SECTION 310:675-17-3. Acceptable Plan of Correction

(a)   All facilities having deficiencies must submit an acceptable plan of correction within ten (10) working days after receipt of notice of violation [63:1-1914.A.]. An acceptable plan of correction must:

(1)   Address how corrective action will be accomplished for those residents and/or clients found to have been affected by the deficient practice.

(2)   Address how the facility will identify other residents and/or clients having the potential to be affected by the same deficient practice. Plans of correction specific to residents identified on the deficiency statement are acceptable only where the deficiency is determined to be unique to that resident and not indicative of a possible systemic problem.

(3)   Address what measures will be put into place or systemic changes made to ensure that the deficient practice will not recur.

(4)   Indicate how the facility plans to monitor its performance to make sure that solutions are sustained. The facility shall develop a plan for ensuring that correction is achieved and sustained. This plan must be implemented, and the corrective action evaluated for its effectiveness. The plan of correction shall be incorporated into the quality assurance system. At the revisit, the quality assurance plan shall be reviewed to determine the earliest date of compliance. If there is no evidence of quality assurance being implemented, the earliest correction date will be the date of the revisit.

(5)   Include dates when corrective action will be completed for each violation. The corrective action completion dates shall not exceed sixty (60) days [63:1-1914.A.]from receipt of notice of violation.

(6)   Be signed by the administrator.

(b)   Upon written request from the facility, the Department may extend the time period within which the violations are to be corrected where correction involves substantial structural improvement [63:1-1914.A.].

(c)   The department shall provide written notice of the acceptance or rejection of a plan of correction. If the Department finds that the plan of correction does not meet the requirements for an acceptable plan of correction as specified in OAC 310:675-17-3(a) the Department shall provide notice of the rejection and the reason for the rejection to the facility. The facility shall have ten (10) working days after receipt of the notice of rejection in which to submit a modified plan. If the modified plan is not timely submitted, or if the modified plan is rejected, the Department shall impose a plan of correction, which the facility shall follow [63:1-1914.A.].

(d)   Acceptance of the plan of correction by the Department does not absolve the facility of the responsibility for compliance should the implementation not result in correction and compliance. Acceptance indicates the Department's acknowledgment that the facility indicated a willingness and ability to make corrections adequately and timely.

(e)   If the violation has been corrected prior to submission and approval of a plan of correction, the facility may submit a report of correction in place of a plan of correction [63:1-1914.B.]. The report of correction shall address those requirements specified in OAC 310:675-17-3(a).

(f)   As specified in 63 O.S. § 1-1914.C., facilities may request an extended correction time.

(g)   As specified in 63 O.S. § 1-1914.D., facilities may contest any Department action under this section.

[Source: Added at 20 Ok Reg 2399, eff 7-11-03]