a. DADS determines if a facility meets DADS licensing rules, including physical plant and
facility operation requirements, by conducting inspections, surveys, investigations, and
on-site visits.
b. DADS lists violations of licensing rules on a report of contact. The report of contact
includes a specific reference to a licensing rule that has been violated.
c. At the conclusion of an inspection, survey, investigation, or on-site visit, a DADS
surveyor conducts an exit conference to advise the facility of the findings resulting from
the inspection, survey, investigation, or on-site visit.
d. At the exit conference, the surveyor provides a copy of the report of contact described in
subsection (b) of this section to the facility.
e. If, after the initial exit conference, a DADS surveyor cites an additional licensing rule
violation, the surveyor conducts another exit conference regarding the newly identified
violations, and updates the report of contact with a specific reference to the licensing rule
that has been violated.
f. DADS provides to the facility a written statement of violations from an inspection,
survey, investigation, or on-site visit on DADS Form 3724 within 10 days after the final
exit conference. The statement of violations includes a clear and concise summary in
nontechnical language of each licensing rule violation. The statement of violations does
not include names of residents or staff, statements that identify a resident, or other
prohibited information.
g. A facility must submit an acceptable plan of correction to the DADS regional director
within 10 days after receiving the statement of violations described in subsection (f) of
this section. An acceptable plan of correction must address:
1. how corrective action will be accomplished for a resident affected by a violation
of a licensing rule;
2. how the facility will identify other residents who may be affected by the violation
of the licensing rule;
3. how the corrective action the facility implements will ensure the violation does
not reoccur;
4. how the facility will monitor its corrective action to ensure the violation is being
corrected and will not reoccur; and
5. dates when corrective action will be completed.