Section 260.1500  Notice of Violation and Plan of Correction

a)         Upon determination that the licensee or applicant is in violation of the Act or this Part, the Department shall issue a written Notice of Violation and request a plan of correction.  The notice shall specify the violations, and shall instruct the licensee or applicant to submit a plan of correction to the Department within 10 days after receipt of the Notice.

b)         Within the ten-day period, a licensee or applicant may request additional time for submission of the plan of correction.  The Department may extend the period for submission of the plan of correction for an additional 30 days, when the Department finds that corrective action by a facility to abate or eliminate the violation will require substantial capital improvement.  The Department will consider the extent and complexity of necessary physical plant repairs and improvements and any impact on the health, safety, or welfare of the patients of the facility in determining whether to grant a requested extension.

c)         Each plan of correction shall be based on an assessment by the facility of the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures which have caused or contributed to the conditions or occurrences.  Evidence of such assessment and evaluation shall be maintained by the facility.  Each plan of correction shall include:

1)         A description of the specific corrective action the facility is taking, or plans to take, to abate, eliminate, or correct the violation cited in the Notice.

2)         A description of the steps that will be taken to avoid future occurrences of the same and similar violations.

3)         A specific date by which the corrective action will be completed.

d)         Submission of a plan of correction shall not be considered an admission by the facility that the violation has occurred.

e)         The Department shall review each plan of correction to ensure that it provides for the abatement, elimination, or correction of the violation.  The Department shall reject a submitted plan only if it finds any of the following deficiencies:

1)         The plan does not appear to address the conditions or occurrences that are the basis of the violation and an evaluation of the practices, policies, and procedures that have caused or contributed to the conditions or occurrences.

2)         The plan is not specific enough to indicate the actual actions the facility will be taking to abate, eliminate, or correct the violation.

3)         The plan does not provide for measures that will abate, eliminate, or correct the violation.

4)         The plan does not provide steps that will avoid future occurrences of the same and similar violations.

5)         The plan does not provide for timely completion of the corrective action, considering the seriousness of the violation, any possible harm to the patients, and the extent and complexity of the corrective action.

f)         The Department shall notify the licensee or applicant in writing of the acceptance or rejection of the plan of correction, including specific reasons for the rejection of the plan.  The facility shall have 10 days after receipt of notice of rejection in which to submit a modified plan that addresses the requirements of subsection (c) of this Section.

g)         If a licensee or applicant fails to make a timely submission of a modified plan of correction, or such modified plan is not acceptable to the Department, a plan of correction shall be specified and imposed by the Department.

h)         The Department shall verify the completion of the corrective action required by the plan of correction within the specified time period during subsequent investigations, surveys and evaluations of the facility.