Inspection IDReason for InspectionInspection DateInspection Status 
SIN-00228922 Unannounced Monitoring 08/02/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #1's Individual Support Plan (ISP) states that they are unable to manage money. There was no receipt for a purchase made by Individual #1 on 5/2/23 for "clothing items" for $82.36. If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Purchases made on this date (5/2/2023) were verified by leadership and 2 DSPs. The staff involved indicated that they left the receipt on the board located in the office and a second DSP confirmed noticing the receipt. 08/03/2023 Implemented
6400.52(b)(1)Staff #2 only had documentation of completed 1 hour of training in the 7/1/22-6/30/23 training year.The following shall complete 12 hours of training each year: Management, program, administrative and fiscal staff persons.At the time of inspection, Staff #2 had 6 hours of training after missing a few months due to illness. Staff #2 has completed an additional 8 hours of training for the current training year. 08/31/2023 Implemented
6400.52(c)(1)Staff #2 did not receive annual training on person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships during the 7/1/22-6/30/23 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The application of person-centered practices, community integration, individual choice and supporting individuals to develop and maintain relationships.Staff #2 received the above mentioned training on 7/27/2023. 08/02/2023 Implemented
6400.52(c)(2)Staff #2 did not receive annual training on the prevention, detection and reporting of abuse, suspected abuse and alleged abuse7/1/22-6/30/22 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: The prevention, detection and reporting of abuse, suspected abuse and alleged abuse in accordance with the Older Adults Protective Services Act (35 P.S. §§ 10225.101-10225.5102). The child protective services law (23 Pa. C.S. §§ 6301-6386) the Adult Protective Services Act (35 P.S. §§ 10210.101 - 10210.704) and applicable protective services regulations.Staff #2 received the above mentioned training on 4/12/2023. The information was not made available during the current inspection due to clerical error. 08/02/2023 Implemented
6400.52(c)(3)Staff #2 did not receive annual training on individual rights during the 7/1/22-6/30/23 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Individual rights.Leadership met with staff #2 for supervision about her trainings and training hours. 08/07/2023 Implemented
6400.52(c)(4)Staff #2 did not receive annual training on recognizing and reporting incidents during the 7/1/22-6/30/23 training year.The annual training hours specified in subsections (a) and (b) must encompass the following areas: Recognizing and reporting incidents.Staff #2 received the training mention above on 4/12/2023 but the documentation was not made available during this inspection. 08/02/2023 Implemented
6400.166(a)(2)Individual #1's August 2023 Medication Administration Record (MAR) did not include their prescriber.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.The provider added missing providers into MARs. 08/02/2023 Implemented
6400.181(f)Individual #1's annual assessment dated 9/6/22 there was no documentation that the assessment was provided to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The program specialist shall provide the assessment to the individual plan team members at least 30 calendar days prior to an individual plan meeting.The provider printed and added the notification document into the individual's file. 08/02/2023 Implemented
SIN-00223258 Unannounced Monitoring 04/20/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.64(a)Clean and sanitary conditions are not maintained in the home. The kitchen cabinets, specifical the cabinets above the stove and the cabinets to the left of the stove above the counter were covered in grease.Clean and sanitary conditions shall be maintained in the home. Provider cleaned the kitchen cabinets. 04/20/2023 Implemented
6400.144Health care services are not being planned for or arranged for Individual #3. Individual #3 was seen at the dermatologist on 10/19/22. Recommendations were to follow up in 3-6 months. There was no documentation that a follow up appointment occurred or has been scheduled. (Repeat Violation 5/12/22, 6/21/22, 7/25/22, 10/18/22, 11/12/22, 2/27/23)Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Provider had previously called the dermatologist who stated that a follow up was not needed as all individual #3's tests were normal. A yearly check was recommended and a date of 10/11/23 secured. 04/20/2023 Implemented
SIN-00221526 Unannounced Monitoring 03/21/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(13)The individual is prescribed straterra 25 mg to be taken daily at 8am. This medication appeared to be dispensed on the appropriate date, however the staff did not initial the Medication Administration Record on 3/19/23.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Staff on duty who administered the medication initialed the medication administration record. 03/21/2023 Implemented
SIN-00220085 Unannounced Monitoring 02/27/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)Surfaces are not free of hazards. The first drawer in the kitchen near the sink has a broken knob with a screw sticking out of the middle of it, potentially creating a hazard. Floors, walls, ceilings and other surfaces shall be free of hazards.Maintenance replaced drawer knob. 02/27/2023 Implemented
6400.166(a)(13)Individual #1 is prescribed Lithium Carb ER 40, take 1 tablet by mouth every 12 hours 8a-8p. The Medication Administration Record did not include the initials of the person administering the medication at 8a on 2/27/23.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name and initials of the person administering the medication.Staff who administered medication still on duty and signed/initialed for the medication. 02/27/2023 Implemented
SIN-00218417 Unannounced Monitoring 01/31/2023 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(b)At the time of inspection, there was a tennis-ball-sized collection of lint in the dryer lint trap. The collection of lint in the dryer lint trap creates an increased risk of fire within the home. Floors, walls, ceilings and other surfaces shall be free of hazards.Provider immediately removed lint from dryer. 01/31/2023 Implemented
SIN-00215006 Unannounced Monitoring 11/14/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.104Notification to the local fire department is not current. The notification to the fire department is dated 5/21 and indicated that there is a gentleman residing in the home. The notification is not current and does not contain accurate information.The home shall notify the local fire department in writing of the address of the home and the exact location of the bedrooms of individuals who need assistance evacuating in the event of an actual fire. The notification shall be kept current. The notification to the fire department was updated and sent to the fire department. 11/15/2022 Implemented
6400.141(c)(14)Individual #3's annual physical exam dated 10/14/22 did not include medical information pertinent to the diagnosis and treatment in case of an emergency.The physical examination shall include: Medical information pertinent to diagnosis and treatment in case of an emergency. Individual #3's annual physical form was returned to the PCP for review and completion of the needed sections. 11/15/2022 Implemented
6400.144Health services including dental services are not being arranged for Individual #1. Individual #1 was referred to an oral surgeon from the individual's dentist on 8/3/22 to have a tooth extracted. This appointment has not been planned for or scheduled.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 was hospitalized from 9/24-10/05 and was unable to see a dentist. An appointment has been scheduled for 12/23/2022. 11/18/2022 Implemented
6400.166(a)(2)Individual #3's medication record does not include the name of the prescriber. There is a physician's name, documented on the Medication Record, however this is not the name of the physician that is the prescriber.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Name of the prescriber.Prescriber names have been added to the MAR. 11/30/2022 Implemented
SIN-00213665 Unannounced Monitoring 10/18/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(a)(11)Individual #1 is prescribed Protonix 40mg tablet to be taken at 8am. The medication does not have a diagnosis or purpose for the medication on the medication administration record.A medication record shall be kept, including the following for each individual for whom a prescription medication is administered: Diagnosis or purpose for the medication, including pro re nata.Provider entered the diagnosis on the MAR per the after visit summary from prescribing doctor. 10/18/2022 Implemented
SIN-00210746 Unannounced Monitoring 08/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.22(e)(3)Individual #'s financial record indicated a purchase for $56 on 8/1/22. There is no receipt of this purchase maintained. (Repeat Violation: 7/25/22) If the home assumes the responsibility of maintaining an individual's financial resources, the following shall be maintained for each individual: Documentation, by actual receipt or expense record, of each single purchase exceeding $15 made on behalf of the individual carried out by or in conjunction with a staff person. Individual #3's ledger was corrected to reflect the correct transaction. 08/25/2022 Implemented
6400.64(a)Clean and sanitary conditions are not being maintained in the home. The vent in Individual #3's bathroom was not clean and sanitary. There was a significant layer of dust covering the vent in the bathroom. (Repeat Violation: 5/12/22, 6/21/22 and 7/25/22)Clean and sanitary conditions shall be maintained in the home. Provider cleaned the vent in the bathroom. 08/25/2022 Implemented
6400.213(1)(i)Individual #3's record that is maintained in the home does not contain a current, dated photograph. The most recent picture was dated 6/11/2020. (Repeat Violation 7/25/22)Each individual's record must include the following information: Personal information, including: (i) The name, sex, admission date, birthdate and Social Security number.Provider printed current photographs and placed them in the books. 08/25/2022 Implemented
SIN-00209278 Unannounced Monitoring 07/25/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.166(b)Individual #5 was prescribed Acetaminophen 500mg Take one tablet by mouth every 6 hours as needed for pain up to 14 days on 7/20/22 upon discharge from the hospital. This medication had been administered on one time on 7/20, 7/21, 7/23 and 7/25: twice on 7/22 and 7/25. The medication was not listed on the Medication Administration Record and was documented as administered under a different prescription for Acetaminophen. The time the medication was administered was not documented for any of the administrations of the medication. (Repeat Violation 5/1/22, 2/12/22, 4/8/22, 1/25/22)The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.The pharmacy was contacted for blank MARs and the correct entry was made until the end of the prescribed period. 08/16/2022 Implemented
SIN-00208706 Unannounced Monitoring 06/21/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.77(b)There were no scissors in the first aid kit. A first aid kit shall contain antiseptic, an assortment of adhesive bandages, sterile gauze pads, a thermometer, tweezers, tape, scissors and syrup of Ipecac, if an individual 4 years of age or younger, or an individual likely to ingest poisons, is served. A pair of scissors was purchased and placed in the first aid kit. 08/16/2022 Implemented
6400.163(h)Individual #1 was prescribed the medication mupiricin 2% ointment to be applied 2 times per day. The medication expired 5/25/2022 but was still with the individual's current medications and was not disposed of properly.Prescription medications that are discontinued or expired shall be destroyed in a safe manner according to Federal and State statutes and regulations.The expired mupricin 2% was removed from the house and disposed of as per established protocols. 08/16/2022 Implemented
SIN-00205240 Unannounced Monitoring 05/12/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)The doorknob on Individual #6's bedroom door is falling off. (Repeat Violation 1/25/22 and 3/11/22)Floors, walls, ceilings and other surfaces shall be in good repair. The doorknob was secured. 08/16/2022 Implemented
6400.212(a)Individual #6 did not have an individual record maintained in the home. There were various documents in multiple binders in the home, none of the binders included personal information, a current, dated photograph, incidents reports relating to the individual, vision or hearing examinations, dental examinations, individual plan, individual physical examination or psychological examinations. A separate record shall be kept for each individual. Individual #6's binders were consolidated and all the required documentations are present. 08/16/2022 Implemented
6400.165(c)Individual #6 is prescribed Clonidine HCL 0.1mg, take 1 tablet by mouth daily at 8PM. Medications are in blister packs and dated with the date that they are administer on the blister pack. The pill that should have been administered on 4/30/22 remained in the blister pack. The Medication Administration Record for April was not available in the home to review and was not provided when requested. The medication was not administered as prescribed. (Repeat violation 4/8/22 and 1/25/22)A prescription medication shall be administered as prescribed.Staff involved was addressed and medication administration process was reviewed. The medical provider was informed but no action was advised because it was too late at that time. 08/16/2022 Implemented
6400.165(g)Individual #6 is prescribed psychotropic medications for psychiatric illness. Individual #6 had a review of psychotropic medications on 3/21/22 and 5/9/22. The medication reviews did not include the individual's diagnosis, the need to continue the medications or the reason the medications are prescribed. (Repeat Violation 4/8/22 and 1/25/22)If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #6 has received medication reviews since this inspection visit. 08/16/2022 Not Implemented
6400.166(b)Individual #6 is prescribed Loperamide 2mg cap, take 1 capsule by mouth 4 times daily as needed for diarrhea. This medication was administered on 5/2, 5/4, 5/6, 5/7, 5/9, 5/11 and 5/12/22. There was no time documented on the Medication Record when this medication was administered or how often on each day it was administered. (Repeat 1/25/22 and 4/8/22)The information in subsection (a)(12) and (13) shall be recorded in the medication record at the time the medication is administered.Staff was retrained on proper documentation and a print out provided with images on the process of documenting PRN administration. 08/16/2022 Implemented
SIN-00203928 Unannounced Monitoring 04/08/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.165(c)At time of monitoring on 4/8/22 at approximately 11:30am there were four blister packs of Ativan 0.5mg in use for Individual #2. Three blister packs were labeled as Ativan 0.5mg take 1 tablet by mouth three times daily @ 8am-Noon and 5pm. The 8am, noon and 5pm doses were filled on 3/24/22. The fourth blister pack with the 8pm dose sticker on it was filled on 12/16/21. This blister pack was labeled as "Ativan 0.5mg take 1 tablet by mouth 3 x daily @ 8am, 2pm and 8pm." The MAR shows that Lorazepam 1mg tablet should be taken nightly at 8PM. There was no Lorazepam 1mg tables available in the home. Staff #1 stated that staff administer 1 tablet; however, when it was pointed out that the order requires a 1mg tablet that was not in the home, Staff #1 stated that two 0.5mg are administered. This medication is not being administered as prescribed. At time of monitoring on 4/8/2022 one blister pack of Clonidine HCL marked PM was in use in the home. Label on the blister pack indicated that "Clonidine HCL 0.1mg 1 tablet by mouth 2 x daily" was to be administered to Individual #2. April 2022 MAR for Individual #2 had a pharmacy generated entry for Clonidine HCL 0.1mg tablet take 1 tablet by mouth daily at bedtime @ 8pm. The "PM" was overwritten with "AM." The pharmacy generated "PM" in the time slot was written over with "AM" and each administration was documented as being given at 8AM. There was no AM blister pack in the home. Only one dose of Clonidine is being administered daily. "Lithium Carbonate 300mg Take 1 capsule by mouth 3 times daily @ 8am-2pm-8pm" was not administered to Individual #2 on 4/6/22 at 2pm or 8pm, 4/7/22 at 8am, 2pm or 8pm and 4/8/22 at 8am. Repeat violation 1/25/22A prescription medication shall be administered as prescribed.Provider went to the psychiatrist's office to verify the order for Ativan 1mg to be administered at 8pm daily. New scripts issued. Provider verified with the pharmacy and medical provider on the correct time to administer Clonodine 0.1. Pharmacy issued new labels. PCP DC'd Lithium 300mg on 4/6/22. Psychiatrist re-prescribed Lithium 300mg on 4/8/22. 04/11/2022 Implemented
6400.165(e)On 3/28/2022 notice was provided to JuLi from Newhard Pharmacy that "Medication discontinued by Dr. Velas please return Carbamazepine 200mg and Divalproex DR 500mg." March 2022 Medication Administration Record for Individual #2 indicates that the Divalproex continued to be given on 3/29, 3/30 and 3/31 as administrations are initialed as administered on the MAR. March 2022 MAR for Individual #2 indicates that the Carbamazepine continued to be given on 3/29, 3/30 and 3/31 as administrations are initialed as administered on the MAR. The April 2022 MAR for Individual #2 had a handwritten entry for "Carbamazepine 200mg 1 tab by mouth twice daily at 8am & 8pm." Date and time slots on the MAR are initialed as being administered on 4/1, 4/2 am, 4/5, 4/6, 4/7 and 4/8am. An "H" was appropriately placed in time and date slots on 4/2, 4/3 and 4/4 to indicate hospitalization. The April 2022 MAR for Individual #2 was updated after administration of the AM dose on 4/8/22 to indicate that the medication had been discontinued. The MAR was not updated immediately when the discontinue order was received. Changes to the medications of Individual #2 were not made upon receipt of written notice of the change. The individual's medication record shall be updated as soon as a written notice of the change is received.Changes in medication may only be made in writing by the prescriber or, in the case of an emergency, an alternate prescriber, except for circumstances in which oral orders may be accepted by a health care professional who is licensed, certified or registered by the Department of State to accept oral orders. The individual's medication record shall be updated as soon as a written notice of the change is received.Carbamazepine 200mg and Divalproex DR 500mg were discontinued. Discontinue documentation arrived at the home with the new cycle medications at the beginning of the month. Staff erroneously reentered the carbamazepine into the MAR. The doctor was informed of the error. 04/08/2022 Implemented
6400.165(g)Documentation of medication reviews for Individual #2 were requested and not provided. There was no documentation to support that medication review by a licensed physician at least every 3 months that includes documentation of the reason for prescribing the medication, the need to continue the medication and the necessary dosage was completed as required. Repeat violation 1/25-26/22If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Provider dropped off psychotropic med review form to the psychiatrist's office on 3/25/22, Med review form was ready for pick up on 4/12/22. 04/12/2022 Implemented
6400.167(b)"Lithium Carbonate 300mg Take 1 capsule by mouth 3 times daily @ 8am-2pm-8pm" was not administered to Individual #2 on 4/6/22 at 2pm or 8pm, 4/7/22 at 8am, 2pm or 8pm and 4/8/22 at 8am. No documentation of the mediation errors, follow-up action taken and the prescriber's response, if applicable, was located in the individual's file. Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.Documentation of medication errors, follow-up action taken and the prescriber's response, if applicable, shall be kept in the individual's record.During the review period, the medication was discontinued by the PCP 4/6/22 and was re-prescribed by the psychiatrist on 4/8/22. 04/11/2022 Implemented
SIN-00202014 Unannounced Monitoring 03/11/2022 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.67(a)In the kitchen, the pull out drawer next to the stove was missing the front cover piece leaving just the piece of particle board exposing the sharp ends of 5 screws and approximately 5 nails.Floors, walls, ceilings and other surfaces shall be in good repair. The drawer was fixed on the same day. 03/11/2022 Implemented
SIN-00199346 Unannounced Monitoring 01/25/2022 Non Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.141(a)Individual #1's annual physical examination was late. Individual #1's most recent physical examination was completed on 9/29/2021; the previous physical examination was completed on 2/27/2020.An individual shall have a physical examination within 12 months prior to admission and annually thereafter. Individual #1's annual appointments will be scheduled and followed up upon at least 30 days before the one year anniversary of the last date. 01/31/2022 Implemented
6400.144Individual #1 received a referral for physical therapy on 12/23/2021 but was not scheduled. Individual #1 is prescribed Guafenesine 100mg/5ml, take 2 teaspoons (10ml) by mouth 3 times daily as needed for cough. The medication was not available in the home.Health services, such as medical, nursing, pharmaceutical, dental, dietary and psychological services that are planned or prescribed for the individual shall be arranged for or provided. Individual #1 attended her initial appointment on 1/28/2022 and has had multiple follow-up appointments thereafter. 01/31/2022 Not Implemented
6400.163(a)Individual #1 is prescribed Estarylla .25-0.035mg., take 1 tablet by mouth daily. This medication was not maintained in its original labeled container.Prescription and nonprescription medications shall be kept in their original labeled containers. Prescription medications shall be labeled with a label issued by a pharmacy.The provider obtained a new box for Estarylla from the pharmacy. 01/31/2022 Implemented
6400.165(c)Individual #1 was prescribed Lorazepam 0.5mg. tablet, take 1 tablet by mouth 3 times daily at 8am, 2pm and 8pm. This medication was changed on 1/24/2022 to Lorazepem 0.5mg tablet, take 1 tablet by mouth 3 times daily at 8am, 2pm and 5pm; and 1mg tablet by mouth once daily at 8pm. The new medication was received in the home 1/24/22 at 4pm; but the Medication Administration Record (MAR) was not updated to reflect the medication dosage change and the individual was still being administered medication based on the old prescription.A prescription medication shall be administered as prescribed.Individual #1 is receiving the medication as per the new order. ((Juli Community Services will contact the physician to notify them of the medication errors and to see if there are any new orders/recommendations. -CH 3/8/2022)) 01/31/2022 Not Implemented
6400.165(g)Individual #1 is prescribed medications to treat the symptoms of a psychiatric illness. The individual has been receiving psychiatric medication reviews every three months by a licensed psychiatrist. The medication reviews do not include documentation of the reason for prescribing the medication, the need to continue the medication, or the necessary dosage.If a medication is prescribed to treat symptoms of a psychiatric illness, there shall be a review by a licensed physician at least every 3 months that includes to document the reason for prescribing the medication, the need to continue the medication and the necessary dosage.Individual #1 will have quarterly medication review completed and documented during the next scheduled appointment. ((Juli Community Services will contact the physician to notify them of the medication errors and to see if there are any new orders/recommendations. -CH 3/8/2022)) 01/31/2022 Implemented
SIN-00184439 Renewal 02/10/2021 Compliant - Finalized
RegulationLIS Non-Compliance AreaCorrection RequiredPlans of CorrectionCorrection DatePOC Status
6400.81(k)(4)Individual #1 did not have a chest of drawers in her room.In bedrooms, each individual shall have the following: A chest of drawers. Chest of drawers brought in from storage. 05/03/2021 Implemented
6400.32(r)(5)Individual #1 bedroom had a lock which was a pin lock. Staff did not have the pin or key accessible to be able to open the door if it was to be locked.Direct service workers who provide services to the individual shall have the key or entry device to lock and unlock the door.Purchased pin locks for individual #1's bedroom. 05/03/2021 Implemented
SIN-00225939 Unannounced Monitoring 06/07/2023 Compliant - Finalized
SIN-00216602 Unannounced Monitoring 12/22/2022 Compliant - Finalized