Plan of correction for inspection violations

So, the OHFLAC inspection team has paid you a visit and things did not go so well. Do not let it get to you! It happens to everyone who has a career in the industry. What you need to do is use the feedback from the inspector to make changes in your facility operations that will lead to successful inspections in the future. You have the ability to submit these changes in the form of plan of correction. Check out the following regulations as to what West Virginia OHFLAC expects from your plan of correction:

 

3.10.  Plans of Correction.

3.10.1.  The licensee of an assisted living residence, found on the basis of inspection or other investigation to have violations of requirements in this rule, shall develop, sign, and date a plan of correction, and submit it to the Secretary within 15 working days of receipt of the statement of deficiencies.

3.10.2.  The Secretary shall require immediate correction of violations identified as constituting immediate and serious threats to the health or safety of a resident or employee.

 

3.10.3.  For deficiencies other than those constituting immediate and serious threats, the licensee is expected to comply with the rule within 60 days of the inspection, unless the Secretary waives this requirement and allows more time to correct certain types of deficiencies.

3.10.4.  The plan of correction shall specify:
3.10.4.a.  The violations to be corrected;
3.10.4.b.  The actions taken or proposed to correct the violations and procedures to prevent their recurrence; and
3.10.4.c.  The dates on which each violation is corrected or by which each will be corrected, that allow the shortest possible time to reasonably correct each specific violation.
3.10.5.  The Secretary shall notify the licensee in writing of his or her approval, suggested modifications, or rejection of the plan of correction, or any part thereof.
3.10.6.  If modifying or rejecting the proposed plan of correction, the Secretary shall state the reasons for the modification or rejection.
3.10.7.  If the Secretary rejects the plan of correction, the licensee has up to 15 working days from the receipt of the  Secretary’s determination to submit a revised plan.
3.10.8.  The Secretary may conduct a follow-up, on-site inspection to verify the correction of any violations identified during an inspection or any other investigation.

Top Takeaways:

 

  • 10.2. The Secretary shall require immediate correction of violations identified as constituting immediate and serious threats to the health or safety of a resident or employee

If you are tagged with any violations that are deemed to be serious threats against resident and staff safety, you must IMMEDIATELY correct the issues. If OHFLAC does not see a correction of the deficiency it will be elevated.

  • 10.3. For deficiencies other than those constituting immediate and serious threats, the licensee is expected to comply with the rule within 60 days of the inspection, unless the Secretary waives this requirement and allows more time to correct certain types of deficiencies

While you only have 15 days post-inspection to submit your plan on correction, OHFLAC provides you with a period of 60 days to make the changes noted in your plan of correction. Be prepared for a reinspection after this period.

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