7.8.2.12                 CORRECTIVE ACTION:  If violations of this rule are cited, the facility will be provided with an official statement of deficiencies within ten (10) business days following the survey.

  1.             Informal dispute review (IDR).  The facility may request an informal review of survey deficiencies by providing a written request to the licensing authority within ten (10) calendar days of receipt of the written survey findings.  With the request, the facility shall include information or evidence that justifies the disagreement with a cited deficiency.

                                (1)           The licensing authority will review the submitted information and make a determination.

                                (2)           If the deficiency is removed, a new statement of deficiencies will be issued to the facility.

                                (3)           The facility shall provide a new plan of correction for all remaining deficiencies upon receipt of the new statement of deficiencies.

                                (4)           A copy of the “IDR operating rules” is available upon request.

  1.             Plan of correction (POC).  The facility shall submit a plan of correction within ten (10) calendar days of receipt of the statement of deficiencies and after receipt of a revised statement of deficiencies, when the findings are changed pursuant to an IDR.

                                (1)           If the first plan of correction (POC) is rejected by the licensing authority, the facility will be sent a second (2nd) copy of the statement of deficiencies.  The facility shall complete and return the second copy of the statement of deficiencies with an acceptable plan of correction within three business days.  The process will repeat until an acceptable plan of correction is received by the department.

                                (2)           Failure to provide an acceptable plan of correction (POC) within a reasonable period of time, may lead to civil monetary penalties or other sanctions.

                                (3)           The plan of correction shall:

                                                (a)           address how all violations identified in the official statement of deficiencies will be corrected;

                                                (b)           address how the facility will monitor the corrective action and ensure ongoing compliance; and

                                                (c)           specify the date that the corrective action will be completed.

                                (4)           All cited violations shall be corrected within thirty (30) calendar days from the date of the survey; unless the licensing authority approves an extended date.

                                (5)           Failure to submit an acceptable plan of correction may result in sanctions, including but not limited to civil monetary penalties, suspension or non-renewal of the facility license.

                                (6)           The licensing authority may accept, reject, or direct the plan of correction.

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