Section 260.1500 Notice of Violation and Plan of Correction

Section 260

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

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

plexity 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.