HELPING KEEP HEARTS BEATING CHILDCARE

During the inspection, it was determined that employment records in the Ohio Professional Registry (OPR) were not created or maintained as noted in number 10 below: 1. The provider had not created or updated their individual profile in the OPR.2. The provider had not created or updated the program's organizational dashboard in the OPR.3. At least one employee, child care staff member, or substitute child care staff member had not created or updated their individual profile in the OPR. 4. At least one employee, child care staff member, or substitute child care staff member had not created an employment record in the OPR for the program on or before the first day of employment, including date of hire.5. At least one employee, child care staff member, or substitute child care staff member had not updated changes to positions or roles in the OPR within five calendar days of the change.6. The program's organizational dashboard in the OPR was not updated within five business days when at least one employee, child care staff member, or substitute child care staff member's scheduled days and hours changed.7. The program's organizational dashboard in the OPR was not updated within five business days when at least one employee, child care staff member, or substitute child care staff member's group assignments changed, if applicable.8. The program's organizational dashboard in the OPR was not updated with the employment end date within five business days when at least one employee, child care staff member, or substitute child care staff member ended employment.9. At least one resident over the age of eighteen had not created a profile and employment record for the family child care provider within five days of becoming a resident or turning eighteen.10. The program's organizational dashboard in the OPR was not updated within five calendar days of a change in residency for at least one resident over the age of eighteen.11.Other: [] Submit the program's corrective action plan to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined that the program's weekly menu did not meet the requirement as noted in number 3 below. 1. The menu was not posted.2. The posted menu was not in a visible place readily accessible to parents.3. The menu was not currently dated.4. The entire menu was substituted.5. At least one item on menu did not match what was served.6. The meal or snack served did not match the posted menu.Submit the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined the following information was not posted for item number 1 below:1. Fire alert plan, including a diagram indicating evacuation routes.2. Weather alert plan was missing details for [ ]. 3. Weather alert plan was missing a diagram indicating evacuation routes. Correct the violation and submit the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

In review of the children's records, it was determined that information had not been secured from the parent/guardian on the JFS 01234 Child Enrollment and Health Information For Child Care, as required, for the items in number 6 below: 1. No enrollment form was completed for at least one child 2. The current JFS 01234 was not completed for at least one child 3. Complete child information 4. Complete parent information 5. Complete emergency contact information 6. Complete physician information 7. Information regarding the parent list 8. Health information 9. Additional information for all boxes checked yes 10. Emergency transportation information 11. Parent/guardians signature 12. Diapering Statement 13. Acknowledgement of Policies and Procedures 14. Enrollment form for at least one child was not updated by either the parent or the administrator 15. Enrollment form for at least one child was not signed by the administrator 16. Other [ ] Submit the program's corrective action plan to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined pets at the program were not properly housed or cared for or posed a threat to the safety or health of the children as noted in number(s) 5. 6 (rabies) below: 1. The animals cage was dirty with feces.2. The aquarium was unclean.3. The litter box was dirty with feces.4. A pet posed a threat to the safety of a child in that [ ].5. A pet requiring a license did not have a current license.6. Proper inoculation records were not on file at the program for a pet requiring inoculations.7. Children were exposed to the pet's urine and/or feces.8. Other [ ].A pet that poses a threat to the children shall not be at the program. All pets at the program must receive proper care and housing. Submit the programs corrective action plan to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

In review of of the children's records, it was determined that completed medical statements were not on file, as required, for children listed on the JFS Children's Record Review For Child Care as indicated in number 2 below:1. No medical was on file for at least one child 2. Medical(s) on file was not updated every 13 months 3. Medical(s) were missing child's name and date of birth4. Medical(s) were missing the date of the medical examination5. The date of the exam was more than 13 months prior to the date the form was signed 6. Medical(s) were missing a statement that the child has been examined and is in suitable condition for participation in group care7. Medical(s) were missing the signature, business address and telephone number of the physician, physician's assistant(PA), advance practice nurse (APN) or certified nurse practitioner (CNP) who examined the child8. Medical(s) were missing a record of immunizations the child has had specifying month, day and year9. Medical(s) were missing a statement from the physician, PA, APN, or CNP that the child has been immunized or is in the process of being immunized against the diseases required by division 5104.014 of the Revised Code and found in appendix A to this rule10. Medical(s) were missing a statement from the childs parent or guardian that he or she has declined to have the child immunized against the disease for reasons of conscience, including religious convictions11. Other [ ] Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule. .

Resolution: Compliance Status: Approved

During the inspection, it was determined that the program did not have a first aid kit onsite as required, that included all items listed in the appendix A of the rule. The kit was missing the item listed in number 8 below: 1. One roll of first-aid tape; 2. Individually wrapped sterile gauze; squares in assorted sizes;3. Sterile adhesive bandages in assorted sizes;4.Tweezers;5. Gauze rolled bandage;6. Triangular bandage;7. Rounded end scissors;8. Tooth preservation system or fresh chilled liquid milk in which to transport a lost permanent tooth, including a written reference indicating location of the refrigerator/freezer where milk is stored if a tooth preservation system is not part of the first aid kit (for programs serving school age children only);9. A working digital thermometer;10. Disposable non-latex gloves;11. A working flashlight;12. An instant cold pack that has not been activated or ice, including a written reference indicating location of the refrigerator/freezer where the ice is stored if an instant cold pack is not part of the first aid kit;13. Sealable leak-proof plastic bags in assorted sizes or double bagged plastic bags that can be securely tied for materials soiled with blood or bodily fluids;14. Pocket mask or face shield, appropriate; for all ages of children in care, for cardiopulmonary resuscitation (CPR) administration;15. Soap or waterless sanitizer (field trip or transporting away from the program only);16. Bottled water (field trip or transporting away from the program only).Correct the violation and submit the program's corrective action plan to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

In review of records, it was determined the provider did not have current valid documentation for training(s) listed in number 14 below:1. First Aid - expired training2. First Aid - did not have verification of the completion of First Aid training3. First Aid - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule4. CPR - expired training5. CPR - had not taken CPR training6. CPR - did not have verification of the completion of CPR training7. CPR - training taken did not include all age groups and developmental levels of all children in care8. CPR - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule9. CPR- audiovisual or electronic media training taken did not include an in-person component of the training10. Communicable Disease - expired training11. Communicable Disease - had not taken CD training12. Communicable Disease - did not have verification of the completion of CD training13. Communicable Disease - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule 14. Child Abuse - expired training15. Child Abuse - had not taken Child Abuse training16. Child Abuse - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the ruleCorrect the violation and submit the documentation of current certification with the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined that the required drills were not completed for item number 1,2 below:1. Monthly fire drills2. Monthly weather emergency drills (March through September)3. Emergency/lockdown drills in each quarter of the calendar year Submit the programs corrective action plan to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, a potentially hazardous item or toxic substance was used or stored where children present had access to it as noted in number 2 below. The potentially hazardous substance or item that posed a risk to children was determined to be accessible to children in bathroom. 1. Bleach.2. Cleaning agent.3. Fish tank chemicals. 4. Gasoline. 5. Pesticide.6. Poison, including insect/rodent poison. 7. Flammable substance.8. Windshield washer fluid.9. Aerosol cans. 10. A lawn mower. 11. A weed trimmer. 12. Hedge trimmers. 13. A snow blower.14. Other potentially hazardous substance, equipment or machinery: [ ]. Provide staff training. Submit the programs corrective action plan, which includes a statement that the potentially hazardous substance or item is no longer accessible to children and/or children will not be outside when machinery is in use and a statement that training was provided, to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

In review of the children's records, it was determined that information had not been secured from the parent/guardian on the JFS 01234 Child Enrollment and Health Information For Child Care, as required, for the items in number 1 below: 1. No enrollment form was completed for at least one child 2. The current JFS 01234 was not completed for at least one child 3. Complete child information 4. Complete parent information 5. Complete emergency contact information 6. Complete physician information 7. Information regarding the parent list 8. Health information 9. Additional information for all boxes checked yes 10. Emergency transportation information 11. Parent/guardians signature 12. Diapering Statement 13. Acknowledgement of Policies and Procedures 14. Enrollment form for at least one child was not updated by either the parent or the administrator 15. Enrollment form for at least one child was not signed by the administrator 16. Other [ ] Submit the program's corrective action plan to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, equipment was determined to be unsafe, hazardous to children, or in need of repair as noted in number 8 below: 1. Manufacturer's guidelines for the [ ] were not followed in that [ ]. 2. The straps were missing on the [ ].3. The straps were attached, but were not used on the [ ]. 4. The straps were attached and were used, but were not used in a safe manner.5. The equipment had sharp points or corners.6. The equipment had splinters.7. The equipment had protruding nails.8. The equipment had loose or rusty parts.9. The equipment had paint which contains lead or other poisonous materials.10. The equipment had hazardous features.11. A fan was unstable and could easily tip over. 12. A fan had openings a finger could enter.13. The pipes from the heat pump felt hot to the touch14. A space heater felt hot to the touch15. The position of a space heater was a tripping hazard16. The air conditioning unit was not enclosed and was accessible to children on the playground. 17. A ball pit, trampoline, inflatable bounce house, inflatable slide, inflatable equipment used for climbing and bouncing was used. 18. Other [ ].Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

In review of of the children's records, it was determined that completed medical statements were not on file, as required, for children listed on the JFS Children's Record Review For Child Care as indicated in number 2 below:1. No medical was on file for at least one child 2. Medical(s) on file was not updated every 13 months 3. Medical(s) were missing child's name and date of birth4. Medical(s) were missing the date of the medical examination5. The date of the exam was more than 13 months prior to the date the form was signed 6. Medical(s) were missing a statement that the child has been examined and is in suitable condition for participation in group care7. Medical(s) were missing the signature, business address and telephone number of the physician, physician's assistant(PA), advance practice nurse (APN) or certified nurse practitioner (CNP) who examined the child8. Medical(s) were missing a record of immunizations the child has had specifying month, day and year9. Medical(s) were missing a statement from the physician, PA, APN, or CNP that the child has been immunized or is in the process of being immunized against the diseases required by division 5104.014 of the Revised Code and found in appendix A to this rule10. Medical(s) were missing a statement from the childs parent or guardian that he or she has declined to have the child immunized against the disease for reasons of conscience, including religious convictions11. Other [ ] Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule. .

Resolution: Compliance Status: Approved

During the inspection, it was determined the program did not meet the requirements for keeping an attendance record as listed in number 6 below:1. No attendance record was being maintained.2. The attendance record was not being consistently completed.3.The record did not include the name of at least one child.4. The record did not include the birth date of at least one child.5.The record did not include the assigned group.6.The record did not include the childs weekly schedule.7.The record did not include the time (hours and minutes) of each childs arrival and departure to the program, including transportation by the program.8. The original attendance record was not kept at the program for a period of one year.Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, a potentially hazardous item or toxic substance was used or stored in a space used for child care during the program's hours of operation, but no children were present, as noted in number 5 below:1. A lawn mower. 2. A weed trimmer.3. Hedge trimmers. 4. A snow blower. 5. Other potentially hazardous substance, equipment or machinery: cleaning agents. Submit the programs corrective action plan, which includes a statement that the potentially hazardous substance or item is no longer accessible to children and/or children will not be outside when machinery is in use to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

In review of records, it was determined the Child Care Staff Member(s) indicated on the Employee Record Chart did not meet the annual professional development requirement as noted in number 1.1. The child care staff member(s) had not completed at least six hours of professional development.2. Documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule. 3. Training topic did not meet the requirements listed in appendix A of this rule. 4. Documentation of training did not meet the requirements of this rule. 5. The substitute(s) had been used more than ninety days annually between July first and June thirtieth and had not completed at least six hours of professional development.6. Other [ ].Submit the programs corrective action plan to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined that an area was used which was not protected from traffic and other hazards by a continuous fence in good condition, or natural barrier, that ensured children were not able to leave the playground area. The fence or natural barrier was determined to present an immediate risk for a child to be able to leave the playground as noted in number 1 below:1. The fence, natural barrier, or combination of fence and natural barrier was not continuous.2. The fencing had missing slat boards through which children could leave the playground.3. The gate was broken and did not close.4. The latch on the gate was broken.5. The gate had no latch.6. The fencing was broken.7. The latch was easily opened by children on the playground.8. The latch was not engaged to prevent children from opening the gate.9. The portable fencing approved for use by the Department was not being used. 10. Other [ ]. Discontinue use of the playground and provide a space for outdoor play which is well defined by a continuous fence or natural barrier and protected from other hazards. Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined the following information was not posted for item number(s)1,3 below:1. Fire alert plan, including a diagram indicating evacuation routes.2. Weather alert plan was missing details for [ ]. 3. Weather alert plan was missing a diagram indicating evacuation routes. Correct the violation and submit the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined the JFS 01201 "Dental First Aid" was not posted. Correct the violation and submit the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined the provider did not have a completed JFS 01933 "Liability Insurance Statement for Family Child Care Providers" completed for each child in care. Correct the violation and submit proof of insurance with the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined the current licensing rules were not available on the premises. Correct the violation and submit the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

In review of records, it was determined the provider did not have current valid documentation for training(s) listed in number 10 below:1. First Aid - expired training2. First Aid - did not have verification of the completion of First Aid training3. First Aid - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule4. CPR - expired training5. CPR - had not taken CPR training6. CPR - did not have verification of the completion of CPR training7. CPR - training taken did not include all age groups and developmental levels of all children in care8. CPR - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule9. CPR- audiovisual or electronic media training taken did not include an in-person component of the training10. Communicable Disease - expired training11. Communicable Disease - had not taken CD training12. Communicable Disease - did not have verification of the completion of CD training13. Communicable Disease - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the rule 14. Child Abuse - expired training15. Child Abuse - had not taken Child Abuse training16. Child Abuse - documentation did not demonstrate the person who provided the training met the trainer qualifications as stated in the ruleCorrect the violation and submit the documentation of current certification with the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined that an outdoor play area was used which was not protected from traffic and other hazards by a fence in good repair, or other barrier. Although the fence or natural barrier was not meeting the rule requirements, it was determined to not present an immediate risk for a child to be able to leave the playground. The fence or gate was not being used inappropriately as noted in number 12 below: 1. The fencing had missing slat boards.2. The fencing was broken.3. The fencing was loose.4. The fencing was rotting.5. The gate was broken and did not close.6. The gate was locked.7. The latch on the gate was broken.8. The latch was easily opened by children on the playground.9. The latch was not engaged to prevent children from opening the gate.10. The gate had no latch. 11. There were bolts with more than two threads exposed along a fence line or gate on a playground.12. Other - fence was not complete, opening between driveway and house.Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

In review of of the children's records, it was determined that completed medical statements were not on file, as required, for children listed on the JFS Children's Record Review For Child Care as indicated in number 2 below:1. No medical was on file for at least one child 2. Medical(s) on file was not updated every 13 months 3. Medical(s) were missing child's name and date of birth4. Medical(s) were missing the date of the medical examination5. The date of the exam was more than 13 months prior to the date the form was signed 6. Medical(s) were missing a statement that the child has been examined and is in suitable condition for participation in group care7. Medical(s) were missing the signature, business address and telephone number of the physician, physician's assistant(PA), advance practice nurse (APN) or certified nurse practitioner (CNP) who examined the child8. Medical(s) were missing a record of immunizations the child has had specifying month, day and year9. Medical(s) were missing a statement from the physician, PA, APN, or CNP that the child has been immunized or is in the process of being immunized against the diseases required by division 5104.014 of the Revised Code and found in appendix A to this rule10. Medical(s) were missing a statement from the childs parent or guardian that he or she has declined to have the child immunized against the disease for reasons of conscience, including religious convictions11. Other [ ] Submit the programs corrective action plan to the Department to verify compliance with the requirements of this rule. .

Resolution: Compliance Status: Approved

During the inspection, it was determined that the required drills were not completed for item number(s) 1, 2 below:1. Monthly fire drills2. Monthly weather emergency drills (March through September)3. Emergency/lockdown drills in each quarter of the calendar year Submit the programs corrective action plan to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined the following information was not posted for item number 1 below:1. Fire alert plan, including a diagram indicating evacuation routes.2. Weather alert plan was missing details for [ ]. 3. Weather alert plan was missing a diagram indicating evacuation routes. Correct the violation and submit the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined the programs written emergency preparedness and response plan did not meet the requirement or was missing the information in number 20 below:Procedures:1. The written emergency and preparedness and response plan had not been completed2. The plan was not provided to all child care staff and employees3. Weather emergencies and natural disasters which include severe thunderstorms, tornadoes, flash flooding, major snowfall, blizzards, ice storms or earthquakes4. Emergency outdoor and indoor lockdown or evacuation due to threats of violence which includes active shooter, bioterrorism or terrorism including a designated safe site where staff and children can safely remain when evacuated5. Emergency or disaster evacuations due to hazardous materials and spills, gas leaks or bomb threats including a designated safe site where staff and children can safely remain when evacuated6. Outbreaks, epidemics or other infectious disease emergencies7. Loss of power, water, or heat8. Other threatening situations that may pose a health or safety hazard to the children in the programDetails:9. Shelter in place or evacuation, how the program will care for and account for the children until they can be reunited with the parent10. Assisting infants, toddlers and children with special needs and/or health conditions11. Emergency contact information for parents and the program12. Procedures for notifying and communicating with parents regarding the location of the children if evacuated13. Procedures for communicating with parents during loss of communications, no phone or internet service available14. The location of supplies and procedures for gathering necessary supplies for staff and children if required to shelter in place15. What to do if a disaster occurs during the transport of children or when on a field trip or routine trip16. Making the plan available to all child care staff members and employees17. Training of staff or reassignment of staff duties as appropriate18. Updating the plan on a yearly basis19. Contact with local emergency management officials20. The plan was unable to be implemented in that the plan was available not at the program.Submit the programs corrective action plan, which includes the missing information, if applicable, to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined that the program did not have a first aid kit onsite that included all items listed in the appendix A of the rule. The kit(s) were missing the item listed in number 7 below: 1. One roll of first-aid tape; 2. Individually wrapped sterile gauze; squares in assorted sizes;3. Sterile adhesive bandages in assorted sizes;4.Tweezers;5. Gauze rolled bandage;6. Triangular bandage;7. Rounded end scissors;8. Tooth preservation system or fresh chilled liquid milk in which to transport a lost permanent tooth, including a written reference indicating location of the refrigerator/freezer where milk is stored if a tooth preservation system is not part of the first aid kit (for programs serving school age children only);9. A working digital thermometer;10. Disposable non-latex gloves;11. A working flashlight;12. An instant cold pack that has not been activated or ice, including a written reference indicating location of the refrigerator/freezer where the ice is stored if an instant cold pack is not part of the first aid kit;13. Sealable leak-proof plastic bags in assorted sizes or double bagged plastic bags that can be securely tied for materials soiled with blood or bodily fluids;14. Pocket mask or face shield, appropriate; for all ages of children in care, for cardiopulmonary resuscitation (CPR) administration;15. Soap or waterless sanitizer (field trip or transporting away from the program only);16. Bottled water (field trip or transporting away from the program only).Correct the violation and submit the program's corrective action plan to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined that daily outdoor play was not provided as required by rule. Submit the programs corrective action plan to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined that employment records in the Ohio Professional Registry (OPR) were not created or maintained as noted in number 2 below: 1. The provider had not created or updated their individual profile in the OPR.2. The provider had not created or updated the program's organizational dashboard in the OPR.3. At least one employee, child care staff member, or substitute child care staff member had not created or updated their individual profile in the OPR. 4. At least one employee, child care staff member, or substitute child care staff member had not created an employment record in the OPR for the program on or before the first day of employment, including date of hire.5. At least one employee, child care staff member, or substitute child care staff member had not updated changes to positions or roles in the OPR within five calendar days of the change.6. The program's organizational dashboard in the OPR was not updated within five business days when at least one employee, child care staff member, or substitute child care staff member's scheduled days and hours changed.7. The program's organizational dashboard in the OPR was not updated within five business days when at least one employee, child care staff member, or substitute child care staff member's group assignments changed, if applicable.8. The program's organizational dashboard in the OPR was not updated with the employment end date within five business days when at least one employee, child care staff member, or substitute child care staff member ended employment.9. At least one resident over the age of eighteen had not created a profile and employment record for the family child care provider within five days of becoming a resident or turning eighteen.10. The program's organizational dashboard in the OPR was not updated within five calendar days of a change in residency for at least one resident over the age of eighteen.11.Other: [] Submit the program's corrective action plan to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved

During the inspection, it was determined the provider did not have a completed JFS 01933 "Liability Insurance Statement for Family Child Care Providers" completed for each child in care. Correct the violation and submit proof of insurance with the program's corrective action plan to verify compliance with the requirement of the rule.

Resolution: Compliance Status: Approved

In review of the children's records, it was determined that information had not been secured from the parent/guardian on the JFS 01234 Child Enrollment and Health Information For Child Care, as required, for the items in number 1 below: 1. No enrollment form was completed for at least one child 2. The current JFS 01234 was not completed for at least one child 3. Complete child information 4. Complete parent information 5. Complete emergency contact information 6. Complete physician information 7. Information regarding the parent list 8. Health information 9. Additional information for all boxes checked yes 10. Emergency transportation information 11. Parent/guardians signature 12. Diapering Statement 13. Acknowledgement of Policies and Procedures 14. Enrollment form for at least one child was not updated by either the parent or the administrator 15. Enrollment form for at least one child was not signed by the administrator 16. Other [ ] Submit the program's corrective action plan to the Department to verify compliance with the requirements of this rule.

Resolution: Compliance Status: Approved