Nursing Investigation Results -

Pennsylvania Department of Health
LECOM AT PRESQUE ISLE, INC.
Patient Care Inspection Results

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LECOM AT PRESQUE ISLE, INC.
Inspection Results For:

There are  122 surveys for this facility. Please select a date to view the survey results.

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LECOM AT PRESQUE ISLE, INC. - Inspection Results Scope of Citation
Number of Residents Affected
By Deficient Practice
Initial comments:

Based on a Medicare/Medicaid Recertification, State Licensure, and Civil Rights Compliance survey and an Abbreviated Complaint survey completed on August 27, 2019, it was determined that LECOM at Presque Isle Inc., was not in compliance with the following requirements of 42 CFR Part 483, Subpart B, Requirements for Long Term Care and the 28 Pa. Code, Commonwealth of Pennsylvania Long Term Care Licensure Regulations.



 Plan of Correction:


483.10(a)(1)(2)(b)(1)(2) REQUIREMENT Resident Rights/Exercise of Rights:This is a less serious (but not lowest level) deficiency and affects more than a limited number of residents, staff, or occurrences. This deficiency is one that results in minimal discomfort to the resident or has the potential (not yet realized) to negatively affect the resident's ability to achieve his/her highest functional status. This deficiency was not found to be throughout this facility.
483.10(a) Resident Rights.
The resident has a right to a dignified existence, self-determination, and communication with and access to persons and services inside and outside the facility, including those specified in this section.

483.10(a)(1) A facility must treat each resident with respect and dignity and care for each resident in a manner and in an environment that promotes maintenance or enhancement of his or her quality of life, recognizing each resident's individuality. The facility must protect and promote the rights of the resident.

483.10(a)(2) The facility must provide equal access to quality care regardless of diagnosis, severity of condition, or payment source. A facility must establish and maintain identical policies and practices regarding transfer, discharge, and the provision of services under the State plan for all residents regardless of payment source.

483.10(b) Exercise of Rights.
The resident has the right to exercise his or her rights as a resident of the facility and as a citizen or resident of the United States.

483.10(b)(1) The facility must ensure that the resident can exercise his or her rights without interference, coercion, discrimination, or reprisal from the facility.

483.10(b)(2) The resident has the right to be free of interference, coercion, discrimination, and reprisal from the facility in exercising his or her rights and to be supported by the facility in the exercise of his or her rights as required under this subpart.
Observations:

Based on resident and staff interviews and clinical record review, it was determined that the facility failed to treat residents in a manner that promoted and enhanced dignity and respect for five of 22 residents. (Residents R8, R79, R81 and R116).

Findings include:

During an interview on 8/24/19, at 2:00 p.m. Resident R116 disclosed a reluctance to request assistance when a couple nurse aides were working as these nurse aides often expressed anger at the resident for activating the call bell to ask for help and made remarks that made the resident feel as though they shouldn't be bothering them. The resident revealed not knowing the names of nurse aides and that they felt the nurse aides would possibly retaliate in response.

During interviews on 8/25/19, from 10:00 a.m. to 3:00 p.m. Residents R8, R79, R81, and R87 expressed concerns that staff were deliberately slow in response time when their assistance was required and that they were afraid to complain because they felt that they would be treated differently in retaliation.

Residents stated concerns with lack of respect given to them from nurse aides, staff not wearing identification badges and at times sarcastic towards residents when answering call bells. Residents stated they experienced fearfulness to report and that nurse aides will seek to "take it out on them" by not responding timely to bells and needs.

Review of Resident Council meeting notes dated 8/7/19, revealed that a resident expressed a concern to a nurse aide not wearing a name badge, who spoke to resident with a "sarcastic response."


Resident R87's clinical record revealed an admission date of 9/05/18, with diagnoses that included short and long-term respiratory failure, abnormal gait, ventilator dependent, malnutrition, and anxiety.

Observation on 8/24/19, at 1:17 p.m. revealed Resident R87 sitting in a straight-back chair between the bed and window of his/her room and wearing a white v-neck tee shirt. He/she was alert, oriented, and non-verbal. Observed to have a large amount of wet, to various stages of drying, thick yellowish drainage on his/her tracheostomy (temporary or permanent opening in the neck in order to place a tube into a person's windpipe) dressing. It was also observed that there was a brown liquid with dark solid (flaky) substance near the collar on his/her shirt and on the chest wall. There was also evidence of various spilled liquids on the front of his/her shirt.

During an interview on 8/24/19, at 2:41 p.m. Resident R87 verified that he/she remained in the same condition with spilled liquids and staining on the front of his/her shirt and a large amount of thick, yellow drainage on his/her tracheostomy dressing.

Observation on 8/25/19, at 11:23 a.m. revealed Resident R87 wearing the same soiled white v-neck tee shirt as yesterday. His/her tracheostomy dressing was soiled with moderate-large amount medium brown colored secretions. There was additionally noted an orange colored staining along with the previously observed brown liquid with dark solid (flaky) substance near the collar. Resident R87 stated that "they" changed his/her dressing last night and this morning.

On 8/26/19, at 10:20 a.m. Resident R87 was observed in the same condition, in the same white v-neck tee shirt as was noted on 8/24/19, and 8/25/19. There was additional staining on the front of the shirt. His/her tracheostomy dressing was clean and intact.

During an interview on 8/26/19, at 1:30 p.m. Nurse Educator Employee E5 confirmed that Resident R87's shirt was soiled with brown, orange, tan stains ranging from dry and crusty to wet.

28 Pa. Code 201.29(i)(j) Nursing Services


















 Plan of Correction - To be completed: 10/11/2019

To ensure that Resident R8, R79, R81, R87 and R116 and all the Residents of the facility are treated with dignity and respect, the following action plan will be instituted:
Resident R8, R79, R81, R87 and R116 will be interviewed and observations of staff interactions will occur via Management Staff or Designee biweekly for 1 month, weekly for 1 month then monthly ongoing
For all other residents of the facility, Management Staff or Designee will complete no less than 10 random resident interviews and observations of staff interactions with residents daily for 1 month, biweekly for 1 month then monthly ongoing
An audit will be completed by the Director of Nursing or Designee documenting the results of the interviews and observations and will be the responsibility of the Administrator.
Results of the audits will be presented at the monthly Quality Assurance meetings monthly for 3 months and then quarterly for review.
All staff will be educated regarding the treatment of residents that includes but is not limited to treating resident in a manner that promotes and enhances dignity and respect. Education will be completed no later than September 30, 2019 and will be the responsibility of the Staff Educator in conjunction with the designated Management Staff

483.15(c)(3)-(6)(8) REQUIREMENT Notice Requirements Before Transfer/Discharge:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.15(c)(3) Notice before transfer.
Before a facility transfers or discharges a resident, the facility must-
(i) Notify the resident and the resident's representative(s) of the transfer or discharge and the reasons for the move in writing and in a language and manner they understand. The facility must send a copy of the notice to a representative of the Office of the State Long-Term Care Ombudsman.
(ii) Record the reasons for the transfer or discharge in the resident's medical record in accordance with paragraph (c)(2) of this section; and
(iii) Include in the notice the items described in paragraph (c)(5) of this section.

483.15(c)(4) Timing of the notice.
(i) Except as specified in paragraphs (c)(4)(ii) and (c)(8) of this section, the notice of transfer or discharge required under this section must be made by the facility at least 30 days before the resident is transferred or discharged.
(ii) Notice must be made as soon as practicable before transfer or discharge when-
(A) The safety of individuals in the facility would be endangered under paragraph (c)(1)(i)(C) of this section;
(B) The health of individuals in the facility would be endangered, under paragraph (c)(1)(i)(D) of this section;
(C) The resident's health improves sufficiently to allow a more immediate transfer or discharge, under paragraph (c)(1)(i)(B) of this section;
(D) An immediate transfer or discharge is required by the resident's urgent medical needs, under paragraph (c)(1)(i)(A) of this section; or
(E) A resident has not resided in the facility for 30 days.

483.15(c)(5) Contents of the notice. The written notice specified in paragraph (c)(3) of this section must include the following:
(i) The reason for transfer or discharge;
(ii) The effective date of transfer or discharge;
(iii) The location to which the resident is transferred or discharged;
(iv) A statement of the resident's appeal rights, including the name, address (mailing and email), and telephone number of the entity which receives such requests; and information on how to obtain an appeal form and assistance in completing the form and submitting the appeal hearing request;
(v) The name, address (mailing and email) and telephone number of the Office of the State Long-Term Care Ombudsman;
(vi) For nursing facility residents with intellectual and developmental disabilities or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with developmental disabilities established under Part C of the Developmental Disabilities Assistance and Bill of Rights Act of 2000 (Pub. L. 106-402, codified at 42 U.S.C. 15001 et seq.); and
(vii) For nursing facility residents with a mental disorder or related disabilities, the mailing and email address and telephone number of the agency responsible for the protection and advocacy of individuals with a mental disorder established under the Protection and Advocacy for Mentally Ill Individuals Act.

483.15(c)(6) Changes to the notice.
If the information in the notice changes prior to effecting the transfer or discharge, the facility must update the recipients of the notice as soon as practicable once the updated information becomes available.

483.15(c)(8) Notice in advance of facility closure
In the case of facility closure, the individual who is the administrator of the facility must provide written notification prior to the impending closure to the State Survey Agency, the Office of the State Long-Term Care Ombudsman, residents of the facility, and the resident representatives, as well as the plan for the transfer and adequate relocation of the residents, as required at 483.70(l).
Observations:


Based on review of clinical records and staff interviews, it was determined that the facility failed to provide residents and their representatives with written transfer notices including required information for six of seven residents (Residents R2, R35, R41, R73, R88, R115) transferred out of the facility.

Findings include:

Resident R2's clinical record revealed an admission date of 6/02/18, with diagnoses that included respiratory failure, cancer, heart failure, septicemia (bacterial infection in the blood), and stroke. The record also revealed that Resident R2 was transferred to the hospital on 5/16/19, for evaluation and returned on 5/20/19. He/she was transferred to the hospital on 6/10/19, for vomiting coffee ground type substance and returned to the facility on 6/12/19. He/she was transferred to the hospital again on 6/15/19, for blood in the urine and abnormal vital signs, and returned on 6/29/19. Resident R2 was again transferred to the hospital on 7/25/19, for evaluation and returned on 7/31/19. He/she was again transferred to the hospital on 8/03/19, for nasogastric tube (a special tube that carries food and medicine to the stomach through the nose) displacement and returned on 8/14/19. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R41 and their representative related to these transfers to the hospital.

Resident R35's clinical record revealed an admission date of 5/23/16, with diagnoses that included kidney disease, diabetes, and depression. The record also revealed that Resident R35 was transferred to the hospital on 7/31/19, for an unresponsive episode and returned to the facility on 8/5/19. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R35 and their representative related to the transfer to the hospital.

Resident R41's clinical record revealed an admission date of 4/17/15, with diagnoses that included sudden and long-term respiratory failure, sepsis (bacterial infection in the blood), non-healing surgical wound, and abnormal heart beat. The record also revealed that Resident R41 was transferred to the hospital on 6/4/19, for difficulty breathing and returned to the facility on 6/9/19. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R41 and their representative related to the transfer to the hospital.

Resident R73's clinical record revealed an admission date of 6/28/19, with diagnoses that included pressure ulcer, fractured pubis, tracheostomy (artificial opening in the airway to allow for breathing), fractured hip, sudden respiratory failure, and fractured back. The record also revealed that Resident R73 was transferred to the hospital on 6/29/19, for change in level of consciousness and returned to the facility on 7/12/19. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R73 and their representative related to the transfer to the hospital.

Resident R88's clinical record revealed an admission date of 6/15/19, with diagnoses that included osteomyelitis (infection in the bone), osteoarthritis, and depression. The record also revealed that Resident R88 was transferred to the hospital on 7/12/19, for hypokalemia (low potassium level) and returned to the facility on 7/16/19. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R88 and their representative related to the transfer to the hospital.

Resident R115's clinical record revealed an admission date of 7/14/19, with diagnoses that included sudden respiratory failure, tracheostomy (artificial opening in the airway to allow for breathing), systemic inflammatory response syndrome, and brain damage due to lack of oxygen. The record also revealed that Resident R115 was transferred to the hospital on 6/20/19, for shortness of breath and returned to the facility on 6/22/19. The clinical record lacked evidence that a written notice of transfer including required information was provided to Resident R115 and their representative related to the transfer to the hospital.

During an interview on 8/27/19, at 9:45 a.m. the Nursing Home Administrator confirmed that the facility wasn't providing notices of transfer to the residents or their representatives when residents were transferred out of the facility.

28 Pa. Code 201.14(a) Responsibility of licensee

28 Pa. Code 201.29(f) Resident Rights









 Plan of Correction - To be completed: 10/11/2019

For resident R2, R35, R41, R73, R88 and R115 and all residents of the facility, to ensure that a transfer agreement will be given when transferred out of the facility, the following will occur:
Staff will review resident records of those residents who have transferred out of the facility over the past 90 days to ensure that the resident and resident representative has received transfer agreement
Staff will provide resident and resident representative for R2, R35, R41, R73, R88 and R115 with required information regarding transfer agreement as well as those residents found from the 90 day review that did not receive a transfer agreement
Staff will provide resident with a transfer form/information prior to resident transferring out of facility. If resident is unable to acknowledge transfer form, one will be provided to the resident representative within 24 hours
Staff will ensure documentation is present in the resident electronic medical record, to acknowledge that transfer information was provided to the resident or resident representative
An audit will be completed by Medical Records each time a resident is transferred to ensure that transfer information was provided to the resident or resident representative. The audit will be the responsibility of the Administrator
Results of the audit will be presented at the Quality Assurance Meeting monthly for 3 months and then quarterly.
Staff Educator in conjunction with the Director of Nursing, will provide in-services that will include documentation in the resident's medical record and handling of the transfer and discharge form to residents or resident representative. Education will be completed no later than September 30, 2019.


483.35(g)(1)-(4) REQUIREMENT Posted Nurse Staffing Information:Least serious deficiency but was found to be widespread throughout the facility and/or has the potential to affect a large portion or all the residents. This deficiency has the potential for causing no more than a minor negative impact on the resident.
483.35(g) Nurse Staffing Information.
483.35(g)(1) Data requirements. The facility must post the following information on a daily basis:
(i) Facility name.
(ii) The current date.
(iii) The total number and the actual hours worked by the following categories of licensed and unlicensed nursing staff directly responsible for resident care per shift:
(A) Registered nurses.
(B) Licensed practical nurses or licensed vocational nurses (as defined under State law).
(C) Certified nurse aides.
(iv) Resident census.

483.35(g)(2) Posting requirements.
(i) The facility must post the nurse staffing data specified in paragraph (g)(1) of this section on a daily basis at the beginning of each shift.
(ii) Data must be posted as follows:
(A) Clear and readable format.
(B) In a prominent place readily accessible to residents and visitors.

483.35(g)(3) Public access to posted nurse staffing data. The facility must, upon oral or written request, make nurse staffing data available to the public for review at a cost not to exceed the community standard.

483.35(g)(4) Facility data retention requirements. The facility must maintain the posted daily nurse staffing data for a minimum of 18 months, or as required by State law, whichever is greater.
Observations:


Based on observations and staff interviews, it was determined that the facility failed to ensure that the required nursing staffing information was posted on a daily basis.

Findings include:

Observations on 8/27/19, at 10:00 a.m. revealed that the daily staffing posting was not posted in the facility.

During an interview on 8/27/19, at 10:20 a.m. the Staff Scheduler/Nursing Assistant Employee E4 confirmed that the staffing was not posted as required. Additionally, upon review of previous postings it was identified that the postings did not include all the required information that identified the total number of direct care staff.

28 Pa. Code 211.12 (c) Nursing services











 Plan of Correction - To be completed: 10/11/2019

August 27, 2019 staff scheduler posted nursing staffing schedule outside Activity room, currently staff nursing schedule remains posted daily and includes number of direct care staff
A form will be created by the staff scheduler that will include the total number of direct care staff
Any changes made to the form will be completed while the form remains in place
Staff scheduler or designee will post nursing staffing data daily outside of Activity room
Education was completed by the Administrator August 27, 2019 with the scheduling staff to confirm that staffing information will remain posted daily and will include number of direct care staff
An audit will be completed by the Director of Nursing or designee daily for 2 months, biweekly for 1 month and weekly for 1 month to ensure that nursing staffing data that includes number of direct care staff is posted daily and will be the responsibility of the Administrator
Results of the audit will be presented at the Quality Assurance Meeting monthly for 3 months and then quarterly.

483.15(d)(1)(2) REQUIREMENT Notice of Bed Hold Policy Before/Upon Trnsfr:Least serious deficiency but affects more than a limited number of residents, staff, or occurrences. This deficiency has the potential for causing no more than a minor negative impact on the resident but is not found to be throughout this facility.
483.15(d) Notice of bed-hold policy and return-

483.15(d)(1) Notice before transfer. Before a nursing facility transfers a resident to a hospital or the resident goes on therapeutic leave, the nursing facility must provide written information to the resident or resident representative that specifies-
(i) The duration of the state bed-hold policy, if any, during which the resident is permitted to return and resume residence in the nursing facility;
(ii) The reserve bed payment policy in the state plan, under 447.40 of this chapter, if any;
(iii) The nursing facility's policies regarding bed-hold periods, which must be consistent with paragraph (e)(1) of this section, permitting a resident to return; and
(iv) The information specified in paragraph (e)(1) of this section.

483.15(d)(2) Bed-hold notice upon transfer. At the time of transfer of a resident for hospitalization or therapeutic leave, a nursing facility must provide to the resident and the resident representative written notice which specifies the duration of the bed-hold policy described in paragraph (d)(1) of this section.
Observations:

Based on review of clinical records and staff interviews it was determined that the facility failed to provide the resident and resident representative with a written notice of the facility bed-hold policy (explanation of how long a bed can be held during a leave of absence and the cost per day) upon or within twenty-four hours of transfer for three of seven Residents (Residents R2, R41, and R115).

Findings include:

Resident R2's clinical record revealed an admission date of 6/02/18, with diagnoses that included respiratory failure, cancer, heart failure, septicemia (bacterial infection in the blood), and stroke. The record also revealed that Resident R2 was transferred to the hospital on 5/16/19, for evaluation and returned on 5/20/19. He/she was transferred to the hospital on 6/10/19, for vomiting coffee ground type substance, and returned to the facility on 6/12/19. Resident R2 was again transferred to the hospital on 7/25/19, for evaluation and returned on 7/31/19. He/she was again transferred to the hospital on 8/03/19, for nasogastric tube (a special tube that carries food and medicine to the stomach through the nose) displacement and returned on 8/14/19. The clinical record lacked documentation that indicated Resident R2 and their representative were provided with a copy of the facility bed-hold policy.

Resident R41's clinical record revealed an admission date of 4/17/15, with diagnoses that included sudden and long-term respiratory failure, sepsis (bacterial infection in the blood), non-healing surgical wound, and abnormal heart beat. The record also revealed that Resident R41 was transferred to the hospital on 6/4/19, for difficulty breathing and returned to the facility on 6/9/19. The clinical record lacked documentation that indicated Resident R41 and their representative were provided with a copy of the facility bed-hold policy.

Resident R73's clinical record revealed an admission date of 6/28/19, with diagnoses that included pressure ulcer, fractured pubis, tracheostomy (artificial opening in the airway to allow for breathing), fractured hip, sudden respiratory failure, and fractured back. The record also revealed that Resident R73 was transferred to the hospital on 6/29/19, for change in level of consciousness and returned to the facility on 7/12/19. The clinical record lacked documentation that indicated Resident R73 and their representative were provided with a copy of the facility bed-hold policy.

Resident R115's clinical record revealed an admission date of 7/14/19, with diagnoses that included sudden respiratory failure, tracheostomy (artificial opening in the airway to allow for breathing), systemic inflammatory response syndrome, and brain damage due to lack of oxygen. The record also revealed that Resident R115 was transferred to the hospital on 6/20/19, for shortness of breath and returned to the facility on 6/22/19. The clinical record lacked documentation that indicated Resident R115 and their representative were provided with a copy of the facility bed-hold policy.

During an interview on 8/27/19, at 11:26 a.m. the Nursing Home Administrator and Assistant Director of Nursing confirmed that the bed-hold policy was not provided to these residents and their representatives.

28 Pa. Code 201.18(e)(1) Management

28 Pa. Code 201.29(f) Resident rights


















 Plan of Correction - To be completed: 10/11/2019

For resident R2, R35, R41, R73, R88 and R115 and all residents of the facility, to ensure that a Bed Hold Policy will be given to those residents who were transferred to the hospital or are on a therapeutic leave the following will occur:
Staff will review resident records of those residents who have transferred to the hospital or have been on therapeutic leave over the past 90 days to ensure that the resident and resident representative has received the Bed Hold Policy
Staff will provide resident and resident representative R2, R41 and R115 as well as those residents found from the 90 day review with information regarding the Bed Hold Policy. And they will document acknowledgement in the resident medical record'
Staff will provide resident and resident representative with Bed Hold Policy as appropriate when they are transferred to the hospital or are on a therapeutic leave. If resident is unable to acknowledge the Bed Hold Police, one will be provided to the resident representative within 24 hours
An audit will be completed by Medical Records each time a resident is transferred to the hospital or has been on therapeutic leave to ensure that a Bed Hold Policy was provided to the resident and resident representative. The audit will be the responsibility of the Administrator
Results of the audit will be presented at the Quality Assurance Meeting monthly for 3 months and then quarterly.
Staff Educator in conjunction with Medical Records , will provide in-services that will include the need for documentation in the resident's medical record of acknowledge of the Bed Hold Policy form to resident and resident representative. Education will be completed no later than September 30, 2019

35 P. S. 448.809b LICENSURE Photo Id Reg:State only Deficiency.
(1) The photo identification tag shall include a recent photograph of the employee, the employee's name, the employee's title and the name of the health care facility or employment agency.

(2) The title of the employee shall be as large as possible in block type and shall occupy a one-half inch tall strip as close as practicable to the bottom edge of the badge.

(3) Titles shall be as follows:
(i) A Medical Doctor shall have the title " Physician. "
(ii) A Doctor of Osteopathy shall have the title " Physician. "
(iii) A Registered Nurse shall have the title " Registered Nurse. "
(iv) A Licensed Practical Nurse shall have the title " Licensed Practical Nurse. "
(v) Abbreviated titles may be used when the title indicates licensure or certification by a Commonwealth agency.


Observations:


Based on observations and staff interview, it was determined that the facility failed to ensure that all employees were wearing photo identification tags that included all the required information for four employees (Licensed Practical Nurse (LPN) Employee E1 and Nurse Aides (NA) Employees E2, E3 and E4).

Findings include:

Observations on 8/24/19, at 10:25 a.m. revealed the lack of any photo or other visual identification for staff, residents, and visitors to know what position he/she was in the facility.

During an interview with LPN Employee E1, he/she stated that identification was in his/her bag and not currently on their uniform. Additional observations during the first shift on 8/24/19, of nursing staff revealed NA Employees E2 and E3 each wearing a piece of tape with their names written on it without any photo identification.

On 8/27/19, at 10:30 a.m. NA Employee E4 was observed to be without any visual identification and at that time the employee confirmed the lack of photo identification.







 Plan of Correction - To be completed: 10/11/2019

E1, E2, E3 and E4 were given photo identifications
A whole house audit was completed August 28, 2019 to ensure that all staff was wearing photo identifications. If they were not wearing photo identifications, one was provided for them
To ensure that all employees are wearing photo or other visual identification that included their name and title, the following will occur:
Human Resource will provide all staff with a Photo ID that includes all required information upon orientation
If Identification is lost or misplaced, the employee will report to the Human Resource office to obtain a temporary Photo Id that will include all required information until permanent one is received
All staff were educated August 29, 2019 on the importance of wearing name tag while on duty in the facility
An audit will be completed by the Management Staff or designee to view no less than 5 assigned staff per shift, to ensure they are wearing photo identification. This audit will be completed daily for 1 month, biweekly for 1 month and weekly for 1 month and will be the responsibility of the Administrator
Results of the audit will be presented at the Quality Assurance Meeting monthly for 3 months and then quarterly.



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