
To ensure the health, safety, and wellbeing of the individual receiving residential services by communicating current and accurate information in a detailed and organized way to support staff by means of the assessment and ISP.
What Happened?
The assessment and ISP content did not match.
Why Did it Happen?
Changes were not correctly and consistently documented in the assessment and ISP.
Immediate Correction
1. Completion Date: 3/23/21 Person Responsible: Staff Member 2 Action Taken: Plan team met to discuss changes in supervision on the ISP and Assessment. Attachment: 38
2. Completion Date: 4/7/21 Person Responsible: SCO Action Taken: The ISP was revised an ISP change form was completed and staff trained reviewed it. Attachment: 4
3. Completion Date: 4/8/21 Person Responsible: Staff Member 2 Action Taken: The Assessment was revised. Attachment: 5
4. Completion Date: 4/12/21 Person Responsible: Staff Member 2 Action Taken: Staff are scheduled to be trained on the ISP and Assessment. Attachment: 7
Review of Records
5. Completion Date: 4/7/21 Person Responsible: Staff Member 2 Action Taken: Email sent to plan team to meet and make corrections to the ISP and Assessment of the only other individual receiving residential services from KLHS. Attachment: 39 |
04/08/2021
| Implemented |
| 6400.31(a) | Individual #1 was deprived of the right to receive medical care for the suspected injury for multiple falls between 2/1/20 and 2/28/21. There were 21 incidents where bruising, pain, or head injuries are noted on Key Life Human Services' fall log in place for Individual #1 and individual was not offered medical services.
Individual #1 had an increased number of falls (13 reported in 8/2020, 14 reported in 9/2020, 7 reported in 12/2020, 9 reported in 1/2021, and 8 reported in 2/2021), and had multiple medical appointments during this time frame. Individual #1's rights were violated in that her increase in falls were not reported to her physicians to determine a potential change in care. This increase was not reported to her physicians until a 1/27/21 neurology appointment. | An individual may not be deprived of rights as provided under § 6400.32 (relating to rights of the individual.) | Why is this Regulation Important?
To ensure the rights and safety of individuals receiving services in residential settings.
What Happened?
The individual did not receive medical care in accordance with Dr. Cherpes Health Alert regarding when to call emergency 911.
There was no written record of KLHS reporting individual 1¿s declining mobility and falls.
Why Did it Happen?
KLHS was unaware of the ODP Health Alert guidance for emergency 911 and instead obtain medical care in accordance with Red Cross standards.
KLHS verbally informed individual 1¿s PCP of falls and declining mobility, as it was a requirement to apply for insurance funded adaptive equipment which was obtained during the time between her neurology appointments.
KLHS sought an assessment from the neurologist when mobility first started declining and results were normal. Individual 1 attended neurology appointments as scheduled by the neurologist and when falls were reported to neurologist on 1/27/21 no additional changes were suggested. There was no indication of concern or reason to increase appointments from the neurologist.
Immediate Correction
1. Completion Date: 4/2/21 Person Responsible: Staff Member 1 Action Taken: Rights violation reported on EIM and certified investigation started. Attachment: 13
2. Completion Date: 3/23/21 Person Responsible: Staff Member 6 Action Taken: Fall protocol was developed then approved by PCP. Attachment: 2
3. Completion Date: 3/21/21 Person Responsible: Staff Member 1 Action Taken: All KLHS employees were assigned Direct Course trainings on the rights of the individual. Attachment: 6
Review of Records
Compliant |
04/08/2021
| Implemented |
| 6400.165(b) | On November 6, 2020, Dr ordered an increase in Individual #1's 8pm dose of Quetiapine from 400mg to 600mg (two 300mg tablets). The change in this medication did not take place in the home until 11/11/20. | A prescription order shall be kept current. | Why is this Regulation Important?
To ensure the individuals health is maintained by administering medications in accordance with prescriptions that accurately reflect the prescribers recommendations.
What Happened?
The script sent to the pharmacy was not in accordance to what the doctor stated verbally during the visit.
Why Did it Happen?
Staff member number 6 called the prescribers office at least two times and was told the script was correct and no other script was then sent to the pharmacy. There was no reason for KLHS to think at that point that the medication should not be administered in accordance with the written script sent to the pharmacy.
Immediate Correction
1. Completion Date: 3/21/21 Person Responsible: Staff Member 1 Action Taken: All employees of KLHS were assigned training from Direct Course on medications. Attachment: 6
Review of Records
Compliant |
04/08/2021
| Implemented |
| 6400.165(c) | On October 9, 2020, Dr ordered an increase in Individual #1's 8pm dose of Quetiapine from 600mg (two 300mg tablets) to 800mg (two 400mg tablets). That same date, Staff person #6 attempted to clarify the order as the doctor's paperwork stated 400mg as opposed to 800mg. On 10/12/2020, clarification was received that 800mg was the correct dose. Staff only administered 400mg of Quetiapine at 8pm beginning 10/14/20 until 11/10/20. On 11/6/20, Dr questioned why the wrong dosage was being administered, but staff only stated that Individual #1 "is doing better." Dr then increased the dose to 600mg (two 300mg tablets), which was began on 11/11/20 by staff at the home. | A prescription medication shall be administered as prescribed. | Why is this Regulation Important?
To ensure the individual¿s health is maintained by administering medications in accordance with prescriptions that accurately reflect the prescriber¿s recommendations.
What Happened?
The script sent to the pharmacy was not in accordance to what the doctor stated verbally during the visit.
Why Did it Happen?
Staff member number 6 called the prescribers office at least two times and was told the script was correct and no other script was then sent to the pharmacy. There was no reason for KLHS to think at that point that the medication should not be administered in accordance with the written script sent to the pharmacy.
Immediate Correction
1. Completion Date: 3/21/21 Person Responsible: Staff Member 1 Action Taken: All employees of KLHS were assigned training from Direct Course on medications. Attachment: 6
Review of Records
Compliant |
04/08/2021
| Implemented |
| 6400.166(c) | There is no record that the provider attempted to report Individual #1's refusal to wear TED stockings, which were prescribed on 6/8/2020, until 3/10/21 when PA-C, wrote a note indicating to discontinue the TED stockings, elevate legs in the evenings, and follow a low sodium diet.
Individual #1 refused her 8pm dose of Ammonium Lactate on 12/23/20, 12/25/20, and 1/19/21. There is no record that the provider attempted to report the refusals to the prescribing doctor. | If an individual refuses to take a prescribed medication, the refusal shall be documented on the medication record. The refusal shall be reported to the prescriber as directed by the prescriber or if there is harm to the individual. | Why is this Regulation Important?
To ensure the health of the individual receiving residential services is maintained by notifying the prescriber that the medication was not taken as prescribed.
What Happened?
The refusal of the TED stockings was communicated verbally to the prescriber and the refusal of the topical cream was not reported to the prescriber.
Why Did it Happen?
KLHS did not have a standard practice for documenting the communication of refused medications to the prescriber.
Immediate Correction
1. Completion Date: 3/10/21 Person Responsible: Staff Member 6 Action Taken: Notified prescriber and received an order to D/C the TED stockings, start a low sodium diet, and elevate feet in the evenings. Attachment: 30
2. Completion Date: 4/7/21 Person Responsible: Staff Member 6 Action Taken: The medications errors were reported to individual 1s PCP Attachment: 25
3. Completion Date: 3/10/21 Person Responsible: Staff Member 6 Action Taken: Ted stockings D/C on MAR. Attachment: 31
4. Completion Date: 3/10/21 Person Responsible: Staff Member 6 Action Taken: Low sodium diet implemented on menu. Attachment: 32
5. Completion Date: 3/24/21 Responsible Person: Staff Member 1 Action Taken: Staff trained on general diet information until individual can be seen at nutritionist. Attachment: 36
6. Completion Date: 4/5/21 Person Responsible: Staff Member 6 Action Taken: Referral request from PCP for Appointment with nutritionist for instructions on low sodium diet. Attachment: 33
7. Completion Date: 3/10/21 Person Responsible: Staff Member 6 Action Taken: Feet elevated in evenings added to the daily agenda. Attachment: 34
8. Completion Date: 4/1/21 Person Responsible: Staff Member 6 Action Taken: Staff trained on procedures for elevating feet in evenings. Attachment: 35
9. Completion Date: 4/7/21 Person Responsible: Staff Member 6 Action Taken: Trained individual 1 on importance of following medication prescription orders especially Ammonium Lactate. Attachment: 23
Review of Records
10. Completion Date: 4/1/21 Person Responsible: Staff Member 6 Action Taken: Reported only other individual receiving residential services from KLHS¿s refusal of medication to prescriber and received a response in writing. Attachment: 26 |
04/08/2021
| Implemented |
| 6400.167(a)(1) | During the March 2021 inspection, Individual #1's Medication Administration Records (MARs) were uploaded on 3/8/21 with a date stamp of 3/8/21 at 11:16am. There was a blank spot on 10/30/20 for the 8am dose of Escitalopram and Folic Acid. When Licensor questioned Key Life Human Services about the blank spot, a new MAR was uploaded with a date stamp of 3/9/21 at 1:50pm. The blank spot was now filled in with the initials of staff person #7. Key life Human Services states that staff person #6 determined that medication was given by staff person #8 . Staff person #6 was not present during this medication administration on 10/30/20 and there's no way to determine if medication was administered as prescribed. | Medication errors include the following: Failure to administer a medication. | Why is this Regulation Important?
To ensure the health and safety of individual¿s receiving residential supports by following procedure to ensure medications are correctly administered and documented.
What Happened?
A documentation error and the attempt at correction led to confusion and an inability to determine concretely if the medication was administered.
Why Did it Happen?
Staff member number 8 accidently selected staff member number 7s initials, which are similar to his own, on the MAR when administering the medication. Staff person number 6 was correcting the MAR and deleted the wrong initials. The corrected initials were not saved before printing and so the electronic MAR still showed staff member number 7s initials but the printed MAR showed blank spaces.
Immediate Correction
1. Completion Date: 4/1/21 Person Responsible: Staff Member 6 Actions Taken: The medication errors were reported on EIM. Attachment: 37
Review of Records
Compliant |
04/08/2021
| Implemented |
| 6400.167(b) | There is no documentation of the medication error for failure to administer Escitalopram and Folic Acid on 10/30/2020 as described in violation 6400.167a1. | Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record. | Why is this Regulation Important?
Documentation of Medication errors is important to record how the wellbeing of the individual was maintained after missing a dose of medication.
What Happened?
A medication error was not reported received confirmation
Why Did it Happen?
A medication error was not reported because staff member 6 received verbal confirmation from staff member 8 that the medications were given and that was consistent with the number of medications in the pack and the initials and date of staff member 8 on the medication pack as well.
Immediate Correction
1. Completion Date: 4/1/21 Person Responsible: Staff Member 6 Action Taken: The medications errors were reported on EIM. Attachment: 37
2. Completion Date: 4/7/21 Person Responsible: Staff Member 6 Action Taken: The medications errors were reported to individual 1¿s PCP Attachment: 25
Review of Records
Compliant |
04/08/2021
| Implemented |
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SIN-00170752
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Renewal
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02/11/2020
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Compliant - Finalized
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | The toilet located in the laundry room had a ring of grime around the bowl and fecal stain at the bottom of the bowl. There were spiders in and around the toilet. There was a white stain around the base of the toilet on the green tiles. | Clean and sanitary conditions shall be maintained in the home. | Why is this regulation important? Clean and sanitary conditions minimize the risk of illness, infection or injury and provide a better living environment.
What happened? Laundry room toilet has been a non-working bathroom from initial inspection. There is no water to or in the toilet, causing a rust stain. There also was a spider in the toilet.
Why did it happen? Nonuse of the toilet, lid kept down.
What do we do right now? The toilet was removed, and a cap was installed over the pluming access hole. The entire laundry room was cleaned including scrubbing the tiles, replacing the utility sink and painting the wall.
How do we prevent this from happening again? Cleaning the laundry room was added to staffs cleaning duties. Team lead will check to make sure the home is kept clean and sanitary weekly.
Supporting Docs:
Fixed toilet picture
Staff cleaning duties form to include cleaning laundry room
Team Lead weekly checks form |
02/28/2020
| Implemented |
| 6400.67(a) | The base board heater located in the laundry room next to the toilet was rusted over 2/3 of it's surface. | Floors, walls, ceilings and other surfaces shall be in good repair. | Why is this regulation important? This regulation focuses on preventing possible safety hazards within the home.
What happened? The cover of the baseboard heater in laundry room had rust on it.
Why did it happen? Moisture, possibly from being located in close proximity to a toilet that was in use by the previous owner, caused baseboard heater cover to rust.
What do we do right now? The baseboard cover was sanded to remove rust and painted to match floor tiles.
How do we prevent this from happening again? The team lead will check that the surfaces in the home are in good repair weekly.
Supporting Docs:
fixed radiator picture
Team Lead weekly checks form |
02/28/2020
| Implemented |
| 6400.112(a) | There was no September 2019 fire drill conducted. | The fire drill must be held without prior notice to staff persons or individuals except for the staff person responsible to set off the alarmed. Record the results of the drill. | Why is this regulation important? To ensure fire drills are competed regularly as it is best practices related to fire safety.
What happened? KLHS personnel had a fire drill from the previous year in the current years records, so it appeared that the drill had been completed when it was not.
Why did it happen? KLHS was in the process of implementing a paperless system so some fire drills were completed on paper and others were completed online which effected the way record were kept.
What do we do right now? KLHS has updated the Fire Safety Policy and procedures to include the Supervisor of Residential Services adding fire drill reminders, for the entire year, to the administration calendar. The Tam Lead will use the Therap system to notify one staff member of the drill on the date the drill is to be performed.
How do we prevent this from happening again? The procedures around fire drills have changed, the policy was updated, electronic reminders were put in place, and a specific people were put in place to monitor that drills are being completed.
Supporting Docs:
Fire Safety Policy |
02/28/2020
| Implemented |
| 6400.112(h) | The fire drill logs for 10/23/19, 11/22/19, 12/16/19, and 1/31/20 did not list if all individuals got to the meeting place. | Individuals shall evacuate to a designated meeting place outside the building or within the fire safe area during each fire drill. | Why is this regulation important? The regulation is important because fire drills are preformed to ensure that in the event of a real fire individuals and staff will be able to exit and get to a safe location. If all individuals were not making it to the safe location it would be important to know and fix during drills.
What happened? The new form on Therap did not address if individuals made it to the identified safe location.
Why did it happen? KLHS transitioned to using the Therap system and the fire drill form implemented did not include the needed information.
What do we do right now? The form has been updated to include the needed information on Therap.
How do we prevent this from happening again? Program Director Brittain Bender will compare new forms to regulation requirements prior to implementing them.
Supporting Docs:
Updated fire drill form to include meeting place and if all people made it there |
02/28/2020
| Implemented |
| 6400.141(c)(3) | The Tetanus/Diphtheria section on Individual #1's physical dated 4/16/19 is marked unknown. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Why is the regulation important? This regulation is important because it will protect individuals from diseases that could cause them serious health problems.
What happened? The Program Specialist failed to put the date on the physical dated 4/16/19 on Individual #1s Tetanus/Diphtheria immunization section.
Why did it happen? The Program Specialist was unable to find the Individual #1s shot record. There was a date discrepancy on the Individual #1s prior physical from the last residence that the individual resided in and the ISP.
What do we do right now? Individual #1 went on 2/14/2020 and received a Tetanus/Diphtheria injection.
How do we prevent this from happening again? Program Director reviewed procedures with Program Specialist for completing the physical form in its entirely and to get the individual the immunization if possible when immunization history is unclear.
Supporting Docs:
Individual #1 dental exam appt summary
Program Specialist duties for physicals training |
02/28/2020
| Implemented |
| 6400.142(a) | On 7/19/19, Individual #1 had a dental exam and was instructed to return in six months. Individual #1's next dental appointment is scheduled for 2/20/20. | An individual 17 years of age or younger shall have a dental examination performed by a licensed dentist semiannually. An individual 18 years of age or older shall have a dental examination performed by a licensed dentist annually. | Why is the regulation important? This regulation is important because the individual will be examined by the dentist, in which, will hopefully result in a thorough cleaning, halting gum disease, avoiding invasive procedures, oral cancer detection, and eliminating risk factors and bad habits.
What happened? Individual #1 had a dental appointment on 7/19/19 and his next appointment was scheduled for 2/7/2020, which was past the six month deadline. On 2/7/2020 the dentist cancelled due to weather and the appointment was rescheduled for 2/20/20.
Why did it happen? When the dental receptionist made the next dental appointment for six months out, staff didnt realize the date was after the six month date.
What do we do right now? Individual #1 has a dental exam scheduled on 2/20/20.
How do we prevent this from happening again?
The program Specialist will monitor appointments through Therap to ensure required appointments are attended within the correct time frames.
Supporting Docs:
Individual #1 dental exam appt summary
¿ Admin procedures for appt summary signed |
02/28/2020
| Implemented |
| 6400.144 | On 9/19/19, Individual #1's psychiatrist ordered weekly blood pressures checks by staff. As of 2/12/20, Individual #1's blood pressure is not being checked.
On 10/23/19, Individual #1's primary care physician instructed him to return in January 2020 and have blood work completed. As of 2/12/20, this bloodwork is not completed, and he didn't attend an appointment with his PCP in January 2020.
On 10/23/19, Individual #1's PCP stated that his bloodwork showed elevations and she instructed him to exercise for 30 minutes per day, five times per week. As of 2/12/20, records of this order are not being maintained. | Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided.
| Why is this regulation important? Doctors place orders with the expectation that the patient will follow them, unfollowed doctors orders can lead to serious health risks. It is imperative the agency arrange follow up appointments and facilitate the means and opportunity to implement recommendations given by doctors.
What happened? The individual missed follow up appointment to have blood work done and staff was not checking his blood pressure in the homme. He has been attending the gym and walking at the mall for exercise, however, key life did not offer written opportunities to exercise daily on his agenda.
Why did it happen? There was a break down in communicating the information listed on the appointment summaries to the Team Lead, Program Specialist, and Medication Administration Trainer since KLHS has become paperless.
What do we do right now? A blood pressure machine was purchased and tested/compared with Doctor office visit for accuracy and blood work was completed at PCP on 2/14/2020. The weekly agenda, which the individual and his staff create together, will offer 30 minutes of exercise. It is entered into Therap on a daily repeat setting at 3 P.M. but explains that it can be offered at any time of the day and by any means of exercise. Documentation of participation in 5 out of 7 days of exercise will be logged in on shift notes on Therap un health/Med. The individual¿s blood pressure will be logged under vital signs in Therap.
How do we prevent this from happening again? KLHS implemented new checks and balances, procedures, and clarified roles related to medication administration, appointment summaries, implementing changes and notifying and updating team members and related plans. All appointment summaries will be entered into Therap. The Team Lead, Program Specialist, and Medication Administration Trainer will have their notifications configured to send them a Scomm when appointments are entered, edited, or a follow appointment is generated. The paper appointment summary will be typed into the appointment summary as well as scanned in and attached. The Team Lead we will be responsible for making sure meds are delivered, the MAR is updated, and recommendations are followed through. The Team lead will complete a weekly checklist on Therap to ensure she is thoroughly completing all tasks. The medication Administration Trainer will over-see the Team Lead monthly to check that proper medication administration procedures are being followed, that only current medications are in the medbox, follow-up appointment were made, and changes were implemented. The program Specialist will monitor appointments through Therap to ensure required appointments are attended within the correct time frames and will notify team members of changes via email to keep on record. The Program Specialist will also update the assessment to include changes as they happen.
Supporting Docs:
Medication Administration Policy
Receipt for blood pressure cuff
Vitals logged in Therap form
Individual #1 bloodwork appt summary
Agenda to include exercise
Updated shift form to include offering exercise
Admin procedures for appt summaries signed |
02/28/2020
| Implemented |
| 6400.145(1) | The emergency medical plan for individual #1 did not address the hospital or source of health care. | The home shall have a written emergency medical plan listing the following: The hospital or source of health care that will be used in an emergency. | Why is this regulation important? Policies should be clear and detailed so in the event of an emergency Support Staff know exactly how to respond and can respond in the safest and fastest manner. The individual has the right to determine where they receive medical care in the event they should need it.
What happened? The policy was not individualized to include the individuals choice of hospital, instead it stated take the individual to the nearest hospital.
Why did it happen? KLHS had a blanket Emergency Medical policy to be applied to all individuals.
What do we do right now? Edited the medical plan to state, Take immediate action to provide emergency intervention: render first aid, notify first responders, police, crisis intervention or transport the individual to the hospital, identified by the individual and recorded on their emergency information page on Therap, in the agency vehicle provided. The policy is then individualized and entered onto the emergency information page on the individuals home page on Therap and printed and put in the front of the individuals record book in his home.
How do we prevent this from happening again? The policy is now added to the emergency medical form so KLHS will be prompted input a tailored policy for each individual.
Supporting Docs:
Updated Emergency Medical policy
Individual #1 emergency information form |
02/28/2020
| Implemented |
| 6400.145(2) | The emergency medical plan for individual #1 did not address the method of transportation. | The home shall have a written emergency medical plan listing the following: The method of transportation to be used. | Why is this regulation important? Policies should be clear and detailed so in the event of an emergency Support Staff know exactly how to respond and can respond in the safest and fastest manner.
What happened? The policy stated, arrange transportation to the nearest hospital location.
Why did it happen? The Policy was intended to allow for staff to determine if they should call an ambulance or drive the individual to the hospital, but the wording is ambiguous.
What do we do right now? The policy was updated to state Take immediate action to provide emergency intervention: render first aid, notify first responders, police, crisis intervention or transport the individual to the hospital, identified by the individual and recorded on their emergency information page on Therap, in the agency vehicle provided.
Support staff must use knowledge from Red Cross first Aid/CPR annual trainings to determine the correct response. Consider the following factors when determining the correct response, if the individual is breathing or struggling to breath, if the individual is losing large amounts of blood, if there is a suspected spinal injury, if the individual is safe to transport, the time in which it will take to get to the hospital vs the time it will take for first responders to arrive and render aid etc.
How do we prevent this from happening again? Program Director, Brittain Bender will be specific, detailed, and clear when developing policies and procedures in the future.
Supporting Docs:
Updated Emergency Medical policy |
02/28/2020
| Implemented |
| 6400.151(c)(2) | Staff #4 had a Tuberculin skin test on 9/25/17 and then did not have one in the two year time frame. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. Tuberculin skin testing may be completed and certified in writing by a registered nurse or a licensed practical nurse instead of a licensed physician, licensed physician's assistant or certified nurse practitioner. | Why is the regulation important? This regulation is important because it protects people from transmitting Tuberculosis from person to person, and it also ensures the health and wellbeing of all staff and individuals.
What happened? On September 16th Staff #4 had an appointment at 1:00 P.M. for a physical and Tuberculin skin testing by Mantoux method. During the physical Staff #4 was asked if they were breast feeding, in which, Staff #4 stated yes. The doctor denied Staff #4 the Tuberculin skin testing by Mantoux method and then gave Staff #4 a Tuberculosis Surveillance Questionnaire.
Why did it happen? The doctor signed the Tuberculosis Surveillance Questionnaire and gave Staff #4 permission to return to work. At no time was a chest x-ray or bloodwork offered to Staff #4.
What do we do right now? Staff #4 got the Tuberculin skin test by Mantous method on 2/14/2020 and the results were read on 2/17/2020 which were NEGATIVE.
How do we prevent this from happening again? The Program Specialist notified Healthforce via a letter that if a KLHS employee could not complete a TB test via Mantoux method then Healthforce is to order a chest x-ray or bloodwork, and that the Tuberculosis Surveillance Questionnaire is insufficient verification for TB testing according to state regulations. Healthforce confirmed via phone that they would implement the procedures.
Supporting Docs:
Staff completed TB
Letter to HealthForce to change TB requirements |
02/28/2020
| Implemented |
| 6400.216(a) | Individual #1's personal protected information was left in glass cabinet that was not locked up at time of the inspection. | An individual's records shall be kept locked when unattended.
| Why is the regulation important? This regulation is important because it protects the privacy and confidentiality of the individual and adheres to HIPPA laws.
What happened? During the inspection of Individual #1s residence the individuals personal protected information was in binders in a cabinet, that was not locked, in his living area.
Why did it happen? Staff did not realize that they were violating his privacy and confidentiality because the individual lives alone and does not typically have anyone that isnt a paid support at his residence and the information was not directly visible due to being in the binders.
What do we do right now? Individual #1¿s personal protected information was moved into the staff office within his home and will be kept locked when unattended.
How do we prevent this from happening again? The Program Specialist will have staff read and acknowledge procedures stating that Individual #1s personal protected information shall be kept locked inside the staffs office when unattended, as well as review HIPPA regulations and confidentiality and what constitutes as personal protected information.
Supporting Docs:
Picture of records in locked office
HIPPA Policy, including procedures to keep records in locked locations, reviewed by KLHS employees |
02/28/2020
| Implemented |
| 6400.162(a) | Staff #3 had medication training on 6/11/18 and then again 6/27/19. She administered medications to individual #1 on 6/14/19, 6/20/19, 6/21/19, 6/25/19. | A home whose staff persons or others are qualified to administer medications as specified in subsection (b) may provide medication administration for an individual who is unable to self-administer the individual's prescribed medication. | Why is the regulation important? The Medication Administration Training and Certification is important because it ensures medications are delivered in the most safe and accurate manner and that.
What happened? The Medication Administration Trainer did not retrain staff #3 based on the exact date but rather on the month of training qualifications expiring.
What do we do right now? Medication Administration Trainer reviewed all employee records to ensure no employees, who are giving medications, have expired certifications.
How do we prevent this from happening again? Annual practicum due dates will be entered into the electronic documentation system, Therap, which generates reminders and due dates so the Trainer can complete practicums on or before the expiration date.
Supporting Docs:
Due dates for medication practicums entered in Therap
Medication Administration Trainer warning |
02/28/2020
| Implemented |
| 6400.163(h) | Individual #1's PRN medication (Ibuprofen 200mg) expired on 5/2019 but still was administered on 6/12/19, 7/10/19 and 12/20/19. | Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations. | Why is this regulation important? The medicine expiration date is a critical part of deciding if the product is safe to use and will work as intended.
What happened? Expired PRN medications were administered to individual 3 different times.
Why did it happen? PRN was not removed from medication box on the expiration date.
What do we do right now? Medication was removed on 2/11/2020 and destroyed in a Drug Buster (chemical drug destruction/ RX destroyer pill destructor). Purchased Ibuprofen 200mg and added to medication locked storage box.
How do we prevent this from happening again? Weekly checks conducted by Team Lead of medication will include reviewing expiration dates. The Team Lead will record her findings on the form in Therap. The Medication Administration Trainer will conduct monthly reviews of medications expiration dates. The
Supporting Docs:
Replaced PRN medications receipt
Medication Administration Policy
¿ Team Lead weekly checks from |
02/28/2020
| Implemented |
| 6400.166(d) | Individual #1's psychiatrist decreased his Risperdal to 2 mg for seven days starting on 3/26/19. He did not receive this medication on 4/1/19 and 4/2/19 as prescribed.
Individual #1's psychiatrist decreased his Risperdal to 1 mg for six days starting on 4/3/19. He did not receive this medication on 4/8/19 and 4/9/19 as prescribed.
Individual #1's psychiatrist prescribed Chlorpromazine 50mg for two days starting on 9/3/19. He did not receive this medication. | The directions of the prescriber shall be followed. | Why is this regulation important? Regulation is to ensure that the individual receives medications and treatments as ordered by doctor to maintain their health and safety.
What happened? Doses of time limited medications were either not given as prescribed or not recorded when given.
Why did it happen? The individual had frequent medication changes during the reviewed time period; staff either did not give the medications as prescribed or errors from the pharmacy in the electronic MAR system caused medications to not be recorded properly. KLHS had to contact the pharmacy frequently to correct the MAR, as the pharmacy is who inputs prescription information.
What do we do right now? Report miss doses in EIM. The Medication Safety Policy will be updated to include procedures intended to prevent medication errors by implementing a system of checks and balances and improving means of notification and communication of medication changes and errors.
How do we prevent this from happening again? Medication changes will be documented on appointment summaries in KLHSs electronic database (Therap) which automatically notifies the Team Lead, Program Specialist, and Medication Administration Trainer. The Team Lead will do weekly checks ensuring that medications have been delivered, that the MAR is correct, and that staff are giving Medications as prescribed. The Medication Administration Trainer will visit the residential home at least monthly to review the Team Leads weekly checks.
Supporting Docs:
Summaries of reported medication errors
Medication Safety Policy |
02/28/2020
| Implemented |
| 6400.181(b) | As of 10/24/19, Individual #1 has been diagnosed with Type 2 diabetes and is prescribed medication and is ordered to check his glucose levels daily. This information is not documented in his current ISP dated 10/1/19 or his current assessment dated 6/1/19.
Due to an incident on 12/28/19 involving physical aggression with staff members, Key Life has increased his staffing ratio from 2:1 (8am to 4pm) to 2:1 (8am to 8pm). Individual #1's current assessment states that Individual #1 has 2:1 staffing from 8a-12am and 1:1 staffing from 12am -- 8am. This change is not reflected current assessment dated 6/1/19. | If the program specialist is making a recommendation to revise a service or outcome in the individual plan, the individual shall have an assessment completed as required under this section. | Why is the regulation important? This regulation is important because making revisions to a specific service or outcome in the individuals plan helps staff stay up to date with accurate information, which is used on a daily basis and for training.
What happened? During the inspection of Individual #1s assessment, it was missing the diagnosis of Type 2 diabetes, the prescribed medication that is to check glucose levels daily, and the correct current staffing ratio.
Why did it happen? The Program Specialist updated the assessment annually before the ISP review to reflect changes made throughout the year, instead of as changes occurred.
What do we do right now? Program Specialist met with Individual #1s Supports Coordinator and Behavior Specialist to make sure that the Assessment, ISP, & BSP were up to date and current.
How do we prevent this from happening again? The Program Specialist and Program Director developed procedures to follow when changes occur with individual #1, which include updating the assessment, communicating changes to the team in writing, ensuring plans are cohesive and accurate, and training staff on updated plans.
Supporting Docs:
Signed procedures for Program Specialist communicating changes to the team
Updated assessment to correct staffing ratio and include diagnosis of diabetes and prescribed glucose level checks
Email confirming updated ISP and BSP plan to correct staffing ratio and include diagnosis of diabetes and prescribed glucose level checks to the team |
02/28/2020
| Implemented |
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SIN-00151312
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Renewal
|
02/26/2019
|
Compliant - Finalized
|
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| Regulation | LIS Non-Compliance Area | Correction Required | Plans of Correction | Correction Date | POC Status |
| 6400.64(a) | Clean & sanitary- There was a large amount of lint in the dryer vent. | Clean and sanitary conditions shall be maintained in the home. | Response:
¿ What specific change will be made? The dryer vent will be cleaned out and maintained by removing lint before and after usage of the dryer.
¿ Who will make the change? The Team Lead in the home.
¿ When will the change be made? Immediately.
¿ What system have you implemented to make sure that the same violation will not occur again? Instructions will be attached to the top of the dryer to ensure staff clean the vent properly.
¿ What training will be provided to your staff? The Team Lead will review the expectations for cleaning the dryer before and after use with DSP¿s.
Supporting Documentation:
¿ Photo of cleaned dryer vent
¿ Photo of instructions on the dryer
¿ Signed record of training |
03/25/2019
| Implemented |
| 6400.111(a) | Fire Extinguisher- The fire extinguisher in the basement is rated a 1-A, this does not meet the requirement of a min 2-A on each floor including the basement and attic. | There shall be at least one operable fire extinguisher with a minimum 2-A rating for each floor, including the basement and attic. | Response:
¿ What specific change will be made? The fire extinguishers on the first floor (in the kitchen) and the basement have been replaced with a 2A-10BC rating fire extinguisher.
¿ Who will make the change? The Team Lead in the home.
¿ When will the change be made? The change was made on 3/5/19.
¿ What system have you implemented to make sure that the same violation will not occur again? The date the fire extinguisher was purchased was put into the Supervisor of Residential Services¿ calendar repeating annually with a reminder one week in advance to purchase new extinguishers. The specific regulation is listed on the reminder to ensure the correct extinguishers are purchased.
¿ What training will be provided to your staff? The director reviewed the regulation with the Supervisor of Residential Services and the Team Lead.
Supporting Documentation:
¿ Photo of the corrected extinguishers
¿ Copy of the receipt of purchase of the new extinguishers
¿ Signed Record of training |
03/25/2019
| Implemented |
| 6400.141(c)(3) | Immunizations Adult- Individual #1 does not have immunizations listed on the physical or the record. | The physical examination shall include: Immunizations for individuals 18 years of age or older as recommended by the United States Public Health Service, Centers for Disease Control, Atlanta, Georgia 30333. | Response:
¿ What specific change will be made? The individual physical form will be corrected to include: Immunizations for individuals 18 years of age or older. KLHS tried to obtain a record of immunizations for individual #1 from before KLHS began supporting him in April 2018 and was not able to garner anything further than what is listed in the ISP.
¿ Who will make the change? Mandi Smith, Program Specialist
¿ When will the change be made? Immediately
¿ What system have you implemented to make sure that the same violation will not occur again? The revised individual physical form has been put into place and will be used going forward to ensure it contains the correct information.
¿ What training will be provided to your staff? The Director reviewed the violation and regulation requirements with the Program Specialist to ensure the physical form is compliant.
Supporting Documentation:
¿ Corrected physical form
¿ Signed record of training |
03/25/2019
| Implemented |
| 6400.141(c)(6) | TB testing- Individual #1 TB test was completed late. The DOA was 4/10/18, the TB test was not completed until 1/10/19. | The physical examination shall include: Tuberculin skin testing by Mantoux method with negative results every 2 years for individuals 1 year of age or older; or, if tuberculin skin test is positive, an initial chest x-ray with results noted. | Response:
¿ What specific change will be made? The individual physical form will be corrected to include: Tuberculin skin testing by Mantoux method if tuberculin skin test is positive, an initial chest x-ray with results noted on the actual form.
¿ Who will make the change? Mandi Smith, Program Specialist
¿ When will the change be made? Immediately
¿ What system have you implemented to make sure that the same violation will not occur again? The revised individual physical form has been put into place and will be used going forward to ensure it contains the correct information. KLHS will ensure an individual has had a physical including Tb within one year prior to moving to KLHS from another agency.
¿ What training will be provided to your staff? The Director reviewed the violation and regulation requirements with the Program Specialist to ensure the physical form is compliant and understands the required timelines for new admissions.
Supporting Documentation:
¿ Revised physical form
¿ Signed record of training |
03/25/2019
| Implemented |
| 6400.141(c)(10) | Communicable Disease- The annual physical form does not contain if Individual #1 is free from communicable diseases. | The physical examination shall include: Specific precautions that must be taken if the individual has a communicable disease, to prevent spread of the disease to other individuals. | Response:
¿ What specific change will be made? The individual physical form will be corrected to specifically state if the individual is free of communicable diseases. The individual¿s current physical which was completed by the Glendale Medical Center states that there are no precautions that must be taken if the individual has a communicable disease, so we know he does not have one at this time.
¿ Who will make the change? Mandi Smith, Program Specialist
¿ When will the change be made? Immediately
¿ What system have you implemented to make sure that the same violation will not occur again? The revised individual physical form has been put into place and will be used going forward to ensure it contains the correct information.
¿ What training will be provided to your staff? The Director reviewed the violation and regulation requirements with the Program Specialist to ensure the physical form is compliant.
Supporting Documentation:
¿ Corrected physical form
¿ Signed record of training |
03/25/2019
| Implemented |
| 6400.181(e)(7) | Heat Sources- Individual #1's assessment dated 6/20/18 did not assesses the ability to move away from heat sources. | The assessment must include the following information: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. | Response:
¿ What specific change will be made? The Individual Assessment form will be corrected to include: The individual's knowledge of the danger of heat sources and ability to sense and move away quickly from heat sources which exceed 120° F and are not insulated. Individual #1¿s assessment will be revised to include the information.
¿ Who will make the change? Mandi Smith, Program Specialist
¿ When will the change be made? Immediately
¿ What system have you implemented to make sure that the same violation will not occur again? The revised individual assessment form has been put into place and will be used going forward to ensure it contains the correct information.
¿ What training will be provided to your staff? The Director reviewed the violation and regulation requirements with the Program Specialist to ensure the assessment is compliant.
Supporting Documentation:
¿ Revised copy of Individual #1¿s assessment using the corrected assessment form.
¿ Signed Record of training |
03/25/2019
| Implemented |
| 6400.181(e)(9) | Individual's disability, including functional & medical limitations- This section on the 6/20/18 said see attached physical & medical history for Individual #1. There were no attachments and when the PS was asked, these documents where not sent with the assessment to the team members. | The assessment must include the following information: Documentation of the individual's disability, including functional and medical limitations. | Response:
¿ What specific change will be made? The Individual Assessment form will be corrected to include: Documentation of the individual's disability, including functional and medical limitations. Individual #1¿s assessment will be revised to include the information.
¿ Who will make the change? Mandi Smith, Program Specialist
¿ When will the change be made? Immediately
¿ What system have you implemented to make sure that the same violation will not occur again? The revised individual assessment form has been put into place and will be used going forward to ensure it contains the correct information.
¿ What training will be provided to your staff? The Director reviewed the violation and regulation requirements with the Program Specialist to ensure the assessment is compliant.
Supporting Documentation:
¿ Revised copy of Individual #1¿s assessment using the corrected assessment form.
¿ Signed record of training |
03/25/2019
| Implemented |
| 6400.181(e)(12) | Recommendations- This section in the 6/10/18 assessment for Individual #1 was missing in the assessment. | The assessment must include the following information: Recommendations for specific areas of training, programming and services. | Response:
¿ What specific change will be made? The Individual Assessment form will be corrected to include: Recommendations for specific areas of training, programming and services. Individual #1¿s assessment will be revised to include the information.
¿ Who will make the change? Mandi Smith, Program Specialist
¿ When will the change be made? Immediately
¿ What system have you implemented to make sure that the same violation will not occur again? The revised individual assessment form has been put into place and will be used going forward to ensure it contains the correct information.
¿ What training will be provided to your staff? The Director reviewed the violation and regulation requirements with the Program Specialist to ensure the assessment is compliant.
Supporting Documentation:
¿ Revised copy of Individual #1¿s assessment using the corrected assessment form.
¿ Signed record of training |
03/25/2019
| Implemented |
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SIN-00129378
|
Initial review
|
02/26/2018
|
Compliant - Finalized
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