Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on April 12, 2022 through April 14, 2022, Fresenius Medical Care Germantown was identified to have the following standard level deficiency that was determined to be in substantial compliance with the requirements of 42 CFR, Part 494.62, Subpart B, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services-Emergency Preparedness.
Plan of Correction:
494.62(d)(3) STANDARD
ESRD Patient Orientation Training
Name - Component - 00
The dialysis facility must provide appropriate orientation and training to patients, including the areas specified in paragraph (d)(1) of this section.
Observations:
Based on a review of facility policy, medical records (MR) and an interview with the director of operations and clinical coordinator, the facility did not provide appropriate emergency preparedness and orientation training to patients for ten (10) of ten (10) MRs. MR#1, 2, 3, 4, 5, 6, 7, 8, 9, and 10.
Findings include:
A review of policy, "Fire Drill" on April 13, 2022 at 1:30 PM states: "Quarterly, all FKC facilities shall perform a fire drill for each shift of patients and staff..."
A review of MRs was conducted on April 13, 2022 at 9:00 AM. The admission date (DATE) is listed below:
MR#1 DATE 4/8/22 (date of readmission) did not have a fire drill completed on readmission.
MR#2 DATE 2/23/15 did not have a fire drill completed for the second and third quarters of 2021.
MR#3 DATE 12/22/2020 did not have a fire drill completed for the second and third quarters of 2021.
MR#4 DATE 9/18/17 did not have a fire drill completed for the first, second, and third quarters of 2021.
MR#5 DATE 7/9/21 did not have a fire drill completed for the first quarter of 2022.
MR#6 DATE 11/16/2020 did not have a fire drill completed for the second and third quarters of 2021.
MR#7 DATE 1/6/16 did not have a fire drill completed for the second and third quarters of 2021.
MR#8 DATE 4/3/2020 did not have a fire drill completed for the first, second, and third quarters of 2021.
MR#9 DATE 3/11/2020 did not have a fire drill completed for the second and third quarters of 2021.
MR#10 DATE 12/4/19 did not have a fire drill completed for the second and third quarters of 2021.
An interview with the director of operations and clinical coordinator on April 14, 2022 at 11:15 AM confirmed the above findings.
Plan of Correction:To ensure compliance, Fire Drills will be completed for the second quarter of 2022 for all patients and staff by April 29, 2022. Records of the drills will be available at the facility for review.
For ongoing compliance, the Clinic Manager (CM) or designee will educate all staff on the following policy:
- Fire Drill
Emphasis will be placed on ensuring that fire drills are completed for all patients quarterly. The meeting also focused on ensuring that all newly admitted patients will have a fire drill completed upon admission to the unit.
Inservicing will be completed by April 22, 2022. All training documentation will be on file at the facility.
To ensure ongoing compliance with quarterly fire drills, the CM/designee will develop a Fire Drill tracking calendar for the remainder of 2022 with the weeks in the quarters that the fire drills are to be held clearly identified. This calendar will be posted at the nurse's station. The CM will also have the weeks of the fire drills for 2022 marked in the computer's electronic calendar. The Fire Drill Tracking calendar will be reviewed in Quality Assessment Improvement (QAI) meetings.
The QAI committee will be informed of the weeks that the drills are scheduled for 2022. The results of the fire drills, when conducted, will be reviewed by the CM at the monthly QAI meeting for ongoing oversight.
Issues of non-compliance will include re-education and counseling by the Director of Operations (DO).
Completion date: May 31, 2022
Initial Comments:
Based on the findings of an onsite unannounced Medicare recertification survey conducted on April 12, 2022 through April 14, 2022, Fresenius Medical Care Germantown Dialysis was identified to have the following standard level deficiencies that were determined to be in substantial compliance with the following requirements of 42 CFR, Part 494, Subparts A, B, C, and D, Conditions for Coverage of Suppliers of End-Stage Renal Disease (ESRD) Services.
Plan of Correction:
494.20 STANDARD
COMPLIANCE WITH FED/STATE/LOCAL LAWS
Name - Component - 00
The facility and its staff must operate and furnish services in compliance with applicable Federal, State, and local laws and regulations pertaining to licensure and any other relevant health and safety requirements.
Observations:
Based on a review of facility policy, CMS memo : QSO-20-36-ESRD dated August 17, 2020, observation and an interview with the director of operations and clinical coordinator, the facility did not follow its policy regarding screening of visitors to the facility for three (3) of three (3) observations (Obs). Obs#1, 2, and 3.
Findings include:
A review of CMS memo QSO-20-36-ESRD on April 14, 2022 at 3:45 PM states:
"Visitor Screening: Facilities should encourage visitors to be aware of signs and symptoms
consistent with COVID-19 and not enter the facility if they have such signs and symptoms.
Screen all visitors entering the healthcare facility for symptoms consistent with COVID-19 or
exposure to others with SARS-CoV-2 infection. Visitors exhibiting a fever or symptoms of
COVID-19 or exposure to others with SARS-CoV-2 infection should be restricted from entering the facility and instructed to seek medical care if needed. Dialysis facilities should ensure that its visitors use cloth face coverings or facemasks to prevent spread of respiratory secretions. Actively take their temperature and document absence of symptoms consistent with COVID-19. According to the CDC, fever is either measured temperature ?100.0or subjective fever. Ask them if they have been advised to self-quarantine because of exposure to someone with SARSinfection.
A review was conducted of facility policy on November 9, 2020 at approximately 11:00 a.m. Policy 'Coronavirus Disease Screening and Infection Control Practices in Fresenius Kidney Care (FKC) Dialysis Clinics' 'Policy' states 'Patient, Visitor, Staff, Physician, and Physician Extender screening' states "All ...., staff, ...entering an FKC dialysis clinic must be screened for ongoing signs and symptoms of COVID-19 disease". "Screening Requirements: Daily monitoring of ......, staff, .... . Use the attached screening documents to record temperatures and perform screening of all ...., staff, ....". 'Related Policies and Procedures' list "FKC Staff and Physician Screening Tool".
Obs#1 April 12, 2022 at approximately 9:00 AM. The facility did not take this surveyor's temperature nor screen for symptoms of Covid 19 upon entry to the facility.
Obs#2 April 13, 2022 at approximately 8:50 AM. The facility did not take this surveyor's temperature nor screen for symptoms of Covid 19 upon entry to the facility.
Obs#1 April 12, 2022 at approximately 8:40 AM. The facility did not take this surveyor's temperature nor screen for symptoms of Covid 19 upon entry to the facility.
An interview with the director of operations on April 14, 2022 at 11:15 AM stated that the receptionist who is absent due to illness would have conducted the screening.
Plan of Correction:The CM or designee re-educated all the DPC staff on the following policy:
- Coronavirus Disease Screening and Infection Control Practices in Fresenius Kidney Care Dialysis Clinics
The meeting reinforced the importance of ensuring that all staff, physicians, physician extenders, patients, and visitors, including any surveyors, are screened for covid upon entering the facility per policy. Documentation of the screening must be recorded on the Covid Screening tool.
The in-servicing of staff will be completed by April 22, 2022. Documentation of the training will be on file at the facility.
The CM or designee will perform daily audits for two (2) weeks. At that time if 100% compliance is observed, the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, if compliance is sustained, the audits will then follow the monthly QAI schedule. A plan of correction (POC) audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audits and report the findings to the QAI Committee at the monthly meeting. The QAI committee will be responsible for further guidance and ongoing oversight.
Completion Date: May 31, 2022
494.30(a)(1) STANDARD
IC-WEAR GLOVES/HAND HYGIENE
Name - Component - 00
Wear disposable gloves when caring for the patient or touching the patient's equipment at the dialysis station. Staff must remove gloves and wash hands between each patient or station.
Observations:
Based on observation of the treatment area, facility policy and an interview with the director of operations and clinical coordinator, the facility did not ensure that patient care staff remove gloves and wash hands during aspects of patient care for two (2) of ten (10) observations (Obs). Observation # 1 and 2.
Findings include:
A review of facility policy, "Hand Hygiene" conducted on April 13, 2022 at 1:30 PM states: "Hands will be decontaminated using alcohol-based hand rub or by washing hands with antimicrobial soap and water, before and after direct contact with patients, before performing any invasive procedure..immediately after removing gloves...after contact with inanimate objects near the patient..."
Observation of the treatment area was conducted on April 12, 2022 from 9:15 AM-1:00 PM.
Obs#1 Patient Care Technician (PCT) #4 at station #5 removed the catheter dressing, removed the old gloves and donned new gloves without performing hand hygiene.
Obs#2 PCT#2 at station#15 removed gloves after touching the dialysis machine and donned new gloves without performing hand hygiene.
An interview with the director of operations and clinical coordinator on April 14, 2022 at 12:00PM confirmed the above findings.
Plan of Correction:To ensure compliance, the CM or designee re-educated all the DPC staff on the following policy:
- Hand Hygiene
Special emphasis will be placed on ensuring that when gloves are removed, hand hygiene is performed before donning new gloves per policy.
The in-servicing will be completed by April 22, 2022, with documentation of the training on file at the facility.
The CM or designee will perform daily audits on the DPC staff for 2 weeks. At that time if compliance is observed the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, if compliance is sustained, the audits will then follow the monthly QAI schedule. A POC audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audits and report the findings to the QAI Committee at the monthly meeting. The QAI committee will be responsible for further guidance and ongoing oversight.
Completion Date: May 31, 2022
494.30(a)(1)(i) STANDARD
IC-GOWNS, SHIELDS/MASKS-NO STAFF EAT/DRINK
Name - Component - 00
Staff members should wear gowns, face shields, eye wear, or masks to protect themselves and prevent soiling of clothing when performing procedures during which spurting or spattering of blood might occur (e.g., during initiation and termination of dialysis, cleaning of dialyzers, and centrifugation of blood). Staff members should not eat, drink, or smoke in the dialysis treatment area or in the laboratory.
Observations:
Based on observation of the treatment area and an interview with the director of operations and clinical coordinator, the facility did not ensure that physicians wear a cover garment which provides an impervious barrier to fluids when providing service to a patient in the treatment area for one (1) of one (1) observation (Obs). Obs#1.
Findings include:
Observation of the treatment area was conducted on April 12, 2022 from 9:15 AM-1:00 PM.
One Physiscan was making rounds on April 12, 2022 at 11:25 AM. The physician was speaking to a patient at Station# 15 and was not wearing a cover garment that provides an impervious barrier to fluids.
An interview with the director of operations and clinical coordinator on April 14, 2022 at 12:00PM confirmed the above findings.
Plan of Correction:The CM or designee will re-educate all the DPC staff on:
- Personal Protective Equipment Policy
Emphasis will be placed on ensuring that appropriate PPE, including gowns, are worn by all staff, including physicians, when providing service to a patient in the patient station area.
The CM or designee will also meet with the physicians and inform them of the policy and reinforce that they must wear a gown when meeting with the patients in the unit.
The Inservicing will be completed by April 22, 2022, with documentation of the training on file at the facility.
The CM or designee will perform daily audits on the DPC staff and physicians for 2 weeks. At that time if compliance is observed the audits will then be completed 2 times/week for 2 weeks to ensure that compliance is maintained. At that time, if compliance is sustained, the audits will then follow the monthly QAI schedule. A POC audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audits and report the findings to the QAI Committee at the monthly meeting. The QAI committee will be responsible for further guidance and ongoing oversight.
Completion Date: May 31, 2022
494.30(a)(4)(ii) STANDARD
IC-DISINFECT SURFACES/EQUIP/WRITTEN PROTOCOL
Name - Component - 00
[The facility must demonstrate that it follows standard infection control precautions by implementing-
(4) And maintaining procedures, in accordance with applicable State and local laws and accepted public health procedures, for the-]
(ii) Cleaning and disinfection of contaminated surfaces, medical devices, and equipment.
Observations:
Based on observation, facility policy and an interview with the director of operations and clinical coordinator, the facility did not ensure cleansing and disinfection of medical equipment for one (1) of three (3) observation (Obs). Obs#1.
Findings include.
A review of policy "Cleaning and Disinfection of the Dialysis Station" on April 13, 2022 at 1:30 PM states: " ...in order to prevent cross contamination a dialysis station must be cleaned and disinfected between dialysis patients...Definition Dialysis Station Area including the dialysis machine, chair/bed and other reusable equipment or supplies utilized during dialysis treatment."
Observation of the treatment area was conducted on April 12, 2022 from 9:15 AM-1:00 PM.
Obs#1 RN#1 did not cleanse/disinfect the stethoscope after performing a pulmonary assessment of the patient at station #15 prior to assessing the next patient.
An interview with the director of operations and clinical coordinator on April 14, 2022 at 12:00PM confirmed the above findings.
Plan of Correction:To ensure compliance the CM or designee will in-service all DPC staff on policy:
- Cleaning and Disinfection of the Dialysis Station
The meeting will focus on ensuring that the dialysis station and all surfaces and reusable items or supplies that are potentially contaminated, including stethoscopes, are thoroughly cleaned and disinfected after each patient use.
Inservicing will be completed by April 22, 2022. All training documentation is on file at the facility.
The CM or designee will perform daily audits for 2 weeks. At that time if compliance is observed the audits will then be completed 2/week for 2 weeks to ensure that compliance is
maintained. At that time, the audits will then follow the monthly QAI schedule. A POC specific audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee.
Completion Date: May 31, 2022
494.30(b)(2) STANDARD
IC-ASEPTIC TECHNIQUES FOR IV MEDS
Name - Component - 00
[The facility must-]
(2) Ensure that clinical staff demonstrate compliance with current aseptic techniques when dispensing and administering intravenous medications from vials and ampules; and
Observations:
Based on a review of facility policy, observation of the treatment area and an interview with the director of operations and clinical coordinator, the facility did not ensure clinical staff to be in compliance with aseptic techniques when dispensing intravenous medications from vials for two (2) of four (4) observations (Obs). Obs#1 and 2.
Findings include:
A review of policy "Medication Preparation and Administration" on April 13, 2022 at 1:30 PM states: "Cleanse the diaphragm of the vial with alcohol prior to accessing the vial..."
Observation of the treatment area was conducted on April 12, 2022 from 9:15 AM-1:00 PM.
Obs#1 Patient Care Technician (PCT)#2 at 10:10 AM withdrew heparin, located on the medication cart at the nurses station into a syringe from the heparin 30,000u (units) 1000u/ml (units per milliliter) vial without first cleansing the diaphragm of the vial with alcohol prior to accessing the vial.
Obs#2 PCT#2 at 11:25 AM withdrew heparin, located on the medication cart at the nurses station into a syringe from the heparin 30,000u (units) 1000u/ml (units per milliliter) vial without first cleansing the diaphragm of the vial with alcohol prior to accessing the vial.
An interview with the director of operations and clinical coordinator on April 14, 2022 at 12:00PM confirmed the above findings.
Plan of Correction:To ensure compliance the CM or designee will in-service all DPC staff on policy
- Medication Preparation and Administration Policy
Emphasis will be placed on ensuring that the stopper of medication vials will be cleansed by wiping the septum with alcohol every time before entering the vial to draw up the medication.
The in-service will be completed by April 22, 2022. All training documentation will be available at the facility for review.
The CM or designee will perform daily audits for 2 weeks. At that time if compliance is observed the audits will then be completed 2/week for 2 weeks to ensure that compliance is
maintained. At that time, the audits will then follow the monthly QAI schedule. A POC specific audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audit results and report the findings to the QAI Committee at the monthly meeting. Sustained compliance will be monitored by the QAI committee.
Completion Date: May 31, 2022
494.80(a)(2) STANDARD
PA-ASSESS B/P, FLUID MANAGEMENT NEEDS
Name - Component - 00
The patient's comprehensive assessment must include, but is not limited to, the following:
Blood pressure, and fluid management needs.
Observations:
Based on a review of medical records (MR), faciity policy and an interview with the director of operations and clinical coordinator, the facility did not follow its policy for blood pressure monitoring for two (2) of ten (10) MRs. MR#3 and 10.
Findings include:
Intradialytic Hypotension
A review of policy "Intradialytic Hypotension" (low blood pressure) was reviewed on April 14, 2022 at 3:00 PM states: Staff, patient...will report intradialytic hypotensive episodes to the nurse in charge. The nurse in charge will report to the physician severe or frequent intradialytic hypotensive episodes...Treating Hypotension on Hemodialysis Step 1. If BP is verified low, administer 100-200 fluid bolus as ordered by the physician and recheck BP (blood pressure) post (after) bolus..."
A review of policy"Hypertension" (high blood pressure) was reviewed on April 14, 2022 at 3:00 PM states:"Staff will recognize report and immediately address systolic blood pressures greater than 180 mmHg (millimeters of mercury) and or diastolic blood pressures greater than 100 mmHg. Treating Hypertension Step 1. Notify the nurse in charge..."
A review of MRs was conducted on April 13, 2022 at 9:00 AM. The admission date (DATE) is listed below:
MR#3 DATE 12/22/2020 documents that "Patient on Midadrine for low blood pressure". A review of treatment flowsheets revealed:
3/30/22: pre dialysis BP 81/50 post dialysis BP 89/50.
11:31 AM BP 72/49 no saline given, BP not retaken, BP not reported to the nurse. Note states denies complaints.
12:03 PM BP 81/57 150 ml saline given, Bp not retaken, BP not reported to the nurse. Note states denies complaints.
12:20 PM BP 78/55 no saline given. BP taken by RN. BP not retaken Note states denies complaints.
13:00 PM BP 73/52 no saline given. BP not reported to RN. BP not retaken .Note states denies complaints.
13:33 PM BP 78/53 150 ml saline given. BP not reported to RN. BP not retaken. Note states denies complaints.
14:00 PM BP 68/44 no saline given. BP not reported to RN. BP not retaken. Note states denies complaints.
14:31 PM BP 76/52 no saline given. BP not reported to RN. BP not retaken. Note states denies complaints.
RN evaluation post treatment states: "No unusual findings noted. pt tolerate treatment fair bp low pt states he took midadrine...left treatment stable."
4/1/22:
14:38 PM BP 86/55 no saline given. BP not reported to RN. BP not retaken. Note states denies complaints. RN evaluation post treatment states :"bp low pt takes midadrine."
4/6/22:
Pre dialysis BP 72/43. Post dialysis BP 92/56.
12:07 PM BP 77/51 no saline given. BP not reported to RN. BP not retaken. Note states denies complaints.
12:41 PM 71/51 no saline given. BP not reported to RN. BP not retaken. Note states denies complaints.
13:05 PM 74/53 no saline given. BP not reported to RN. BP not retaken. Note states denies complaints.
13:38 PM BP 74/52 no saline given. BP not reported to RN. BP not retaken. Note states denies complaints.
14;10 PM BP 79/72 no saline given. BP not reported to RN. BP not retaken. Note states denies complaints.
14:30 PM BP 67/44 150 ml saline given. BP not reported to RN. Note states denies complaints...pt asymptomatic (without symptoms). BP not retaken.
RN evaluation post treatment states:" No unusual findings..."
MR#10 DATE 12/4/19 patient has an order for Clonidine 0.1 mg PO (by mouth) for high BP.
A review of treatment sheets revealed:
4/4/22:
Pre dialysis BP 178/149
6:23 AM BP 227/102 note states "denies complaints." RN not notified. Clonidine not administered.
9:10 AM BP 206/100 RN not notified. Clonidine not administered.
9:30 AM BP 219/119 note states "denies complaints". RN not notified. Clonidine not administered.
RN evaluation states "no unusual findings noted."
4/8/22:BP 211/102
7:36 AM BP 211/102 note states "denies complaints". RN not notified. Clonidine not administered.
7:53 AM BP 188/109 note states "denies complaints". RN not notified. Clonidine not administered.
8:41 AM BP 187/115 note states "denies complaints". RN not notified. Clonidine not administered.
9:01 AM BP 170/111 note states "denies complaints". RN not notified. Clonidine not administered.
RN post treatment evaluation states "No unusual findings noted..."
An interview with the director of operations and clinical coordinator on April 14, 2022 at 11:15 AM confirmed the above findings.
Plan of Correction:To ensure compliance the CM or designee will in-service all DPC staff on policy:
- Intradialytic Hypotension
- Hypertension
Emphasis will be placed on ensuring that the patient care technician (PCT) must report any treatment abnormal findings, including hypotension or hypertension, to the registered nurse (RN). The staff were also informed that there must be documentation of the RN notification. The RN will then complete an evaluation of the patient with documentation of the assessment along with an intervention with if indicated. A follow up blood pressure (BP) must be performed with documentation of results of the intervention. The nurses will also be informed that the physician must be informed with document the physician notification.
Inservicing will be completed by May 22, 2022. All training documentation is on file at the facility.
The CM or designee will perform daily audits for 2 weeks. At that time if compliance is observed the audits will then be completed 2/week for 2 weeks to ensure that compliance is maintained. At that time, the audits will then follow the monthly QAI schedule. A POC specific audit tool will be used for the audits.
Staff found to be non-compliant will be re-educated and referred for counseling.
The CM will review the audits and report the findings to the QAI Committee at the monthly meeting. The QAI committee will be responsible for further guidance and ongoing oversight.
Completion Date: May 31, 2022
494.110(a)(2)(ix) STANDARD
QAPI-INDICATOR-INF CONT-TREND/PLAN/ACT
Name - Component - 00
The program must include, but not be limited to, the following:
(ix) Infection control; with respect to this component the facility must-
(A) Analyze and document the incidence of infection to identify trends and establish baseline information on infection incidence;
(B) Develop recommendations and action plans to minimize infection transmission, promote immunization; and
(C) Take actions to reduce future incidents.
Observations:
Based on a review of quality assessment performance improvement (QAPI) meeting minutes, facility policy, and an interview with the director of operations and clinical coordinator, the facility did not analyze and document the incidence of infection to identify trends for six (6) of six (6) months.
Findings include:
A review of facility policy "Quality Assessment and Performance Improvement (QAI)"on April 14, 2022 at 4:00 PM states: "QAI Meeting Requirements...Review of aggregate patient data to identify opportunities for improvement for clinical outcomes, and track progress by: 1. Evaluating data from clinical reports and trending tools.,,2. Identify commonalities among patients who do not reach the minim expected patient targets 3. Develop a plan to address those causes 4. Implement the plan 5. Monitor the effectiveness of the plan t. Adjust portions of the plan that are not successful...Elements of QAI...Infection Surveillance..."
A review of QAI meeting minutes and documentation was conducted on April 14, 2022 at 9:45 AM.
A review of infection data blood stream infections (BSI) for the months of September-December 2021 and January-February 2022 indicated a range of 0.49. A review of Medical Records and facility hospital logs revealed patients hospitalized for BSI. The QAPI monthly data listed patients with bacteremia. There was no documentation discussing the data, analyzing trends and looking for root causes.
An interview with the director of operations and clinical coordinator on April 14, 2022 at 11:00 AM confirmed the above findings.
Plan of Correction:The Director of Operations (DO) or designee will re-educate the QAI committee on policy:
- Quality Assessment and Performance Improvement Program (QAPI) Policy
Emphasis will be placed on the importance of recognizing a focus area, including blood stream infections (BSI), completing a root cause analysis with development of action plans. The meeting will also reinforce the importance of including auditing for commonalities and risk factors, and oversight of the implementation and follow up with action plans. Education also included monitoring and sustaining improvements, as well as what actions the committee will take if improvements with the action plans are not noted.
The in-services were completed by April 22, 2022. Documentation of the in-servicing will be on file at the facility.
To maintain compliance, the DO will monitor the monthly QAI minutes to ensure that BSI are being completed and tracked on the QAI schedule. The DO will ensure the development, implementation and monthly review of action plans if indicated. The DO review of the QAI minutes will be performed monthly over the next three (3) months to ensure 100% compliance is achieved. The auditing will then be completed bimonthly for another 3 months. The DO will report the findings of the QAI meeting review to the CM who will report the results at the monthly QAI Meeting. The QAI committee will provide ongoing monitoring for sustained compliance.
Non-adherence will result in re-education and counseling.
Completion Date: May 31, 2022
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