LYNN'S HERITAGE HOUSE, INC.

PRINTED: 03/4 2/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED 8. WING 21055C 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 KELLY LANE LYNN'S HERITAGE HOUSE, INC LOUISIANA, MO 63353 PROVIDER'S PLAN OF CORRECTION (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY} SUMMARY STATEMENT OF DEFICIENCIES {EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) (X4) [ID PREFIX TAG (X5) COMPLETE DATE A4781) 19 CSR 30-86.047(40) Self-Control of Medication | A4781 Requirements Self-contro] of prescription medication by a resident may be allowed only if approved in writing by the resident‘ s physician and included in the resident ' s individualized service plan. A resident may be permitted to control the storage and use of nonprescription medication unless there is a physician ‘ s written order or facility policy to the contrary. Written approval for self-control of prescription medication shall be rewritten as needed but at least annually and after any period of hospitalization. II/il This regulation is not met as evidenced by: Class li* Based on observation, interview and record review, the facility failed to provide a safe and effective medication system for a resident, when residents were allowed to self-administer medications without an order. The residents’ medications were not verified by a nurse, physician or pharmacist for three of six sampled residents (Resident #1, #2, and #3). The census was 25. The facility had no policy to share following request. 4. Record Review of Resident #1's face sheet showed the following: - Resident was admitted to the facility on 2/6/23; - Resident's diagnoses included hypothyroidism (hormonal imbalance), congestive heart failure (heart disease), hyperlipidemia (high blood cholesterol), allergic rhinitis (inflammation of the nose), and cerebral vascular accident (stroke). | Review of the resident's Physician Order Sheets Missouri Department of Health and Senlor Services LABORATORY DIRECTOR'S OR PROVIDER/SUPPLIER REPRES! QYATURE f . TITLE (46) DATE SI . {fh HAY) l STATE FORM ~ Td8i4 if contingation' sheet ‘fof 10 PRINTED: 03/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 21055C B. WING 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 KELLY LANE LOUISIANA, MO 63353 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION {X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL i (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG - REGULATORY OR LSC IDENTIFYING INFORMATION} i ' CROSS-REFERENCED TO THE APPROPRIATE DATE | i DEFICIENCY) } LYNN'S HERITAGE HOUSE, INC Continued From page 1 (POS) dated February, 2023 showed the following orders: - Atorvastatin (medication to treat high blood cholesterol), 20 milligrams (mg), every evening; ~ Chlordiazepoxide (medication to treat anxiety), 10 mg, twice daily; - Clopidogrel (medication to treat blood clotting disorders), 75 mg, daily; - Dicyclomine (medication to treat digestive disorders), 20 mg, daily; - Ketoconazole (anti-fungal cream), 2%, administered topically twice a day; - Lantanoprost (liquid drops to treat glaucoma), 0.005%, 1 drop in each eye daily; ~ Levothyroxine (medication to treat hormonal disorder), 75 micrograms (mcg), daily; - Nystatin (anti-fungal cream), administered topically twice a day; - Oxybutinin (medication to treat bladder spasms), 5 mg, twice a day; - Trelegy (medication to treat breathing disorder), 100-62.5 mcg, one puff daily; - Acetaminophen (medication to treat pain), 500 mg, three times a day as needed; - Chlorpheniramine (medication to treat allergies), 4 mg, four times a day as needed; - Gas relief tablets (medication to treat digestive disorders), 125 mg, three times a day as needed; - Zofran (medication to treat nausea), 4 mg, every 8 hours as needed; - Ventolin (inhaled medication to treat breathing disorder), 90 mcg, four times a day as needed. Review of the resident's POS showed no orders for the resident to keep the medication at bedside and self-administer any prescription or over-the-counter medication. Observation of a table in Resident #1's room on 2/28/24 at 11:37 A.M. showed the following: Missouri Department of Health and Senior Services STATE FORM 6899 TJ8l14 If continuation sheet 2 of 10 PRINTED: 03/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION {X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 21055C B.WING 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 KELLY LANE LOUISIANA, MO 63353 (X4} ID SUMMARY STATEMENT OF DEFICIENCIES \ PROVIDER'S PLAN OF CORRECTION PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL {EACH CORRECTIVE ACTION SHOULD BE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) CROSS-REFERENCED TO THE APPROPRIATE | ' DEFICIENCY) LYNN'S HERITAGE HOUSE, INC Continued From page 2 - Abottle bearing prescription label with resident's name and medication name clotrimazole (liquid antifungal medication), 3% solution, with instructions to apply topically twice a day; - Abottie of Univera (over-the-counter mineral supplement) with instructions to take 15 milliliters (ml) twice a day; - A Trelegy inhaler without a prescription label and not labeled with the resident's name. During interview on 2/28/24 at 11:37 A.M., the resident said staff was aware that he/she had the | prescription and non-prescription medications in | his/her room and self-administered them. | 2. Record review of Resident #2's face sheet showed the following: ~ Resident admitted to the facility on 12/4/23; - Resident's diagnoses included diabetes mellitus (blood sugar disorder), hypertension (high blood | pressure), and Parkinson's disease (degenerative | disorder effecting muscle movements). ; Record review of the resident's POS dated February, 2023 showed the following orders: - Alprazolam (medication to treat anxiety), 0.5 mg, every evening; - Amiodarone (medication to treat irregular heart beats), 200 mg, daily; - Atorvastatin, 10 mg, every evening; - Sinemet (medication to treat Parkinson's disease), 25-100 mg, three times a day; - Cetirizine (medication to treat allergy), 10 mg, daily; - Clopidogrel, 75 mg, daily; - Diltiazem (medication to treat high blood pressure), 240 mg, daily; - Duloxetine (medication to treat depression), 60 mg, twice a day; - Furosamide (medication to treat swelling), 20 Missouri Department of Health and Senior Services STATE FORM 6899 T38111 if continuation sheet 3 of 10 PRINTED: 03/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X41) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED B. WING 21055C 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 KELLY LANE LYNN’S HERITAGE HOUSE, INC LOUISIANA, MO 63353 (x4) ID SUMMARY STATEMENT OF DEFICIENCIES | ) PROVIDER'S PLAN OF CORRECTION (x5) PREEIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL | PREFIX (EACH CORRECTIVE ACTION SHOULD BE i COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG CROSS-REFERENCED TO THEAPPROPRIATE | DATE DEFICIENCY) | Continued From page 3 mg, daily; - Lansoprazole (medication to treat digestive | disorder), 30 mg, daily; - Levothyroxine (medication to treat hormonal disorder), 75 mcg, daily; - Multi-vitamin, daily; - Paroxetine (medication to treat depression), 10 mg, daily: - Proglitazone (medication to treat blood sugar disorder), 15 mg, daily - Miralax (medication to treat digestive disorder), 17 grams (gm), daily; i - Preservision 2 (vitamin to treat eye disorders), | daily; - Spironolactone (medication to treat swelling), 25 mg, daily; - Restasis (liquid medication to treat eye disorders), one drop in each eye, twice a day, - Acetaminophen, 325 mg, two tablets every 4 i hours as needed; - Albuterol (inhaled medication to treat breath I disorder), 90 mcg, 2 puffs every 6 hours as needed; - Alprazolam, 0.5 mg, one-half tablet daily as needed; ~- Cyclobenzapine (medication to treat muscle discomfort), 10 mg, three times a day as needed; - Meclizine (medication to treat nausea), 12.5 mg, | three times a day as needed; - Zofran, 8 mg, every 6 hours as needed; and - Tramadol (medication to treat pain), 50 mg, | every 6 hours as needed. Review of the resident's POS showed no orders for the resident to keep at bedside and self-administer any prescription or over-the-counter medication. Observation of a table in Resident #2's room on 2/28/24 at 4:35 P.M., showed a bottle of Missouri Department of Health and Senior Services STATE FORM 6899 Tushit if continuation sheet 4 of 10 PRINTED: 03/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 21055C B. WING 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 KELLY LANE LOUISIANA, MO 63353 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES PROVIDER'S PLAN OF CORRECTION (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) i : CROSS-REFERENCED TO THE APPROPRIATE j DATE i DEFICIENCY) LYNN'S HERITAGE HOUSE, INC Continued From page 4 oxymetazoline (over-the-counter nasal spray | medication to treat congestion), 0.05% pump mist. with instructions to administer every 10-12 hours as needed but no more than twice in 24 hours. During interview on 2/28/24 at 4:35 P.M., the resident said he/she did not think of the nasal spray as a medication. 3. Record review of Resident #3's face sheet showed the following: - Resident was admitted on 10/9/23; - Diagnoses included chronic allergic rhinitis, hypertension, anxiety (mental illness characterized by persistent fears), and deficiencies of vitamins B12 and D. Review of the resident's POS dated February, 2023 showed the following orders: - Alprazolam, 0.25 mg, every evening; - Vitamin B12, 1000 mcg, intramuscular injection once a month; - Loratadine (medication to treat allergies), 10 mg, one half to one full tablet, daily; - Losartan (medication to treat high biood pressure}, 25 mg, twice a day; - Vitamin D3, 1000 international units (iu), daily; - Acetaminophen, 325 mg, two tablets every 4 hours as needed; - Alprazolam, 0.25 mg, daily as needed; - Gas Relief medication, four times a day as needed; - Milk of Magnesia (medication to treat digestive disorder), 30 ml, daily. Review of the resident's POS showed no orders for resident to keep at bedside and self-administer any prescription or over-the-counter medication. Missouri Department of Health and Senior Services STATE FORM 6899 TJ8141 if continuation sheet 5 of 10 PRINTED: 03/12/2024 FORM APPROVED STATEMENT OF DEFICIENCIES (X11) PROVIDER/SUPPLIER/CLIA {X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 21055C B. WING 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 KELLY LANE LOUISIANA, MO 63353 LYNN'S HERITAGE HOUSE, iNC (X4) ID SUMMARY STATEMENT OF DEFICIENCIES \ ] PROVIDER'S PLAN OF CORRECTION i (X5} PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL ; (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) T CROSS-REFERENCED TO THE APPROPRIATE | DATE 1 DEFICIENCY) i Continued From page 5 Observation of a table in the resident's room on 2/28/24 at 4:45 P.M. showed the following: - A bottle of over-the-counter eye drops labeled Eye Drop Relief with instructions to place one drop in each affected eye up to four times per day; - Can of saline sinus spray (over-the-counter spray to treat nasal congestion and allergies) with instructions to spray into each affected nostril as often as needed. During interview on 2/28/24 at 4:45 P.M., the resident said he/she had gotten the over-the-counter medications from a local store. 4. During interview on 2/28/24 at 5:10 P.M., the administrator and Director of Nursing said the following: - They were not aware that the residents had over-the-counter and/or prescription medications | in their rooms; - It was their expectation that residents and care staff would report the presence of over-the-counter or prescription medications in resident rooms so that a self-administration physician's order could be promptly secured if appropriate or the medication relocated to the medication cart. *The higher classification merited due to the extent of the violation. 19 CSR 30-86.047(58)(B) Resident Condition/Medication Review The facility shall maintain a record in the facility for each resident, which shail include the following: (B) Areview monthly or more frequently, if Missouri Department of Health and Senior Services STATE FORM 6899 TJSI44 If continuation sheet 6 of 10 PRINTED: 03/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A, BUILDING: (X3) DATE SURVEY COMPLETED B. WING 21055C 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 KELLY LANE LOUISIANA, MO 63353 SUMMARY STATEMENT OF DEFICIENCIES i 3) PROVIDER'S PLAN OF CORRECTION (X5) (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE REGULATORY OR LSC IDENTIFYING INFORMATION) TAG i CROSS-REFERENCED TO THE APPROPRIATE DATE j DEFICIENCY) LYNN'S HERITAGE HOUSE, INC (X4) ID PREFIX TAG A4837 | Continued From page 6 | A4837 indicated, of the resident 's general condition and needs; a monthly review of medication consumption of any resident controlling his or her own medication, noting if prescription medications are being used in appropriate quantities; a daily record of administration of medication; a logging of the medication regimen | review process; a monthly weight; a record of each referral of a resident for services from an outside service; and a record of any resident incidents including behaviors that present a reasonable likelihood of serious harm to himself or herself or others and accidents that potentially could result in injury or did result in injuries invoiving the resident; fl This regulation is not met as evidenced by: Class III Based on record review and interview, the facility ; failed to ensure that a monthly weight and resident condition review was recorded for six residents (Residents #1, #2, #3, #4, #5 and #6) of six sampled residents. The facility census was 25. 1. Record review of Resident #1's face sheet showed the following: - Resident was admitted on 2/6/23; - Diagnoses included hypothyroidism (hormonal disorder), congestive heart failure (heart disease), | hyperlipidemia (high blood cholesterol), allergic thinitis (nose disorder caused by a reaction to allergies in the environment), and cerebral vascular accident (stroke). Review of Resident #1's records showed no monthly summary from admission to date of Missouri Department of Health and Senior Services STATE FORM 6699 TJ8111 if continuation sheet 7 of 10 PRINTED: 03/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (Xt) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: (X2) MULTIPLE CONSTRUCTION A. BUILDING: (X3) DATE SURVEY COMPLETED B. WING 21055C 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 KELLY LANE LOUISIANA, MO 63353 (X4} ID SUMMARY STATEMENT OF DEFICIENCIES i ID PROVIDER'S PLAN OF CORRECTION ' (X5) PREFIX (EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX (EACH CORRECTIVE ACTION SHOULD BE | COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE | DATE i DEFICIENCY) | LYNN'S HERITAGE HOUSE, INC Continued From page 7 inspection (12 months). 2. Record review of Resident #2's face sheet showed the following: - Resident was admitted on 12/11/23; i - Diagnoses included diabetes mellitus (blood sugar disorder), hypertension (high blood pressure), and Parkinson's (a progressive disease characterized by tremors and muscle weakening). Review of Resident #2's record showed no monthly summary from admission to the date of inspection. (13 months) 3. Record review of Resident #3's face sheet showed the following: - Resident was admitted on 10/9/23; - Diagnoses included allergic rhinitis, , hypertension, anxiety (mental illness i characterized by persistent fears), and deficiencies of vitamins D and B12. Review of Resident #3's record showed no monthly summary from admission to the date of | inspection. (15 months) 4. Record review of Resident #4's face sheet showed the following: - Resident was admitted on 10/14/21; | - Diagnoses included benign prostatic hyperplasia | (disorder of the male urinary tract system), hyperkalemia (high potassium level), diabetes i mellitus, coronary artery disease (heart disease), hypertension, cerebral vascular accident, dementia (memory disorder), hypercholesterolemia (high blood cholesterol), chronic back pain, and history of a pituitary mass | (brain tumor impacting hormone levels). Missouri Department of Health and Senior Services STATE FORM 6899 Td8i4 (f continuation sheet 8 of 10 Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA AND PLAN OF CORRECTION IDENTIFICATION NUMBER: NAME OF PROVIDER OR SUPPLIER 21055C PRINTED: 03/12/2024 FORM APPROVED (X2) MULTIPLE CONSTRUCTION (X3) DATE SURVEY A. BUILDING: B. WING STREET ADDRESS, CITY, STATE, ZiP CODE 800 KELLY LANE LYNN'S HERITAGE HOUSE, INC (X4) ID PREFIX TAG LOUISIANA, MO 63353 SUMMARY STATEMENT OF DEFICIENCIES (EACH DEFICIENCY MUST BE PRECEDED BY FULL REGULATORY OR LSC IDENTIFYING INFORMATION) | Continued From page 8 Review of Resident #4's record showed no monthly summary from admission to the date of inspection. (15 months) 5. Record review of Resident #5's face sheet showed the following: i - Resident was admitted on 1/28/22; - Diagnoses included gastroesophageal reflux disease (digestive disorder), renal insufficiency (kidney disease), dementia, hypertension, osteo-arthritis (boone and joint disease), osteoporosis (bone density disorder), rheumatoid arthritis (bone and joint disease), glaucoma (eye disease), macular degeneration (eye disease), hyperlipidemia, depression (mental illness characterized by persistent sadness), and history of trans-ischemic attack (brief blockage of blood | flow to the brain). Review of Resident #5's record showed no monthly summary from admission to the date of inspection. (over two years) 6. Record review of Resident #6's face sheet showed the following: - Resident was readmitted to the facility on 2/14/22; - Diagnoses included dementia, Alzheimer's disease (memory disorder), atrial fibrillation (erratic heart rhythm), hyperlipidemia, essential tremors (nervous system disorder which causes involuntary shaking), hallucinations (false perceptions of reality), hypertension, and the presence of a pacemaker (implanted medical device to regulate heart rhythm). Review of Resident #6's record showed no monthly summary from readmission to the date of inspection. (two years) Missouri Department of Health and Senior Services STATE FORM ID PREFIX 6899 COMPLETED 02/28/2024 PROVIDER'S PLAN OF CORRECTION (x8) (EACH CORRECTIVE ACTION SHOULD BE COMPLETE CROSS-REFERENCED TO THE APPROPRIATE DATE DEFICIENCY) TJ8111 if continuation sheet 9 of 10 PRINTED: 03/12/2024 FORM APPROVED Missouri Department of Health and Senior Services STATEMENT OF DEFICIENCIES (X1) PROVIDER/SUPPLIER/CLIA (X2}) MULTIPLE CONSTRUCTION (X3} DATE SURVEY AND PLAN OF CORRECTION IDENTIFICATION NUMBER: A. BUILDING: COMPLETED 21055C B. WING 02/28/2024 NAME OF PROVIDER OR SUPPLIER STREET ADDRESS, CITY, STATE, ZIP CODE 800 KELLY LANE LOUISIANA, MO 63353 (X4) ID SUMMARY STATEMENT OF DEFICIENCIES ID | PROVIDER'S PLAN OF CORRECTION {X5) PREFIX {EACH DEFICIENCY MUST BE PRECEDED BY FULL PREFIX | (EACH CORRECTIVE ACTION SHOULD BE COMPLETE TAG REGULATORY OR LSC IDENTIFYING INFORMATION) TAG | CROSS-REFERENCED TO THE APPROPRIATE | DATE i | DEFICIENCY) : LYNN'S HERITAGE HOUSE, INC Continued From page 9 7. During interview on 2/28/24 at 5:10 P.M., the Director of Nursing said the she had not been completing monthly summaries and was not aware of a facility policy requiring monthly summaries to be completed by nursing staff. During interview on 2/28/24 at 5:10 P.M., the administrator said it was her expectation that monthly summaries including residents’ monthly weights and condition review be completed by nursing staff monthly in accordance with the regulation. Missouri Department of Health and Senior Services STATE FORM 6899 yJai11 If continuation sheet 10 of 10 PLAN OF CORRECTION Provider/Supplier Name: Lynn's Heritage House, Inc Street Address, City, Zip: 800 Kelly Lane Louisiana, MO 63353 Date of Survey: 2/28/2024 PROVIDER/SUPPLIER/CLIA IDENTIFICATION NUMBER PROVIDER'S PLAN OF CORRECTION: (EACH CORRECTIVE ACTION SHOULD BE CROSS-REFERENCED TO THE APPROPRIATE DEFICIENCY) The Administrator notified residents and families on 3/1/2024 of deficiency. Residents and family were educated on may keep at bedside orders and that residents should not purchase OTC medications while out of facility. Weekly room inspections began on 3/1/2024 by DON. DON will continue to monitor and inspect medications in resident’s rooms and obtain MKABS orders as needed. In-service was given to all staff by DON on 3/8/24 regarding reporting medication found in resident's rooms. COMPLETION DATE A4781 A4837 3/1/2024 3/1/2024 DON began monthly summaries on all residents. This will be done on an ongoing monthly basis by DON. Administrator will do chart reviews quarterly to ensure summaries are being completed. 3/1/2024 The Administrator signing and dating the first page of the CMS-2567/State Form is indicating their approval of the plan of correction being submitted on this form.