Description: A licensee must do all of the following: review and, if necessary, revise the policies and procedures at least once each year

Corrective Actions Required: Ensure all policies are reviewed and if necessary, revised at least once each year.

Corrective Actions Taken By Licensee:

Actions Required By Licensing: Follow Up Inspection to be conducted.

To Be Corrected By: February 11, 2026

Observations: Licensing observed the facility policies and procedures. Three policies had not been reviewed within the last year.